DK_Derma_3_2022

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DK – NO – SE / NO. 3 / 2022

Dermatology

35th NCDV 2022 Congress Highlights Page 12

Sexuality in dermatologic nursing care Page 16

Atopic dermatitis and exposure to antibiotics in early life Page 40

Share clinical knowledge and best practice to improve health and patient care.


Vælg Taltz til dine patienter

med moderat til svær plaque-psoriasis når målet er fuldstændig afglatning af huden,1-2 vedvarende respons1-2 samt hurtig* indsættende effekt3 5 H2H# STUDIER HVOR TALTZ ER SUPERIOR VS AKTIV KOMPARATOR3-6§

5

5 H2H STUDIER MED HURTIG INDSÆTTENDE EFFEKT AF TALTZ3-6

5 H2H STUDIER SOM ALLE VISER PASI100 SUPERIORITET3-6#

5 ÅRS VEDVARENDE EFFEKT OG FULDSTÆNDIG AFGLATNING AF HUDEN HOS 48% (MNRI)1†

5 ÅRS SIKKERHEDSDATABASE MED >17.000 PATIENTÅRS EKSPONERING7

Taltz er indiceret til behandling af moderat til svær plaque-psoriasis hos voksne, der er kandidater til systemisk behandling. Taltz er indiceret til behandling af moderat til svær plaque-psoriasis hos børn og unge fra 6 år med en vægt på mindst 25 kg, der er kandidater til systemisk behandling. Taltz, alene eller i kombination med methotrexat, er indiceret til behandling af aktiv psoriasisartrit hos voksne patienter, der ikke har responderet tilstrækkeligt på eller ikke tåler et eller flere sygdomsmodificerende antireumatiske lægemidler (DMARD).

* § # †

Hurtig=PASI50 målt ved uge 1 og PASI75 ved uge 2 jf. ref. 3. adalimumab, etanercept, ustekinumab, guselkumab. 1 undersøgelse i PsA, 4 undersøgelser i PsO. Patienter, der fortsat modtog godkendt ixekizumab dosis, var statiske Physician’s Global Assessment (sPGA) (0,1) respondere ved uge 12 samt gennemførte 60 ugers behandling, kunne indgå i langtidsstudieperioden.

1. Taltz SPC. 2. Leonardi C et al. Dermatol Ther (Heidelb). https://doi.org/10.1007/s13555-020-00367-x. 3. Blauvelt A et al. Br J Dermatol. 2020;182(6):1348–58. 4. Paul C et al. J Am Acad Dermatol. 2019;80(1):70-79. PP-IX-DK-0511 / 29.10.2021

5. Mease PJ, et al. Ann Rheum Dis 2020;79:123–131. doi:10.1136/annrheumdis -2019-215386 6. Griffiths C et al. Lancet 2015;386(9993):541-551. 7. Armstrong A et al. Dermatol Ther (Heidelb). 2019; doi:10.1007/s13555-019-00340-3.

Se pligttekst side 44.


Welcome to BestPractice Nordic BestPractice Nordic is an independent journal published by: BestPractice Nordic ApS Teknikerbyen 5, 2. sal 2830 Virum, Denmark +45 4466 9210 info@bpno.dk www.bpno.dk Editor in chief: Jan Andreasen MD & Journalist +45 5151 8831 jan@bpno.dk The articles in BestPractice Nordic are independent of interests. Most pieces are written from the author’s professional perspective, and the message of the articles does not necessarily reflect an expression of the views of the editor. This magazine is distributed to Nordic dermatologists. Advertising: Stine-Maria Halstrøm Customer Relations Manager +45 5354 6481 sha@bpno.dk Copyright© 2022 BestPractice Nordic ApS Circulation: 300 ISSN 2794-1582 Layout: Helle Rindom Printing house: Strandbygaard A/S

Best Practice Nordic is a clinical platform that facilitates an arena for

more than 35.000 active clinical specialists in the Nordic region. They

all work to improve public health and patient care through dialogue and sharing best practices amongst doctors and healthcare professionals.

At BestPractice Nordic we hope to break down barriers between the

fields to facilitate a more holistic patient view and care by commu-

nicating current and clinically relevant knowledge of new indications and treatments, studies, guidelines and best practice, all of which optimize patient care.

VA

E T

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All content is made by clinicians for clinicians and edited by the edNE MER K

itorial desk. We hope and encourage all of you to continue contrib-

uting to the development by asking questions and sharing your knowledge and research with your colleagues.

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Our mission is to share clinical knowledge and best practice to improve health and patient care.

BestPractice Nordic / Dermatology / NO. 3 / 2022

Last year we shared more than 3.000 articles covering best practic-

es in dermatology, oncology, haematology, neurology, rheumatol-

ogy, general practice, gastroenterology, psychiatry, pharmacy and now adding endocrinology to our portfolio.

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Content

3

Velkomst

5

Indhold

6

Leder / Henrik Nielsen

8

New nordic clinical advisory board for dermatology 2022

TEMA

Dermatology 12 Highlights from the 35th NCDV 2022 / Line Kibsgaard

16 Addressing sexuality in dermatologic nursing care / Astrid Blikstad

19 Interaction between hand eczema, HRQOL, and changed exposures for health care

workers during the COVID-19 pandemic / Yasemin Topal Yüksel

23 The role of patients in the development of Nordic dermatology / Lars F. Werner

25

NCDV 2022 MEDtalk highlights

29

Proteomics in the dermatology of the

future – inclusion of the skin proteome

in clinical research and practice / Bjørn

31 Nail fold changes as a marker for psoriatic arthritis in psoriasis of the skin / Jørgen Guldberg-Møller and Mette Mogensen 35

Environmental factors and auto-immune diseases – a hypothesis / Henrik Nielsen and Merete Engelhart

40 The relationship between atopic dermatitis and exposure to antibiotics in early life / Mwenya Mubanga

42 Low prevalence of patients diagnosed

with psoriasis in Nuuk: a call for increased awareness of chronic skin disease in

Greenland / Sofia Hedvig Christensen Botvid and Carsten Sauer Mikkelsen

Kromann Hansen and Beatrice DyringAndersen

BestPractice Nordic / Dermatology / NO. 3 / 2022

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Leder

The importance of protecting gut/skin biodiversity to preserve health The gut/skin microbiome biodiversity is central to the body’s defense and disease presentations. During COVID-19, the

decline in gut biodiversity has come into focus. The ques-

tensively studied over the years. Less well-studied are several chronic diseases that all have commonalities with

late-COVID-19 symptoms: fatigue, memory discomfort,

tion is how reduced gut/skin biodiversity may increase

and diffuse pain. The factors surrounding these chronic

attacks. And what can we do to prevent a reduction in

and effect are not currently understood.

the risk of death or secondary manifestations from viral the body’s defense in the future?

diseases can only be evaluated with more time – cause

New insights into gut-brain communication1 have emerged

Today, thousands of people are living with diseases that

from studies that have sought to link the gut microbiome to

factors. This goes far beyond infections due to bacteria and

Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS).

are the direct consequence of negative environmental viruses. People know of course about environmental fac-

diseases we do not yet understand, for example Myalgia

tal factors can result in a breakdown of the body’s pro-

Understanding the gut defense system The emergence of atypical chronic diseases such as ME/ CFS is a mystery, but when virus intrusion and degraded environmental conditions (leading to degraded gut/skin biodiversity) are taken into consideration, then we can

and make us more vulnerable to a wide range of diseases.

factor in these diseases. Studies of COVID-19 and the sur-

tors like smoking, obesity, etc. that are harmful to health, but negative impacts also come from more hidden sources such as synthetic chemicals and pesticides in foods, and

microparticles in urban air. These negative environmentection, impair the biodiversity in our mucous membranes,

The role of skin microbiotas Skin-barrier structure and function are essential for health. Skin microbiotas play an integral role in the maturation

focus on the question of whether biodiversity failure is a rounding environmental conditions, where the setting for

disease outbreak was present before the pandemic, will bring us closer to understanding the gut defense system.

As researchers, we are limited by the fact that it is not

and homeostatic regulation of keratinocytes and host

ethically justifiable to conduct experiments on humans.

portance of gut/skin biodiversity. Indeed, disturbances

Regardless, it is important that we do not let our actions

immune networks, with systemic implications for the im-

of the stratum corneum have been noted in allergic diseases (eczema and food allergy), psoriasis, rosacea, acne

We simply must lean on statistics and considerations. be slowed down by lack of evidence.

Greater focus should be put on the importance of gut/

vulgaris and with the skin-aging process.

skin biodiversity in relation to the health of the body. If we

Impaired gut biodiversity Examples of diseases related to impaired gut biodiversity include chronic fatigue syndrome, post-traumatic stress disorder (PTSD), and Gulf War Illness. These have been in-

species could go extinct. The biodiversity that we have

6

fail to do this, things will go as we see in nature – and the

all acquired early in life affects the development of our immune system and is responsible for the health and development of diseases later in life.

BestPractice Nordic / Dermatology / NO. 3 / 2022


Henrik Nielsen / M.D., D.M.Sc., specialist in intern medicine and rheumatology.

sity of the mucous membranes) in infants leads to many

A call for action This is too serious an issue for us to slow our efforts be-

diabetes, obesity, and autoimmune diseases. Lack of ex-

eses and act now. There is a need for increased research

Many studies have shown that dysbiosis (lack of biodiverdiseases, such as lung diseases, asthma, food allergies,

posure to microorganisms in early life can cause allergies. Studies have shown that children who grow up in

natural environments have fewer allergy symptoms than

children who grow up in urban areas. One of the reasons that children in urban areas have less diversity in their intestines is due to pollution from microparticles in the air.

The human gut microbiome Recently, many studies have shown the important role of the human gut microbiome. This includes, among other things, the ability to extract energy from food, to increase the harvest of nutrients, to change the appetite signal

cause of a lack of evidence. We need to lean on hypothinto the health consequences of pollution from synthet-

ic chemicals and microparticles, and the accompanying degradation of the gut/skin-biodiversity.

From a political perspective, this means more research

stimulation and funding. From a medical perspective, we need more focus on matters we do not understand; ME/

CFS has had long periods of neglect. General practition-

ers have not been trained in this disease, despite the fact

it was the most ANA-positive disease back in 1986 in the Stanford lab where ANAs were defined (ANA = antinuclear antibodies).

The study done by König RS et al as applied to ME/CFS

and to maintain the production of vitamins, to name just

serves as an example. We should use the same approach

100 trillion microorganisms and has 150 times more genes

asis. Studies with similar assessments of biodiversity-loss

a few examples. The gut microbiome includes more than than the human genome itself. It is involved in basic bio-

logical processes, including the regulation of intestinal development, graduation of the individual metabolic na-

to study diseases such as lupus, Parkinson’s, and psori-

due to environmental factors have the potential to bring us closer to understanding chronic diseases in general.

ture, and stimulation of innate immunity, as well as the production of antimicrobial substances that kill microbial organisms (the organism’s own antibiotics).

That’s why it’s important to have more research into the

body’s gut-biodiversity. Also, it is important that we make a significant effort to increase biodiversity in nature so it

can “rub off” on us as human beings. Two positive steps

would be to preserve more space for wild nature and to

Reference:

kind of action is necessary if we, as humans, have a chance

1. König RS, Albrich WC, Kahlert CR, et al. The Gut Microbiome in Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS. Front Immunol. 2022. https://doi.org/10.3389/fimmu.2021.628741

limit pesticides that exterminate insects and bees. This of staying healthy.

BestPractice Nordic / Dermatology / NO. 3 / 2022

7


BestPractice Nordic proudly presents: In this magazine, we are happy to introduce our newly established dermatology advisory board. The doctors who have

taken on this job will act as sparring partners to the editorial desk on topics, studies, and newest research.

Our board members will ensure the high

quality of our publications and keep our readers up to date within the field.

All content published through BestPrac-

tice Nordic’s channels is made by clini-

cians, for clinicians within the field. We hope and encourage all of you to con-

tinue to contribute to the development

by asking questions and sharing your knowledge and research.

Kristina Ibler Medical doctor at Zealand University Hospital since 2007. Specialty: AD. Country: Denmark.

Being part of the clinical advisory board is unpaid, but makes a great difference,

not only by ensuring knowledge sharing between Nordic health professionals but

also by supporting our collaboration with Doctors Without Borders. Hence, last year

we were able to donate close to DKK 100,000 on behalf of all of our contributors.

We are looking forward to a great collabo­ ration with this new board of experts.

Usha Hartgill Specialist in dermatovenereology and leader at Olafiaklinikken in Oslo (sexual health clinic). Specialty: Venereology and genital dermatoses. Country: Norway.

8

BestPractice Nordic / Dermatology / NO. 3 / 2022


The new nordic clinical advisory board for Dermatology 2022.

Kristian Kofoed Medical doctor, Ph.D. Specialist in dermatology, Hud­klinikken, Rødovre, Denmark. Specialty: AD. Country: Denmark.

Amra Osmancevic Medical doctor, PhD at Sahlgrenska University Hospital since 1997. Specialty: PsO. Country: Sweden.

BestPractice Nordic / Dermatology / NO. 3 / 2022

Line Kibsgaard Specialist registrar at the Department of Dermatology, Aarhus University Hospital since 2020. Specialty: Venerology, genital dermatoses. Country: Denmark.

Carsten Sauer Mikkelsen MD, specialist in dermato-venereology. GP and part of the research unit at Dept. of Dermatology, Aalborg University Hospital. Specialty: PsO, AD, NMMSC, HAE. Country: Denmark.

9


Pligtoplysninger/Forkortet produktresumé Olumiant® 2 mg og 4 mg filmovertrukne tabletter (baricitinib) Indikationsområde: Reumatoid artritis: Olumiant er indiceret til behandling af moderat til svær aktiv reumatoid artritis hos voksne patienter, der ikke har responderet tilstrækkeligt på eller ikke tåler et eller flere sygdomsmodificerende antireumatiske lægemidler (DMARDs). Olumiant kan anvendes som monoterapi eller i kombination med methotrexat. Atopisk dermatitis: Olumiant er indiceret til behandling af moderat til svær atopisk dermatitis hos voksne patienter, der er kandidater til systemtisk behandling. Dosering: Den anbefalede dosis af Olumiant er 4 mg én gang dagligt. En dosis på 2 mg én gang dagligt er passende til f.eks. patienter ≥ 75 år og kan være passende til patienter med kroniske eller tilbagevendende infektioner i anamnesen. En dosis på 2 mg én gang dagligt kan også overvejes til patienter, der har opnået vedvarende kontrol af sygdomsaktivitet med 4 mg én gang dagligt og er egnede til nedtrapning af dosis. Atopisk dermatitis: Olumiant kan anvendes med eller uden topikale kortikosteroider. Olumiants virkning kan øges, når det gives sammen med topikale kortikosteroider. Topikale calcineurin-hæmmere kan anvendes, men skal udelukkende forbeholdes følsomme områder, såsom ansigtet, halsen, intertriginøse- og genitale områder. Det bør overvejes at seponere behandlingen hos patienter, som ikke viser tegn på terapeutisk effekt efter 8 ugers behandling. Behandling bør ikke indledes hos patienter med absolut lymfocyttal (ALC) < 0,5 x 109 celler/l, absolut neutrofiltal (ANC) < 1 x 109 celler/l eller med hæmoglobin < 4,96 mmol/l. Behandling kan indledes, når værdierne er kommet op over disse grænser. Der henvises til produktresume for dosisjustering hos særlige populationer. Bivirkninger: Meget almindelig (≥1/10): Infektioner i øvre luftveje. Hyperkolesterolæmi. Almindelig (≥1/100 til <1/10): Herpes zoster. Herpes simplex. Gastroenteritis. Urinvejsinfektioner. Pneumoni. Trombocytose > 600 x 109 celler/l. Hovedpine. Kvalme. Abdominalsmerter. Alanin-aminotransferase (ALAT) ≥ 3 x øvre normal grænse (ULN). Udslæt. Akne. Forhøjet kreatinkinase >5 x ULN. Ikke almindelig (≥1/1.000 til <1/100): Neutropeni < 1 x 109 celler/l. Hypertriglyceridæmi. Divertikulitis. Aspartat-aminotransferase (ASAT) ≥ 3 x ULN. Hævelse i ansigtet. Urticaria. Lungeemboli. Dyb venetrombose. Vægtstigning. Kontraindikationer: Graviditet. Overfølsomhed over for det aktive stof eller over for et eller flere af hjælpestofferne. Særlige advarsler og forsigtighedsregler: Infektioner: Baricitinib er forbundet med en øget forekomst af infektioner, f.eks. infektioner i øvre luftveje. Risiciene og fordelene ved Olumiant-behandling skal derfor nøje overvejes forud for indledning af behandling hos patienter med aktive, kroniske eller tilbagevendende infektioner. Patienter bør screenes for tuberkulose (TB), før behandling med Olumiant indledes. Olumiant må ikke gives til patienter med aktiv TB. Viral reaktivering: I kliniske studier blev der rapporteret viral reaktivering (f.eks. herpes zoster, herpes simplex). Hvis en patient udvikler herpes zoster, bør Olumiant-behandlingen afbrydes midlertidigt, indtil episoden er gået over. Før opstart af behandling med Olumiant bør udføres screening for viral hepatitis i overensstemmelse med kliniske retningslinjer. Hvis hepatitis B virus (HBV-DNA) påvises, bør en specialist i leversygdomme konsulteres. Vaccination: Anvendelse af levende, svækkede vacciner under eller umiddelbart før behandling med Olumiant anbefales ikke. Før behandling med Olumiant påbegyndes, anbefales det, at patienterne bringes a jour med al immunisering i overensstemmelse med gældende retningslinjer for immunisering. Lipider:

10 Se annonce side 11.

Lipidparametre bør vurderes ca. 12 uger efter indledning af behandling med Olumiant, og herefter bør patienterne håndteres i overensstemmelse med internationale kliniske retningslinjer for hyperlipidæmi. Hematologiske anomalier: Behandlingen bør midlertidigt afbrydes ved lav ALC/ANC/hæmoglobin, henvisning til afsnittet “dosering”. Risikoen for lymfocytose er øget hos ældre patienter med reumatoid artritis. Sjældne tilfælde af lymfoproliferative tilstande er blevet rapporteret. Stigning i leveraminotransferaser: Der blev rapporteret dosisafhængige stigninger i ALAT og ASAT i blodet hos patienter, der blev behandlet med bacitinib. Hvis der observeres stigning i ALAT eller ASAT under den rutinemæssige kontrol af patienterne, og der er mistanke om lægemiddelinduceret leverskade, skal behandlingen med Olumiant afbrydes midlertidigt, indtil denne diagnose er udelukket. Malignitet: Immunmodulerende lægemidler kan øge risikoen for malign sygdom, herunder lymfom. De kliniske data er ikke tilstrækkelige til at vurdere den potentielle incidens af malign sygdom efter eksponering for baricitinib. Venøs tromboembolisme: Olumiant skal anvendes med forsigtighed til patienter med kendte risici for dyb venetrombose (DVT) og lungeemboli (PE). Behandling med Olumiant skal seponeres, hvis der opstår kliniske symptomer på DVT/PE, og patienten skal straks vurderes efterfulgt af en passende behandling. Overfølsomhed: Efter markedsføring er der rapporteret om tilfælde af lægemiddeloverfølsomhed forbundet med administration af baricitinib. Hvis der opstår en alvorlig allergisk eller anafylaktisk reaktion, skal behandling med baricitinib straks seponeres Divertikulitis: Der er rapporteret om tilfælde af divertikulitis og gastrointestinal perforation i kliniske studier og efter markedsføring. Baricitinib bør anvendes med forsigtighed hos patienter med divertikelsygdom og især hos patienter, der er i kronisk behandling med samtidige lægemidler, som er forbundet med øget risiko for divertikulitis: non-steroide anti-inflammatoriske lægemidler, kortikosteroider og opioider. Patienter, der har ny forekomst af abdominale tegn og symptomer, bør undersøges øjeblikkeligt med henblik på tidlig identifikation af divertikulitis eller gastrointestinal perforation. Fertilitet, graviditet og amning: Olumiant er kontraindiceret under graviditet. Fertile kvinder skal anvende sikker kontraception under behandlingen og i mindst 1 uge efter afsluttet behandling. Hvis en patient bliver gravid under behandling med Olumiant, skal kvinden og hendes partner informeres om den potentielle risiko for fosteret. Det vides ikke, om baricitinib/metabolitter udskilles i human mælk og Olumiant bør ikke anvendes under amning. Overdosering: Enkeltdoser på op til 40 mg og flere doser på op til 20 mg dagligt i 10 dage er blevet administreret i kliniske studier uden dosisbegrænsende toksicitet. Bivirkningerne var sammenlignelige med de bivirkninger, der blev set ved lavere doser, og der blev ikke identificeret nogen specifikke toksiske virkninger. I tilfælde af overdosering anbefales det, at patienten monitoreres for symptomer på bivirkninger. Lægemiddelformer: Filmovertrukne tabletter. Pakningsstørrelser og priser: 2 mg og 4 mg i pakninger af 28 tabletter. For dagsaktuel pris henvises til medicinpriser.dk Udleveringsgruppe: NBS Derm.Reuma Tilskudsstatus: Ingen Indehaver af markedsføringstilladelsen: Eli Lilly Nederland B.V., Papendorpseweg 83, 3528 BJ Utrecht, Holland. Produktresumeet er omskrevet og forkortet i henhold til det produktresume, som er godkendt af det Europæiske Lægemiddelagentur. Det fuldstændige produktresumé kan vederlagsfrit rekvireres hos Eli Lilly Danmark A/S, Lyskær 3E, 2. tv., 2730 Herlev. Telefon: 45 26 60 00. PP-BA-DK-0334

BestPractice Nordic / Dermatology / NO. 3 / 2022


Olumiant® er

GODKENDT

til moderat til svær atopisk dermatitis (AD)1

én tablet om dagen billede er kun til information og viser ikke aktuel størrelse

Olumiant er den FØRSTE JAK-hæmmer, som er godkendt til voksne patienter, som er kandidater til systemisk behandling. Overvej Olumiant til de patienter, hvor du ikke når i mål med topikale behandlinger alene: En tablet daglig1 Hurtig effekt på kløe inden for 1-2 uger1* Veletableret sikkerhedsprofil på tværs af indikationer1

Reference: 1. Olumiant® (baricitinib) SPC 2021. * ≥ 4 point forbedring af NRS for kløe blev set indenfor første uge i Breeze AD1+AD2 og ved uge 2 i AD7; p <0,002 hos patienter randomiseret til baricitinib 4 mg vs placebo1 © 2022 Eli Lilly and Company. All rights reserved. BestPractice Nordic / Dermatology / NO. 3 / 2022 Lilly and Olumiant® are registered trademarks of Eli Lilly and Company. PP-BA-DK-0441 / 11.04.2022

11 Se pligttekst side 10.


Highlights from the 35th NCDV 2022 At NCDV 2022, Nordic and Baltic dermatologists came together to share the newest research and discuss hot topics. In this summary of events, Dr. Line Kibsgaard offers an overview of the 35th congress. LINE KIBSGAARD is MD and Ph.D. at the Department of Dermatovenereology, Aarhus Univer-

sity Hospital, Denmark. Her special interests include venereology, urticaria and hidrosadenitis suppurativa.

Dear colleagues,

audience attracter, as he manages to share his

It is my absolute pleasure to share my obser-

genesis of itch.

vations from the 35th Nordic Congress of Der-

Itch is one of the most frustrating parame-

mato-venereology. So, lean back and enjoy my

ters in treating patients with AD. It’s frustrating

give you a picture of some of the highlights of

also for the physician who tries to resolve the

journey through this congress, which I hope will special interest to you.

The venue was the beautiful Tivoli Hotel in the

for the patient and family members, and often serious issues of their patient’s disease.

One of my favourite learnings as a junior der-

centre of Copenhagen. The pre-programme

matologist was the fact that itch sensations dif-

and an evening Network Event, hosted by the

pared to patients with urticaria. This is easy to

started on April 19 with on-site board-meetings

LEO Foundation as proud presenters of the new and visionary Skin Immunology Research Centre at the Maersk Tower in Copenhagen. The

centre has collected biomaterials from 3,000 patients which will yield insights into how skin diseases develop over time.

Day 1: Psoriasis, AD, and chronic urticaria On Wednesday, April 20, the official programme started with the General assembly meeting of the Danish Dermatological Society (DDS). The chair position of DDS changed. Christian Vester­ gaard, Aarhus University Hospital is succeeded by Simon Francis Thomsen, Bispebjerg Hospital. Kristina Ibler, Bispebjerg Hospital becomes treasurer. The autumn meeting of DDS will be held in Aarhus on November 4-5 in a new and exciting format. All members are more than welcome to join.

Understanding and treating itch

Afternoon plenary sessions were split into par-

allel sessions on the two major chronic skin dis-

eases: Psoriasis and Atopic Dermatitis (AD). Each session had excellent speakers from across the

Nordic countries. The “itch session” held by Jes-

per Elberling, Gentofte Hospital, was quite an

12

enthusiasm for getting to grips with the patho-

fer significantly between patients with AD comsee in our clinics, as AD is often plastered by

secondary excoriations, which is almost never seen in patients suffering from urticaria. In AD,

itch is an inflammatory signal and part of the cascade of immunological reactions from the patient’s skin, which seeks to get rid of the sensation by initiating a mechanical action in the

form of scratch. The efferent sensation is led by the epidermal non-myelinated polymodal C-fi-

bres. The afferent mechanism is led by motor neurons that innovate and activate muscle contractions to achieve relief from itch. Itch is a

sensation that is rewarded with increased levels of oxytocin in the postsynaptic nerve endings of the CNS.

In addition, functional MRI studies of itch have

shown repeated activity in specific areas in the cerebral cortex. This can be imaged faster/ear-

lier than when the patient recognizes the visual

signs of dermatitis on their skin. Hence, itch in AD should be referred to as an inflammatory, and even more important, non-histaminerge itch. In contrast, in urticaria the itch sensation is a consequence of the rapid release of antihistamines

and prostaglandins from epidermal mast cells.

It is merely a consequence of the human innate immune response. In AD patients, JAK inhibitors

BestPractice Nordic / Dermatology / NO. 3 / 2022


and dupilumab (anti-IL13/anti-IL4) are first-line

ments throughout history. This was, in my opin-

treatments (MTX, azathioprine, or cyclosporine)

congress.

biologics; if using systemic anti-inflammatory does not afford acceptable disease control.

ion, the most entertaining session of the whole

Biologics targeting chronic urticaria

Day 2: HS, hot topics The future of treatment in HS and biologics

egantly followed up on this topic with his pres-

dradenitis Suppurativa (HS), focusing on the

Simon Francis Thomsen, Bispebjerg Hospital, elentation of future targets for treatment in chronic urticaria patients (CSU) who do not respond

or have a slow or insufficient response to omal-

izumab (type IIb CSU patients). In about 15% of all CSU patients, blockage of the FRI receptor is not sufficient to relieve symptoms. Small molecule treatments (cytokine and tyrosine kinase inhibitors) may be the answer in the future for

this patient group, along with ligelizumab (anti-IgE), benralizumab (anti-IL5), and mepolizumab (anti-IL5). Hence, the future holds prom-

Thursday morning set off with a session on Hiworldwide epidemiology, treatment challenges,

bio-eligibility, DLQI and when to consider surgery for this group of patients, and future rec-

ommendations yet to come. According to the upcoming revision of the European guidelines,

we will distinguish between active and inactive

inflammatory disease, and measure disease activity according to the IHS4-scoring system, in which the number of nodules, abscesses, and draining fistulas are all considered.

Clinical trials have shown equal response to

ise for the Xolair non- or insufficient respond-

Doxycycline and the Clindamycin-plus-Rifam­

itive basophile histamine release tests and low

logic treatments (anti-TNF α) much earlier than

ers, who may be suspected in cases with poslevels of basophils, eosinophils, and total IgE.

In the following parallel sessions, some of the

leading Nordic experts in AD and psoriasis gave presentations on comorbidities, pathogenesis, and treatment strategies. Patient-reported outcomes were an emerging topic of interest, along

with EASI scores that are about to match the reported scores of PASI, for example EASI-50, EASI75 and EASI-90.

Highlighting our international landmarks

At a late-afternoon session on Wednesday, rep-

picin regimes. This gives us hope to offer biobefore, combined with the increasing know­

ledge and interests in biological treatments of patients with HCS, where secukinumab (anti IL17),

bimekizumab (anti IL17A/F), spesolimab (anti-IL36) and JAK pathway inhibitors are under investigation.

For people with a special interest in HS, the

speakers were proud to announce the dates of

the upcoming 2023 Conference of the European HAS-society, which will be held February 8-10 in Florence.

resentatives from Sweden, Norway, Iceland, Fin-

Hot topics in Nordic dermatology

each invited to give a talk on their respective na-

a brilliant pros-and-cons session on the themes

land, the Baltic countries and Denmark were

tions’ global contributions to Dermato-venereology. This inspired a wide range of topics: famous Nordic dermatologists and venereologists from the 19th and 20th centuries, highlights of

cohort-studies on syphilis from Norway and

Sweden, the Norwegian contemplation of the

Parallel to the morning session on Thursday was of 1) Melanoma screening and 2) Emollients, both ongoing subjects of debate among patients, colleagues, and from a pharmaceutical and socioeconomic point of view, where it seems as if there are no uniform or final conclusions.

Other topics of interest were skin infections

Hanifin-Rajka criteria from 1979, the Danish No-

(COVID-19 skin manifestations), melanomas,

the inventor of light therapy, highlights of the

of artificial intelligence in our daily work prac-

bel prize winner from 1903, Niels Finsen, who was Baltic congresses of Dermato-venereology over the years, and finally the Icelandic “Keresis´ad-

work-related eczemas, and the increasing use tice as dermatologists.

When it comes to future infections within our

venture”; A very fine presentation of the world’s

specialty, our concerns should not be limited

from a fish skin model.

ylococci; a general phenomenon in the Nordic

5th largest deliverers of skin transplants evolved All attending nationalities were – in a very un-­

Nordic manner – encouraged to be proud of

their fellow Dermato-venereologists’ achieve-

BestPractice Nordic / Dermatology / NO. 3 / 2022

to meat-eating bacteria and resistant staphcountries is the rising prevalence of sexually

transmitted diseases. In Denmark, the incidence of gonorrhea and syphilis are at their highest

13


levels in 20 years, and it seems as if this is a

to the most educational poster (Systematic re-

tional interventions. Thus, it was very comfort-

the congress committee members.

trend that is not going to decrease without naing to hear the talk of Usha Hartgill from Nor-

view on Prurigo Nodularis Hyde) assessed by

way, who has done important research on gon-

Bright future for treatment of dermatological

against gonorrhea may become realistic.

In conclusion, the Congress left a great deal of

orrhea that gives us hope that a future vaccine

Young colleagues sharing new ideas

The Poster Walk on Thursday afternoon was converted into short presentations of studies by

some of our younger colleagues, who shared

their enthusiastic and clever ideas. For me, this was the most inspiring moment of the congress,

as it is in forums like these ideas come to life and the finest core of research becomes visible to everyone.

Thursday night, the congress dinner was held

at the Langelinie Pavilion next to the Little Mer-

maid. We arrived by boat, and Copenhagen

conditions

joy and excitement among attendees about fi-

nally being able to meet again. We were able to share our common passion to treat, comfort,

and relieve itch, sores, and the various agonies of our dermatological patients. There is no doubt that we are about to face an explosion of pos-

sible treatment strategies when treating AD patients with biologics, an explosion that is similar to the one psoriasis treatment has gone

through during the last decade or two, and where EASI-90 is a realistic treatment goal in the future to come.

Lots of antibody and small molecule treat-

showed itself from its most beautiful and sun-

ments are on their way, and I have high expec-

ued to be shared while glasses were raised in

caria, and AD patients, in particular. I think that

ny side. Ideas and inspiring moments contin-

celebration of finally being able to meet faceto-face after two years of COVID-19-lockdown.

Day 3: Microbiomes, rosacea, acne, and trends in psoriasis Microbiomes, rosacea, acne, and trends in psoriasis research were the topics on Friday morning in parallel with the second and well visited

nurse section. It was a pleasure to observe how specialized dermatological care issues were shared and discussed on a highly competent level, where I am sure that we can all gain price-

less experiences, if we dare to share our personal stories of success and flaws with our neighboring countries who must face similar

challenges, when it comes to socioeconomic,

geographical and political issues within our field of expertise.

Free communication and poster awards

The final sessions of the congress were two free communication sessions, where ten projects

were presented by the conducting scientists

tations for the future medical care of HS, urti-

multidisciplinary approaches are going to be the future “new black”, not only in treating cas-

es of psoriasis, dermatological cancer patients,

and wound-care but also in the treatment of AD-, urticaria- and HS-patients. These are disease areas where initial multidisciplinary expert assessments may turn out to be the most

cost-beneficial model from a long-term per-

spective and a way to plan treatment courses, which can be maintained by our excellent col-

laborators in the primary health care sector. From a patient perspective: A way to receive expert assessments in one setting with close

and expert follow up until complete disease con-

trol, where-after patients may again gain from the undebatable advantages offered by the primary health care sector.

I would like to thank the organizing commit-

tee of this wonderful congress. For all of you who could not join us, I hereby give my warmest recommendations. I sincerely hope to meet you all at the next congress.

with the opportunity to discuss methodology

With best wishes

most remarkable posters were selected in sev-

MD, Ph.D. Line Kibsgaard

to wash your socks to avoid fungal infections)

Aarhus University Hospital, Denmark.

and future perspectives of their ideas. The ten eral categories, from the most original idea (how

Department of Dermatovenereology

CONFLICT OF INTEREST: Speaker at a LEO Pharma industrial symposium. Attendee at congress, sponsored by UCB. Attendee at symposium hosted by Eli Lilly. Attendee at symposium hosted by Abbvie.

14

BestPractice Nordic / Dermatology / NO. 3 / 2022


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BestPractice Nordic / Dermatology / NO. 3 / 2022

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15


Addressing sexuality in dermatologic nursing care Sexuality is a basic human need. However, sexuality is not always included in the nursing assessment. Studies have uncovered barriers that give us insights into how we can improve our clinical practice and assess sexuality more frequently with our patients. How can we assess sexuality by increasing our knowledge? And how do we promote a positive attitude toward sexuality, combined with standardized use of the “Dermatology Life Quality Index”? ASTRID BLIKSTAD is Clinical Nurse Educator

paired sexuality.1 This issue should be addressed

pital and senior advisor for The Norwegian

in a healthcare setting. However, studies have

at Ward of Dermatology, Oslo University Hos-

at an equal level with other kinds of treatment

Psoriasis and Eczema Association (PEF).

uncovered barriers, which include lack of

Sexuality is a basic human need. It’s a part of our primal instincts. Its biological complexity

makes us able to survive and reproduce as a species. We all know that sex is fun, too – alone

or with others – regardless of our socio-cul-

knowledge, taboos, fear of negative feedback and the lack of clinical practice guidelines.2 Having uncovered these barriers also provides

us with knowledge about how we can improve our clinical practice and assess sexuality more frequently with our patients.

We can self-reflect, and we can reflect upon

tural norms that have tried to keep this fact a

our practise together with our colleagues. Self­

sexuality.

communicative skills. This is important, and

well-kept secret, especially for gay and female Understanding what the term sexuality means

is important. Sexuality is sex, health, gender

identity, sexual orientation, fantasies, intimacy, reproduction, pleasure, identity and so much more. Just as important is to understand our

own attitudes toward sexuality. As for many

other aspects of our profession, it is important that we explore our own values, beliefs and disbeliefs, insecurities, and prejudices.

Addressing impaired sexuality Clinical studies recognize that people living with different skin diseases are at risk of im-

reflection is, in my mind, a key to increase our

ideally, we should also create a safe and positive work environment where we can discuss

sexual health topics and promote professional development in our field of nursing.

Ask the question: “How do we assess sexual-

ity in my workplace?” If you don’t have an ans­ wer, find out why.

A holistic understanding of sexuality As nurses, we can analyse disease impact on sexuality in two assessment/intervention domains – both the direct impact and indirect

impact of sexuality. A direct impact would be

A systematic assessment of the patient’s sexual health status gives us the opportunity to support sexuality by normalizing, providing information, and facilitating positive coping strategies. 16

BestPractice Nordic / Dermatology / NO. 3 / 2022


physical changes causing a form of sexual

the case for people living with other skin dis-

cho-social: : self-esteem, body image, shame,

chen sclerosis or genital ulcers.

impairment. And indirect would be the psystigma, or identity changes.

eases that affect the genitals directly like li-

Indirectly, a skin disease regardless of wheth-

Assessing and addressing sexuality in a ho-

er occurring on the genitals or on other parts

opportunity to facilitate our patient’s explo-

body image, and self-perceived stigma, among

listic and positive approach can give us the

ration of sexuality – what it means for them. Sexuality is not only sexual activities like mas-

turbation or intercourse. It’s a very subjective experience and includes kissing, hugging, cuddling, and other forms of intimacy.

Disease manifestations affecting sexuality We all know that the skin is a huge sensory organ as well as providing other vital functions of the skin. If we didn’t have skin, we would all

of the body can induce low self-esteem, altered other psychosocial factors.4 Itching is a common symptom that can affect the feeling of

pleasure or the surplus energy to have sexual play. Psychological diseases such as anxiety and depression also play a role in an individ-

ual’s sexual health, and we now know that

several chronic skin diseases are linked to an increased risk of mental health issues.3

hanging out on display – which would not mat-

DLQI in a multidisciplinary approach In a variety of diagnoses, from cancer to bowel disease, nurses and health personnel describe in the literature barriers to why sexuality or

to the sensory function. We communicate with

nicated between health personnel and their

be dead, and we would look horrible with our leaking bodies, with muscles and tendons

ter because we would all be dead. But back our environment through touch, and socially with our skin itself. So how can a skin disease affect our sexuality?

A direct impact can be exemplified with in-

sexual health is not always so well commupatients.2 Some of these barriers are lack of knowledge, embarrassment or taboo, fear of negative feedback, lack of angle or motive to initiate the talk, lack of time and suitable en-

verse psoriasis where the genitals may be di-

vironment, or lack of procedures and routines.

it painful to masturbate or have intercourse.

tion in a dermatological setting, the idea is to

ful boils, wounds, and fistulas with secretion

Quality Index (DLQI) questionnaire. All adult pa-

rectly affected by the disease and hence make

For people with hidradenitis suppurativa, pain-

in the genital region make wanting or having

sexual activities problematic. The same thing is

BestPractice Nordic / Dermatology / NO. 3 / 2022

To facilitate the assessment of sexual func-

standardize the use of the Dermatology Life

tients can receive the questionnaire when ad-

mitted to the dermatological ward. Nurses can

17


CONCLUSION: We can inform, guide, and help the patient to adopt positive coping strategies, and normalize sexual challenges. Skin disease or not, many of us cherish our looks as a central aspect of our sense of sexuality. Not all patients want to talk about their sexuality and that’s fine! However, we can open the door. Using the DLQI questionnaire in a multidisciplinary approach may help meet the patient’s needs and raise awareness of sexual health in dermatology. use the DLQI in the nursing assessment, and

strategies. In our experience, it may accelerate

tient’s Quality of Living (QoL) including sexu-

may be a support to our patients, such as a

the form provides information about the paality. Especially questions 2, 8, and 9 address this issue.

Question 2 investigates perceived embar-

rassment or self-consciousness, which may relate to the experience of stigma or shame

referral to other types of health personnel who psychiatric nurse or a social worker.

A key aspect is to talk through the form to-

gether with the patient after documenting the score of the DLQI questionnaire.

After handing out and collecting the form

from having the skin disease. Questions 8 and

routinely at admission, collect the score and

and/or problems with friends and sexual dif-

timeframe. You can say to the patient: “I have

9 address perceived problems with a partner ficulties.5 The qualitative and quantitative prop-

erties of the questionnaire are important for both the dermatological nurse and the dermatologist.

A systematic assessment of the patient’s

sexual health status gives us the opportunity

to support sexuality by normalizing, providing information, and facilitating positive coping

document it. Then give, let’s say a 15-minute 15 minutes. I want to hear more about your

quality of life, including your sexual life”. In this way, you have a natural way of assessing sexuality and QoL in a fair timeframe.

This article is based on my manuscript

from the talk “Addressing sexuality in

dermatologic nursing care” in nurse session 2 at the 35th NCDV 2022 in Copenhagen Friday April 22.

References: 1. Sampogna F, Abeni D, Gieler U, et al. Impairment of Sexual Life in 3,485 Dermatological Outpatients from a Multicentre Study in 13 European Countries. Acta Dermatovenereologica. 2017;97(4): 478-482. 2. Blikstad A, Falch- Koslung L,Tschudi-Madsen C. Samtaleverktøyet BETTER kan gjøre det lettere å snakke om seksualitet. (2020). Oslo: Sykepleien.no. 3. Dalgard F, Gieler U, Tomas- Aragones L. et al. The Psychological Burden of Skin Diseases: A Cross-Sectional Multicenter Study among Dermatological Out-Patients in 13 European Countries. J Invest Dermatol. 2015 Apr;135(4): 984-991. 4. Barisone M, Bagnasco A, Hayter M, et al. Dermatological diseases, sexuality and intimate relationships: A qualitative meta-synthesis. J Clin Nurs. 2020;29(17-18): 3136-3153. 5. Finlay, A Y, Khan G K. Dermatology Life Quality Index (DLQI)--a simple practical measure for routine clinical use.” Clin exp dermatolvol. 1994 May;19(3): 210-6.

CONFLICT OF INTEREST: The Norwegian Psoriasis and Eczema Association (PEF) collaborates with LMI.

18

BestPractice Nordic / Dermatology / NO. 3 / 2022


Interaction between hand eczema, HRQOL, and changed exposures for health care workers during the COVID-19 pandemic Studies on the prevalence of hand eczema during the pandemic found that more than one-third of health care workers reported hand eczema. But a 11-month follow-up study conducted during the COVID-19 pandemic with healthcare workers exposed to covid patients suggests that the links between changed exposures including hand hygiene procedures in patient care, and hand eczema are complex, and cannot be linked to a single factor. YASEMIN TOPAL YÜKSEL is MD and Ph.D. student at Department of

measures prohibiting the transmission of mi-

She is also a board member of The Group of Young Researchers.

use are also well-known risk factors for the

Dermato-Venerology at Bispebjerg Hospital, Copenhagen, Denmark.

Studies on the prevalence of hand eczema

during the pandemic found that more than one-third of health care workers reported hand eczema.1-5 Higher prevalence was reported in

studies on symptom-based hand eczema diagnosis.

croorganisms.8,9 But hand washings and glove development of hand eczema.

The use of alcohol-based hand rubs (ABHRs)

has not previously been considered a risk factor for skin barrier damage10; however, irrita-

tion of the skin as an effect of ABHRs applied on wet skin has recently been suggested.11,12

The enormous workload and fear of being

Suggested causes include the in-

infected with COVID-19 have affected the well-­

cohol-based hand rubs (ABHRs) during the

eczema is known to have a negative influ-

6,7

creased use of hand washings and use of alpandemic.

being of many healthcare workers.13,14 Hand ence on the health-related quality of life.15 In

This study from Denmark regarding hand

addition, occupational stress is anticipated

low-up study where health care workers re-

on health care workers with hand eczema dur-

eczema and exposures is a prospective fol-

sponded to a questionnaire at the beginning of the pandemic and again 11 months later.

The aim was to evaluate changes in the prev-

alence of hand eczema, wet work exposures, and quality of life in healthcare workers with hand eczema.

Participants were nurses, physicians, aux-

iliary nurses, biotechnicians, physiotherapists

to worsen life quality further. However, data ing the pandemic are limited.16,17

The change of exposures with and without hand eczema The study sought, among other things, to find differences in exposure between healthcare workers with and without hand eczema.

Figure 1A shows data from all healthcare

and midwives. More than half the target group

workers. It shows that the use of ABHRs on wet

posure to COVID-19 patients.

ly, increased more than it decreased during

were employed at departments with high ex-

Well-known risk factors for hand eczema Hand washings, the use of alcohol-based hand rubs, and gloves are important preventive

BestPractice Nordic / Dermatology / NO. 3 / 2022

skin and gloves on dry or wet skin, respective-

the pandemic, but the number of hand wash-

ings decreased more than it increased. The use of alcohol-based hand-rubs increased with the same magnitude as it decreased.

19


The increased use of alcohol-based hand rubs on wet skin and increased use of gloves (on dry and wet skin) in health care workers were associated with hand eczema during the pandemic.

Figure 1B shows data from healthcare work-

gesting an increasing prevalence of hand ec-

wet skin and gloves on dry or wet skin, respec-

ly decreasing prevalence during this period, how-

ers with hand eczema. The use of ABHRs on tively, increased more than it decreased during the pandemic. Hand washings, the use of

ABHRs, and nonoccupational wet work in-

creased with the same magnitude as they decreased.

Slightly decreasing prevalence of hand eczema The onset of hand eczema during the pandemic was more often reported by health-

zema during the pandemic, we found a slightever, an increasing severity of the hand eczema.

The increased use of alcohol-based hand rubs on wet skin and increased use of gloves in health

care workers with hand eczema may have had an impact on the worsening of the hand ec-

zema symptoms. Quality of life worsened slightly, with hand eczema severity and frequent flares

being risk factors for a reduced quality of life in healthcare workers with hand eczema.

The decrease in the prevalence during the

care workers with atopic dermatitis compared

study period likely reflects the change of expo-

no association between changed exposures

ber of hand washings may have contributed to

with those without atopic dermatitis. We found

and hand eczema at follow-up in healthcare workers with atopic dermatitis.

During this study, the prevalence of hand

eczema declined from 16.0% to 13.0% at the follow-up 11 months later. During this period, the

number of hand washings decreased, where-

sures reported in our study. The reduced numthe lower hand eczema prevalence since it is

a well-known risk factor for hand eczema.10,18 At the same time, the exposure to ABHRs on wet

skin increased markedly and was significant-

ly associated with hand eczema at follow up.

This is in alignment with an experimental study

as the use of ABHRs on wet skin increased sig-

indicating that alcohol-based hand rubs may

of gloves. The increased exposure to ABHRs on

on wet or moist skin,11 as opposed to findings

nificantly, together with an increase in the use wet skin was significantly associated with hand eczema.

Compared to other data, the prevalence of

hand eczema was 14.9% in German health-

care workers; however, the prevalence was between 29% and 33% in other European studies and up to 90.4% in Asian studies.3,5-7

Quality of life worsened slightly Despite the increased focus on intensive hand hygiene measures and several studies sug-

20

induce a skin barrier disruption when applied on ABHRs on dry skin.10 It can be anticipated that

the risk of applying ABHRs on wet skin increases with the increased use of ABHRs.

Reflects the recommendations given by health authorities The change in the exposures reflects the efficacy of hand-hygiene recommendations of the Danish health authorities, who recommend fewer hand washings and increased use of alcohol-based hand rubs.

BestPractice Nordic / Dermatology / NO. 3 / 2022


Figure 1 – The change of exposures in all health care workers with and without eczema. Figure 1 - Thehand change of exposures in all health care workers with and without hand eczema. Figure 1 - The change of exposures in all health care workers with and without hand eczema.

*

*

* *

*

*

* *

* *

Hand washing

ABHR use

ABHR on wet skin

Glove use

Gloves on wet skin

non-occupational wet skin

Hand washing

ABHR use

ABHR on wet skin

Glove use

Gloves on wet skin

non-occupational wet skin

Hand washing

ABHR use

*

*

*

*

*

*

ABHR on wet skin

Glove use

Gloves on wet skin

non-occupational wet skin

ABHR Hand Glove use ABHR use Gloves non-occupational A, Bar washing plot showing the change of exposures all HCWs on wetfrom skin baseline to follow-up oninwet skin wet skin (N = 795). The use of ABHRs on the wet skin and gloves on the dry and wet skin, respectively, increased more than it decreased during the pandemic. The number of hand washings A, Bar plot showing the change of exposures from baseline to follow-up in all HCWs decreased more than it increased. The use of ABHRs increased with the same magnitude as it (N = 795). The use of ABHRs on the wet skin and gloves on the dry and wet skin, respectively, decreased. Statistically significant difference in change of exposures between baseline and more than it decreased during from the pandemic. numberinofall hand washings A , increased Bar plot showing the change of exposures baseline toThe follow-up HCWs (N = 795). The use of ABHRs follow-up is marked with asterisk (Wilcoxon Signed Rank Test). more it on increased. The wet use skin, of ABHRs increased with the same magnitude as it ondecreased the wet skin andthan gloves the dry and respectively, increased more than decreased B, Bar plot showing the change of exposures from baseline to follow-up in HCWsitwith HE (Nduring = 93). the pandemic. TheStatistically number of hand washings decreased more than it increased. The use of ABHRs increased with the decreased. significant difference in change of exposures between baseline and The use of ABHRs on the wet skin and gloves on the dry and wet skin, respectively, increased more than it same magnitude as it decreased. Statistically significant in change of exposures between baseline and follow-up is marked with asterisk (Wilcoxon Signed difference Rank Test). decreased during the pandemic. Hand washings, the use of ABHRs, and nonoccupational wet work follow-up is marked with Signed Rank Test).to follow-up in HCWs with HE (N = 93). B, Bar plot showing theasterisk change(Wilcoxon of exposures from baseline increased with the same magnitude as they decreased. Statistically significant difference in B, Bar the of skin exposures from baseline to follow-up in HCWs with HE (N = 93). Themore use of ABHRs Theplot useshowing of ABHRs onchange the wet and gloves on the dry and wet skin, respectively, increased than it change of exposures between baseline and follow-up is marked with asterisk (Wilcoxon on decreased the wet skin and gloves on the dryHand and wet skin, respectively, increased more than it decreased during the pandemic. washings, the use of ABHRs, and nonoccupational wetduring work the Signed Rank Test). ABHR, Alcohol-based hand rub; HCW, health care worker; HE, hand eczema. pandemic. Hand use of ABHRs, and nonoccupational wet work increased with theinsame magnitude increased withwashings, the samethe magnitude as they decreased. Statistically significant difference as they decreased. Statistically significant in change of exposures between(Wilcoxon baseline and follow-up is change of exposures between baselinedifference and follow-up is marked with asterisk marked with asterisk Signed Rank Test). Alcohol-based rub;HE, HCW, health care worker; Signed Rank Test).(Wilcoxon ABHR, Alcohol-based hand ABHR, rub; HCW, health carehand worker; hand eczema. HE, hand eczema.

BestPractice Nordic / Dermatology / NO. 3 / 2022

21


CONCLUSION: Despite intense focus on hand hygiene during the pandemic, a slightly declining hand eczema prevalence was found in health care workers, but with a significant worsening of the hand eczema severity. We found a reduction in hand washings, but an increase in the use of ABHRs on wet skin and glove use, which was significantly associated with hand eczema. Our findings suggest that the interaction between hand eczema and changed exposures is quite complex and cannot be linked to a single factor. The prolonged use of gloves has previously

protective measures in relation to the pan-

and the slightly increased exposure

might have resulted in a behavioral change

been identified as a risk factor for hand eczema,

12,18

may have facilitated the skin barrier damage. The increased information campaigns on skin

demic, both in public media and in hospitals, in healthcare workers.19,20

ORIGINAL PUBLICATION: Yüksel YT, Nørreslet LB, MD, Meulengracht EF, Ebbehøj NE, Agner T. Hand eczema, wet work exposure, and quality of life in health care workers in Denmark during the COVID-19 pandemic. JAAD International. 2022;7: 86-94.

References: 1. Guertler A, Moellhoff N, Schenck TL, et al. Onset of occupational hand eczema among healthcare workers during the SARS-CoV-2 pandemic: comparing a single surgical site with a COVID-19 intensive care unit. Contact Dermatitis. 2020;83(2): 108-114. 2. Techasatian L, Thaowandee W, Chaiyarit J, et al. Hand hygiene habits and prevalence of hand eczema during the COVID-19 pandemic. J Prim Care Community Health. 2021;12: 21501327211018013. 3. Reinholz M, Kendziora B, Frey S, et al. Increased prevalence of irritant hand eczema in health care workers in a dermatolog-ical clinic due to increased hygiene measures during the SARS-CoV-2 pandemic. Eur J Dermatol. 2021;31(3): 392-395. 4. Erdem Y, Altunay IK, Aksu ¸Cerman A, et al. The risk of hand eczema in healthcare workers during the COVID-19 pandemic: do we need specific attention or prevention strategies?Contact Dermatitis. 2020;83(5): 422-423. 5. Hamnerius N, Pontén A, Bergendorff O, Bruze M, Bjök J, Svedman C. Skin exposures, hand eczema and facial skin disease in healthcare workers during the COVID-19 pandemic: a cross-sectional study. Acta Derm Venereol. 2021;101(9): adv00543. 6. Lan J, Song Z, Miao X, et al. Skin damage among health care workers managing coronavirus disease-2019. J Am Acad Dermatol. 2020;82(5): 1215-1216. 7. Lin P, Zhu S, Huang Y, et al. Adverse skin reactions among healthcare workers during the coronavirus disease 2019 outbreak: a survey in Wuhan and its surrounding regions. Br J Dermatol. 2020;183(1): 190-192. 8. Pittet D, Allegranzi B, Sax H, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis. 2006;6(10): 641-652. 9. Pittet D. WHO guidelines on hand hygiene in health care : a summary. World Heal Organ. 2009;30(1): 270. 10. Pedersen LK, Held E, Johansen JD, Agner T. Less skin irritation from alcohol-based disinfectant than from detergent used for hand disinfection. Br J Dermatol. 2005;153(6):1142-1146. 11. Plum F, Yüksel YT, Agner T, Nørreslet LB. Skin barrier function after repeated short-term application of alcohol-based hand rub following intervention with water immersion or occlusion 1. Contact Dermatitis. 2020;83(3): 215-219. 12. Yüksel YT, Ebbehøj NE, Agner T. An update on the prevalence and risk exposures associated with hand eczema in Danish hospital employees: a cross-sectional questionnaire-based study. Contact Dermatitis. 2022;86(2): 89-97. 13. An Y, Yang Y, Wang A, et al. Prevalence of depression and its impact on quality of life among frontline nurses in emergency departments during the COVID-19 outbreak. J Affect Disord. 2020;276: 312-315. 14. Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020;3(3): e203976. 15. Nørreslet LB, Agner T, Sørensen JA, Ebbehøj NE, Bonde JP, Fisker MH. Impact of hand eczema on quality of life: metropolitan versus non-metropolitan areas. Contact Dermatitis. 2018;78(5): 348-354. 16. Lee JY, Lee JY, Lee SH, et al. The experiences of health care workers during the COVID-19 pandemic in Korea: a qualitative study. J Korean Med Sci. 2021;36(23): e170. 17. Chernyshov PV, Kolodzinska L. Prospective study on hand dermatitis in nurses and doctors during COVID-19 pandemic and its improvement by use of adopted recommendations of the European Academy of Dermatology and Venereology Task Force on Contact Dermatitis. Dermatol Ther. 2020;33(6): e14396. 18. Hamnerius N, Svedman C, Bergendorff O, Björk J, Bruze M, Pontén A. Wet work exposure and hand eczema among healthcare workers: a cross-sectional study. Br J Dermatol. 2018;178(2): 452-461. 19. Take care of the teacher’s hands: best advice from the re-searchers. BUPL. Accessed September 9, 2021. 20. Children should use moisturizers and wash hands carefully. Statens Serum Institut. Accessed September 9, 2021. https://www.sst.dk/da/nyheder/2020/boern-boer-bruge-haandcreme-og-vaske-haenderne-skaansomt.

CONFLICT OF INTEREST: None.

22

BestPractice Nordic / Dermatology / NO. 3 / 2022


The role of patients in the development of Nordic dermatology How can we include the patient’s perspective in future dermatological treatment? Here is an update on hot topics in patient-centered treatment from the 35th NCDV Congress 2022 as seen from the patient’s perspective. LARS WERNER is Managing Director at the Danish Psoriasis Association

and it seems that it can be tempting some-

in the field of psoriasis.

we do see that the overall treatment result im-

and a long-term patient research partner and advisory board member

At the recent Nordic Congress of Dermatology and Venereology held in Copenhagen, Denmark

times to make consultations swift. However,

proves by implementing the practice (or philosophy, if you like) of concordance.

Both “compliance” and “adherence” focus

April 19-22, I was invited to give a small oral pres-

more on patient behavior regarding medica-

in the development of Nordic dermatology”.

lights the processes that underlie medica-

entation on the subject of “The role of patients I chose to focus on the recent development

in treatment options, the life quality aspect, and patient empowerment.

Concordance as guidance in treatment Certainly, within the area of psoriasis, the number of new treatments has increased significantly over the past 20 years. The biological

tion-taking. In contrast, “concordance” hightion-taking, such as an equal and effective

therapeutic relationship that supports the patient during the entire course of long-term treatment.

From a patient perspective, concordance

should be a standard operating procedure (SOP) in all corners of the health care system.

When it comes to communication between

Biomarker diagnostics personalizes treatment In years to come, patients may look forward

come a long way in achieving a mutually re-

tion that is driven by the implementation of

treatments have given hope to many patients. health care providers and patients, we have

spectful dialogue. The number of patients in

the dermatological field seems to be endless,

to a more personalized treatment/medica-

biomarker diagnostics on a much larger scale than is the case today (figure 1).

Figure 1 – Benefits of personalized medicine

Adapted from Bayer Healthcare, “Personalized Medicine”.

BestPractice Nordic / Dermatology / NO. 3 / 2022

23


Table 1 – Depression in patients with common skin diseases and controls Table 1. Depression in patients withconfidence common skin diseasesN and controls in percentages and ORs in percentages and ORs (95% interval) = 4,994 (95% confidence interval) N = 4,994 Diagnosis Psoriasis

Non-melanoma skin cancer Infections skin Eczema Acne

Depression clinical case HADS ≥ 11% (n)

3.23 (2.06-5.05)

3.02 (1.86-4.90)

8.9 (21)

0.001

2.59 (1.40-4.76)

2.65 (1.39-5.06)

0.007

10.1 (16)

<0.001

15.1 (21)

<0.001

4.3 (58)

4.8 (7)

Dermatological out-patients overall Controls

0.729

8.0 (18)

Benign skin tumors Leg ulcers

Adjusted OR2 depression clinical case HADS > 11

<0.001

4.8 (18)

Nevi

Hand eczema

Crude OR1 depression clinical case HADS > 11

13.8 (84)

5.7. (12) 6.0 (11)

Atopic eczema

P-value

24.3 (28) 10.1 (357)

1.21 (0.62-2.36)

1.79 (0.89-3.59)

0.97 (0.41-2.32)

1.68 (0.80-3.53)

0.311 0.215

1.53 (0.74-3.13) 2.05 (0.99-4.22)

0.587

1.50 (0.69-3.65)

1.43 (0.55-3.74)

<0.001 <0.001

11.23 (5.71-22.09) 2.69 (1.88-3.84)

10.217 (4.07-25.41) 2.40 (1.67-3.47)

3.55 (1.28-6.92)

4.85 (2.59-9.10)

1

1.74 (0.73-4.17) 2.14 (1.01-4.53)

3.27 (1.61-6.62)

4.00 (2.01-7.97)

1

Abbreviations:HADS, HADS,hospital hospitalanxiety anxiety and depression scale; MD, missing data; anxiety depression scale-depresAbbreviations: and depression scale; MD, missing data; OR, OR, oddsodds ratio.ratio. Missing data hospital 1 2 sion = 109 (patients 102; controls = 71).scale-depression Without participants with missing for one or more of the predictors. Regression model for each disease Missing data hospital=anxiety depression = 109 (patients = 102;data controls = 71). 1 separately, adjusting with for gender, status, stress, and co-morbidity. Adapted from: Dalgard FJ, Gieler U, Tomas-Aragones L, et al. Without participants missingage, datasocio-economic for one or more of the predictors. 2 The Psychological Skin Diseases: A adjusting Cross-Sectional Multicenter Study among Dermatological Out-Patients in 13 European Countries. Journal Regression model Burden for eachof disease separately, for gender, age, socio-economic status, stress, and co-morbidity. Invest Dermatol. 2015;135(4): 984–991. Table 3. L, et al. The Psychological Burden of Skin Diseases: A Cross-Sectional Multicenter Adapted from: Dalgard FJ, Gieler U, Tomas-Aragones Study among Dermatological Out-Patients in 13 European Countries. Journal Invest Dermatol. 2015;135(4): 984–991. Table 3.

Life Quality – Patient-reported outcome measures The psychological burden of skin diseases is

a psoriasis patient will also be asked ques-

with the esteemed professor Jemec as one Overall, 10.1% of dermatological patients were

Patient Empowerment I would also like to briefly touch upon the area of patient empowerment. WHO’s definition of

trols. And the numbers of depressed patients

which people gain greater control over deci-

well known. Here is the result of a 2015 study of the co-authors:

clinically depressed compared with 4.3% of con-

were higher for those with leg ulcers, hand eczema, and psoriasis, as measured on the HADS

tions related to how the skin disease affects the person’s daily life – his or her life quality.

patient empowerment is “A process through sions and actions affecting their health.”

As a patient organization, we know that many

score (Hospital Anxiety and Depression Scale).

patients want to learn more about their skin

aspects of skin diseases is Patient-Reported

Patient organizations in all the Nordic countries put

One tool that is very useful to capture all

Outcome Measures (PROM), which is a questionnaire capturing relevant issues for both

health care providers and patients. In 2022, we are implementing this tool for psoriasis in Denmark. This means that at least once a year,

disease, particularly how to control symptoms. a lot of resources to support this by developing: • Patient education – in print

• Patient education – face-to-face (e.g. patient schools)

• Patient education – virtual.

CONCLUSION: The next step toward more patient-centered treatments includes: A movement away from a narrow focus on compliance, and towards more concordance-based interaction. We also need development and implementation of biomarker diagnostics to supply precision medicine­-based treatments , and utilization of PROM to support patient empowerment. CONFLICT OF INTEREST: Se None. annonce side 29.

24

BestPractice Nordic / Dermatology / NO. 3 / 2022


NCDV 2022 MEDtalk Highlights This year BestPractice Nordic was present at the 35th NCDV congress, covering the latest news from der­ matology. On bpno.dk, bpno.no, and bpno.se some of the partici­pants share highlights from their research with MEDtalks covering a wide range of topics. In the follow­ing, we will present some of the highlights all available through our platform.

Ida Vittrup Nielsen, MD, Ph.D. Student, Department of Dermatology, Herlev and Gentofte Hospital, Denmark.

Academic achievements and atopic dermatitis It is well-known that AD is associated with school absenteeism and social problems. But a new substan-

PG could trigger the action of PAD

Adriana Caixinha took the audience through a case series and literature review on pyodermagangreno-

sum (PG) and peripheral arterial disease (PAD). Six out of seven of the patients had a poor outcome, ultimately requiring either bilateral or unilateral am-

tial study presented by Ida Vittrup Nielsen, gives many insights into the link between AD and academic achievement in both upper and lower secondary schools

and which groups are most affected. One of her fin-

dings is that children in lower secondary school have a higher risk of receiving special educational assistance.

putation, even though aggressive therapies were initiated in the early stages. The data suggest that the

presence of PAD is a risk factor for a poor prognosis of PG. The simultaneous presence of PG and PAD seems to aggravate the prognosis, resulting in amputation in a significant proportion of our patients.

Thus, screening and diagnosis of PAD in the clinical setting of PG are essential for the prognosis. However, the rapid development of severe PAD in patients with initial standard TBI could suggest that the pres-

ence of PG could trigger the action of PAD. More stud-

ies are required to optimize the management of this

complex subgroup of PG patients and to investigate a possible causality effect between PAD and PG.

Mattias Henning Dermatological Department, Zealand University Hospital, Roskilde.

COVID-19 lockdown affected the well-being of

dermatologic patients Mattias Henning presented his latest study on whether

the pandemic and the subsequent societal lockdown have affected different dermatoses sensitive to va-

rying degrees of stress. The results suggest that patients with hidradenitis suppurativa showed worse physical well-being during the pandemic; in contrast,

patients with hyperhidrosis experienced a worsened mental well-being and a higher risk of stress independent of the habitual HRQoL and stress. Adriana Caixinha, MD, Aarhus University Hospital.

BestPractice Nordic / Dermatology / NO. 3 / 2022

25


Do patients with hidradenitis suppurativa have an increased cancer incidence?

Rune Kjærsgaard Andersen presented a nationwide Danish study with data showing a 40% increased risk of cancer from multiple different organ systems within patients suffering from hidradenitis suppurativa.

This finding is important since the typical patients

with hidradenitis suppurativa are young women. In general, this demographic group is less likely to deElisabeth H. Taudorf, MD, Zealand University Hospital.

velop cancer however, this subset of patients with HS has an increased risk.

PDE-4 inhibitor treatment may improve perception

of illness in patients with HS Elisabeth H. Taudorf took a deep dive into a patient

case with severe hidradenitis suppurativa where the

patient was treated with a PDE-4 inhibitor. This phaseII study focused on reduced pain and increased qual-

ity of life following the treatment. After 57 days of treat-

ment, the study showed small indicators of improve-

ment, but more interesting was that the patient’s own experience of a reduced perception of illness, and pain index went from nine to six.

Rune Kjærsgaard Andersen MD, Ph.D., Dermatology department, Zealand University Hospital.

SII could be lower in patients treated with biologics Psoriasis is considered a systemic inflammatory disease. The systemic immune-inflammation index (SII),

based on peripheral blood, neutrophil, platelet, and

lymphocyte counts, has shown to be elevated in patients with psoriasis compared to healthy controls.

The results presented by Amanda Kvist-Hansen sugJesper Vraamark Elberling, Chief Physician, Clinical Associate Professor, Ph.D., Department of Dermatology and Allergy, Herlev and Gentofte Hospital.

gest that SII is lower for patients treated with biological treatments.

Understanding itching in dermatological disorders Itching is associated with most dermatological disorders and is a significant challenge in dermatolog-

ical practice. Chief physician Jesper Elberling shared his vast knowledge of itching and the definition of how we understand – and neurologically perceive – itching and why the brain picks up a reward effect when

we feel the need to scratch. He has high hopes for the

development of treatments since some of the latest treatments, both the biological and small molecule, already target the itch neuron and result in treatments

Amanda Kvist-Hansen, MD, Ph.D. student, Department of Allergy, Skin and Venereal Diseases, Herlev and Gentofte Hospital.

that can turn off the itching.

26

BestPractice Nordic / Dermatology / NO. 3 / 2022


læs pligttekst her s. 28

BestPractice Nordic / Dermatology / NO. 3 / 2022

27


Se annonce side 27.

28

BestPractice Nordic / Dermatology / NO. 3 / 2022


Proteomics in the dermatology of the future – inclusion of the skin proteome in clinical research and practice This article reviews current and future perspectives on the use of proteomics in a dermatological context. Proteomics refers to studies of the presence and physiological significance of proteins. This article focuses on mass spectrometry as an analysis method with great potential in both research and clinical practice. BJØRN KROMANN HANSEN is a doctor and Ph.D. student at the De-

as many proteins as possible in a single sam-

Hospital. Bjørn’s research focuses on mapping characteristic protein

its application in the dermatological context.

partment of Allergy, Skin, and Venereal Diseases at Herlev and Gentofte

compositions in inflammatory skin diseases, with a primary focus on

psoriasis. BEATRICE DYRING-ANDERSEN is a doctor and Ph.D. in der-

ple.2,3 This article focuses on this method and

matology. In addition, she is an associate professor at the Novo Nor-

The future of mass spectrometry research Until now, immunohistochemical and anti-

researcher in molecular protein signatures for inflammatory skin dis-

for identifying and quantifying proteins in clin-

disk Foundation Center for Protein Research. She is a group leader and eases, melanoma, and fungal infections.

Medical diagnosis and treatment have tra-

ditionally been based on a combination of the patient’s medical history and objective find-

body-based methods have been preferred ical practice and research. Although these

methods are reliable and validated, they have

certain limitations. The most important of these is that the methods only allow examination of relatively few selected proteins at a time.

With mass spectrometry, it is currently pos-

ings. In recent decades, biotechnological break-

sible to identify thousands of proteins and their

alized medical treatments tailored to the phys-

ple. The technology is constantly being improved.

throughs have opened the door to individuiology of each individual.

Developments in gene sequencing have made

it possible to involve the genome both diagnostically and therapeutically; the genome is a

stable foundation for an individual’s phy­siology and thus phenotypic expression. Because proteins are end-products of the genome and

perform all enzymatic processes, the proteome is an important part of the dynamic foundation of a phenotype. Thus, a complete overview

of the proteins will be necessary to obtain a

relative abundance in a single biological samAn important part of the development of this

technology is due to vastly expanded computer power, as large amounts of data are generated. The rapid development in the field has already

resulted in several clinical applications in mi-

crobiology, screening of newborns for congenital diseases, and urinary toxicology studies.4

In the future, mass spectrometric protein re-

search is expected to enable further findings

of biomarkers of importance for diagnosis, prog-

nosis, or treatment response. Furthermore, there

full understanding of the physiology.

is potential to identify the presence of patho-

teomics covers several interrelated areas, in-

could target. LC-MS / MS is used in studies for

An independent field of research called pro-

cluding studies of the total protein composition, the structure, function, and interactions

logical proteins that new drug candidates protein analysis of human skin.

Histology and immunohistochemical stain-

of the proteins. There are several methods to

ing are also used for proteins and other com-

material. Liquid chromatography-tandem mass

dermatology. Compared to modern prote­

study the composition of proteins in biological

spectrometry (LC-MS / MS) is frequently used to-

day because it is superior to other technologies in identifying and at the same time quantifying

BestPractice Nordic / Dermatology / NO. 3 / 2022

ponents as part of the diagnostic process in omics, however, it must be noted that only a limited sample of the total protein composition can be examined with these methods.

29


CONCLUSION: Mass spectrometric protein studies have already contributed to an increased understanding of physiological and pathological changes in the protein composition of the skin. The technology is becoming further accessible and is expected in the future to increasingly support clinical practice and research. Conversely, thousands of proteins can be iden-

conditions, including malignant melanoma,

trometry.

dermatitis.1

tified and quantified in the skin via mass specIn this connection, it is relevant to first know

chronic hand eczema, psoriasis and atopic

largest number of proteins found in healthy

Challenges and perspectives Today mass spectromtric protein research is considered to be a fast and robust method for examining protein compositions in very small amounts of tissues or even few cells. However, there are still challenges and areas where the technology can be further developed.

teins and proteins that have not previously

amount of data is generated, and this plac-

Data from this study are publicly available at

fact that mass spectrometry is suitable for ex-

Using proteomics, significant findings have

ically-fixed tissue samples opens the possi-

the proteome in healthy skin. In our research

group, we have used surplus skin from plastic surgery to characterize the proteome in four separate skin layers and four different cell

types that occur in the skin. In total, we have identified 10,700 different proteins, which is the

skin in a single study. Several unknown probeen associated with the skin were found.5 https://skin.science/.

also been made concerning the pathogene­ sis, diagnosis and/or prognosis for several skin

One of the challenges is that a very large

es great demands on computer power. The

amining the protein composition in histolog-

bility of making analyzes on skin collected in a

clinical context or from previous studies.

Figure 1 – Techniques for collecting skin samples With different techniques, it is possible to select which skin layers are to be examined. Mass spectrometric protein analysis can be performed on whole or selected skin layers. Cell fractions can be isolated via fluorescence cytometry or laser microscopy.

ORIGINAL PUBLICATION: Fredman G, Skov L, Mann M, Dyring-Andersen B. Towards Precision Dermatology: Emerging Role of Proteomic Analysis of the Skin. Dermatology. 2022; 238 (2): 185-194.

References: 1. Fredman G, Skov L, Mann M, Dyring-Andersen B. Towards Precision Dermatology: Emerging Role of Proteomic Analysis of the Skin. Dermatology. 2022;238(2): 185-194. 2. Aebersold R, Mann M. Mass-spectrometric exploration of proteome structure and function. Nature. 2016;537: 347-355. 3. Sinha A, Mann M. A beginner’s guide to mass spectrometry-based proteomics. Biochem (London). 2020;42(5): 64-69. 4. Sabbagh B, Mindt S, Neumaier M, Findeisen P. Clinical applications of MS-based protein quantification. Proteomics Clin Appl. 2016;10: 323-345. 5. Dyring-Andersen B, Løvendorf MB, Coscia F, et al. Spatially and cell-type resolved quantitative proteomic atlas of healthy human skin. Nat Commun. 2020;11(1): 5587.

CONFLICT OF INTEREST: None.

30

BestPractice Nordic / Dermatology / NO. 3 / 2022


Nail fold changes as a marker for psoriatic arthritis in psoriasis of the skin Patients with psoriatic arthritis may have decreased capillary density and blood flow as well as microbleeds in the nail fold. However, no single diagnostic capillary pattern could identify psoriatic arthritis. JØRGEN GULDBERG-MØLLER is a trained physiotherapist, doctor and PhD. He is employed as a ward doctor at Sjællands Universitetshospital in Køge as an ultrasound manager. He specializes in musculoskeletal diagnostic imaging and has a special interest in ultrasound. METTE MOGENSEN is a dermatologist. For more than 15 years, she has been working with the development of new advanced imaging diagnostics to detect skin diseases faster, easier, and more accurately by scanning the skin – in close collaboration with the Technical University of Denmark and leading international research groups.

She has a special focus on rapid diagnosis of breast cancer, but also imaging of autoimmune skin diseases and detection of vascular changes in the skin in patients with psoriasis and psoriatic arthritis, so-called nail fold capillaroscopy.

Up to 30% of patients with skin psoriasis (PsO)

tant to be aware of other factors that may help

riatic arthritis (PsA)1 with a time-lag of approx-

especially the occurrence of onycholysis (nail

later develop symptoms compatible with pso-

imately seven years. This delay provides a 2

unique opportunity for early detection in this

disease group already associated with highly specialized treatment for their skin disease

identify at-risk patients. Psoriatic nail changes, plate solution) and nail pitting (thimble dots),

are important prognostic markers for the development of arthritis in the outer joints.4

Against this background, nail fold capillaros-

by a dermatologist.

copy (NVK) by plain dermoscopy and optical

atic arthritis is of utmost importance, as a de-

tial to diagnose PsA, and to differentiate the

Alertness for early manifestations of psori-

lay in diagnosis of as little as six months may be associated with a lower treatment response.

3

An early intervention with anti-inflammatory drugs can significantly improve the clinical

coherence tomography (OCT) has the potendisease from PsO and even from osteoarthritis of the outer joints (OA), where differential diagnostic plays a role.

We aimed to assess the diagnostic pro­

and radiographic results. Dermatologists and

perties of NVK and OCT in patients with PsA

skin psoriasis are primarily responsible for as-

on capillary patterns at the nail bed.

general practitioners treating patients with sessing factors that could signal a transition

from primary skin disease to also include joint and tendon attachments.

Prognostic factors for disease development The onset symptom of PsA is rarely a swollen joint or a sausage finger. Therefore, it is impor-

compared to patients with PsO and OA based

Can patients with PsA be differentiated from patients with PsO and OA? We included 50 patients with PsA, 12 with PsO, and 13 with OA from rheumatology and der-

matological outpatient clinics in Zealand, a total of five centers.

Patients with PsA could be differentiated from patients with PsO and OA by significantly lower capillary density and blood flow assessed on OCT, and by the presence of microbleeds in the nail fold at NVK. BestPractice Nordic / Dermatology / NO. 3 / 2022

31


Figure 1: Qualitative NVK-morphology in patients with PsA,in PsO and OA with PsA, PsO and OA Figure 1 – Qualitative NVK-morphology patients

A: branched capillary arm in PsA. B: Extended capillaries in PsA. C: Implementing capillaries with microbleeds in PsA. A: branched capillary arm in PsA. B: Extended capillaries in PsA. C: Implementing capillaries with microbleeds in PsA. D: D: Microbleeds in PsA E: Glomerular and dilated capillaries in OA. F: Glomerular and dilated capillaries in PSO. Microbleeds in PsA E: Glomerular capillaries OA. F: Glomerular and dilated capillaries in PSO. G: Crossed / G: Crossed / meandering capillaries inand PsA. dilated H: Capillary branches in in OA. meandering capillaries in PsA. H: diameters Capillaryofbranches in OA. Definition: Extended capillaries have diameters of 20-50 mm. Definition: Extended capillaries have 20-50 mm

Table 1 – Distribution ofOCTA NVK and OCTA capillary morphology by PsA, PsO and OA Table 1: Distribution of NVK and capillary morphology by PsA, PsO and OA PsA (n=188)

PsO (n=42)

OA (n=48)

PsA vs PsO

PsA vs OA

Below mean capillary density, n (%)

95 (51 %)

14 (31 %)

24 (51 %)

P=0.019

P=1.000

Irregularly enlarged capillaries, n (%)

42 (22 %)

14 (33 %)

12 (25 %)

P=0.163

P=0.703

Giant capillary, n (%)

3 (2 %)

0

0

P=0.631

P=0.610

NVK ad modum EULAR

OCT

OCTA ad modum Cutolo

NVK ad modum Cutolo

NVK – rating

Microhaemorrhages, n (%)

24 (13 %)

3 (7 %)

1 (2 %)

P=0.429

P=0.034

Capillary ramifications, n (%)

27 (14 %)

10 (24 %)

14 (29 %)

P=0.162

P=0.020

Capillary disorganization, n (%)

84 (45 %)

24 (57 %)

23 (48 %)

P=0.172

P=0.746

OCTA – rating

PsA n=193

PsO n=48

OA n=52

PsA vs PsO

PsA vs OA

Below mean capillary density, n (%)

103 (53 %)

10 (21 %)

17 (33 %)

P<0.001

P=0.012

Irregularly enlarged capillaries, n (%)

66 (34 %)

27 (56 %)

10 (19 %)

p=0.005

P=0.062

Giant capillary, n (%)

0

0

0

-

-

Microhaemorrhages, n (%)

0

0

0

-

-

0

0

0

-

-

Capillary disorganization, n (%)

Capillary

ramifications, n (%)

108 (55 %)

22 (46 %)

25 (49 %)

P=0.263

P=0.529

Nail thickness*, mm., mean (SD)

0.62 (0.13)

0.73 (0.39)

0.59 (0.08)

p=0.876

P=0.020

P=0.052

P<0.001

OCTA blood flow

6.00

6.94

7.88

percentage, mean (SD)

(2.94)

(3.08)

(3.30)

Capillary morphology

PsA n=192

PsO n=48

OA n=52

PsA vs PsO

PsA vs OA

Tortuous/Crossed capillaries, n (%)

105 (55 %)

34 (71 %)

29 (56 %)

P=0.050

P=1.000

Ramified capillaries, n (%)

24 (13 %)

7 (15 %)

10 (19 %)

P=0.810

P=0.258

Microhaemorrhages, n (%)

32 (17 %)

3 (6 %)

4 (8 %)

P=0.106

P=0.125

Elongated capillaries, n (%)

11 (6 %)

2 (4 %)

2 (4 %)

P=0.747

P=0.741

Different capillary shapes, glomerular, n (%)

5 (3 %)

6 (13 %)

1 (2 %)

P=0.010

P=1.000

Enlarged capillary diameter, n (%)

33 (17 %)

10 (21 %)

9 (17 %)

P=0.674

P=1.000

Data presented as a percentage of the capillary findings within the group, unless otherwise indicated. Differences between PsA and the other groups are presented as a two-sided p-value p <0.05 is considered significant.

32

BestPractice Nordic / Dermatology / NO. 3 / 2022


CONCLUSION: Even though we identified several characteristic capillary features by NVK and OCT examination in the three patient groups, no single capillary pattern was associated with either increased or decreased likelihood of being diagnosed with PsA. Although patients with PsO showed the most

or a particular degree of blood flow that was

nail changes on clinical examination, patients

significantly associated with an increased or

with PsO and OA by significantly lower capil-

PsA.

with PsA could be differentiated from patients lary density and blood flow assessed on OCT

decreased likelihood of being diagnosed with From a clinical perspective, the results may

and by the presence of microbleeds in the nail

require greater collaboration between der-

Patients with PsO could be characterized

patient. With knowledge of common exami-

fold at NVK.

by a high incidence of crossed and glomer-

ular capillaries assessed on NVK and irregularly enlarged capillaries on OCT.

The OA group showed a significantly high-

er incidence of capillary branches on NVK,

which could perhaps be attributed to a high-

matologists and rheumatologists to benefit the

nation tools and a common understanding

of the significance of nail changes and arthritis in the outer joints in PsA, patients at risk can hopefully be identified earlier and avoid

permanent joint damage with early treatment.

A lower capillary density and low blood flow

er age in this group and is also seen in 47% of

by OCT examination and the presence of

Despite these differences in capillary mor-

ing questions for further research. Is there an

healthy individuals.5

phology between the three patient groups, we

could not identify a specific capillary pattern

micro­bleeds in patients with PsA raise excit-

expression of a higher inflammatory burden in PsA compared to PsO and OA?

ORIGINAL PUBLICATION: Guldberg-Møller J, Henriksen M, Ellegaard K et. al. Novel application of optical coherence

tomography and capillaroscopy in psoriatic arthritis concerning psoriasis and hand osteoarthritis. Rheumatol Adv Pract. 2021;5(3). DOI: 10.1093 / rap / rkab065.

References: 1. Ritchlin CT, Colbert RA, Gladman DD. Psoriatic arthritis. N Engl J Med. 2017;376(10): 957-970. 2. Tillett W, Charlton R, Nightingale A, et al. interval between the onset of psoriasis and psoriatic arthritis comparing the UK Clinical Practice Research Datalink with a hospital-based cohort. Rheumatol (Oxford). 2017;56(12): 2109-2113. 3. Haroon M, Gallagher P, FitzGerald O. Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis. Ann Rheum Dis. 2015;74(6): 1045-1050. 4. Love TJ, Gudjonsson JE, Valdimarsson H, Gudbjornsson B. Small joint involvement in psoriatic arthritis is associated with onycholysis: The Reykjavik psoriatic arthritis study. Scand J Rheumatol. 2010;39(4): 299-302. 5. Hoerth, Kundi, Katzenschlager, Hirschl. Qualitative and quantitative assessment of nailfold capillaries by capillaroscopy in healthy volunteers. Vasa. 2012;41(1): 19-26.

CONFLICT OF INTEREST: None. BestPractice Nordic / Dermatology / NO. 3 / 2022

33


Psoriasis Treatment Trajectory

34

BestPractice Nordic / Dermatology / NO. 3 / 2022


Environmental factors and autoimmune diseases – a hypothesis

The use of pesticides and chemicals may give us new insights and predictions about the human intestinal virome’s handling of chronic diseases, for example, COVID19, using cytochrome polymorphism as a measurement. HENRIK NIELSEN is a rheumatologist and specialist in internal medicine and rheumatology. He holds several research and advisory positions in rheumatology. His professional interests cover environmental issues, and he works to promote aware-

ness of the negative impact of pesticide use on autoimmune diseases. MERETE ENGELHART is a specialist in internal medi­ cine and rheumatology at Department of Rheumatology, Gentofte and Center for Rheumatology and Spine Diseases, Rigshospitalet, Denmark. Her research is focused on connective tissue diseases, Raynaud Phenomenon, and connective tissue lung diseases.

For many years, the dialogue involving rheu-

matic diseases has focused on triggers involv-

ing environmental factors combined with viral components in the body; the triggers reactivat-

ing the sleeping virus, also called “the human intestinal virome.” But the interplay is poorly

understood between environmental factors

and possible viral components. The use of pesticides, chemicals, and other factors may give

us new insights into chronic diseases, especially if these diseases arise at an earlier living age resulting in new manifestations.

Organophosphate pesticides Organophosphate pesticides (OPs) are among the most widely used synthetic chemicals for the control of a variety of pests. Reactive oxygen species (ROS) caused by OPs might be involved in one of several toxicities of various pesticides. Previous studies have demonstrated that

the reactivation of Epstein-Barr virus (EBV), la-

tent in the human body (>95%), could involve

oxidative stress. In one study, OPs were able

to reactivate EBV through ROS accumulation.

Data showed that OP (chlorpyriphos, abbrevi-

ated as CPF) induces oxidative stress, accom-

Studies have suggested OP compounds have an “immunotoxin” potential in human and non-target organisms, representing an unseen risk of escalating SARSCOV-2 pathology. BestPractice Nordic / Dermatology / NO. 3 / 2022

35


panied by an increase in ROS production, DNA

tive stress (OS) and increase the susceptibil-

damage, superoxide dismutase and catalase

ity to SARS-CoV-2 infection. Pesticides like or-

enhances the expression of BZLF-1.1

immunity, increasing mortality by infectious

activity. Moreover, CPF exposure significantly These results suggest that OPs could contribute

to the reactivation of the EBV lytic cycle through ROS induction, a process that may play an im-

portant role in the development of EBV-­associated diseases as well as other rheumatic diseases.

EBV is a well-known factor in the mechanism

in systemic lupus erythematosus (SLE) , tak2

ing part in the crosstalk between the entero­

virus. But reactivation of EBV because of pes-

ticide exposure in SLE has not been reported. A postulate that rheumatoid arthritis could

be an occupational disease has been open

for discussion in past years – but bigger pop3

ulation studies are needed to confirm this hypothesis.

OP compounds: “immunotoxin” potential in human and non-target organisms Due to the overuse of pesticides, OP-residues have contaminated drinking water, grains, vegetables, fruits, and other food items, and for many years this has provoked a global health concern about potential neurological disorders.4 These chemicals block the activity of

acetylcholine esterase at synapses, leading to a disproportionate accumulation of the neurotransmitter acetylcholine.

Moreover, recent investigations have linked

OPs to several biological responses mediating severe toxic outcomes. Studies have sug-

ganochlorines impair cellular and humoral

diseases8. This represents a new potential trigger with a badly understood mechanism.

Contact with environmental chemicals can result in clinical warning signals that arise ei-

ther later or acutely. For example, exposure to carbamates (OP) is followed by hypersensitivity reactions, inflammatory/chronic man-

ifestations, or cancers. Short-term exposure to atrazine, a widely used herbicide, can persist for a longer duration even after termination of the exposure.9

The agricultural uses of OP pesticides are

gaining in popularity, and they account for

more than 30% of global insecticide sales. The global market for sales of OP pesticides is ex-

pected to grow by a compound annual growth rate of 5.5% during the period 2018–2023.10

Unfortunately, in many developing coun-

tries, OPs are being used indiscriminately in ways that could further amplify unintentional exposure to these compounds.

Systemic lupus erythematosus The etiology of SLE is not well understood, but it is known that certain demographic groups are more affected than others. SLE is signifi-

cantly more common among women; approximately 90% of patients diagnosed with SLE are women.

The prevalence of SLE is also significantly

gested OP compounds have an “immunotox-

higher in African Americans compared to West

isms5, representing an unseen risk of esca-

increase of SLE in the urban population of Af-

in” potential in human and non-target organlating SARS-COV-2 pathology.

A major determinant of the biotransforma-

tion of OPs and other pesticides is our body’s

detoxification system, the cytochrome (CYP)

P450 gene families. Genetic polymorphism in

Africans. Previous data has shown a two-fold rican American adult women. This suggests

that environmental factors in western culture (e.g. OP or other factors) could play a key role in SLE pathogenesis in African Americans.11

As discussed, the decreased anti-viral de-

CYPs is known to alter metabolic pathways and

fense due to CYP polymorphism could further

phism has been considered to be an impor-

like OP affect different cultures disproportion-

induce false cellular response. CYP polymor-

tant risk factor for various pathological con-

ditions induced by chronic organochlorine ex-

posure.6 Racial disparity CYP polymorphism and mortality due to COVID-19 have been reported

support the hypothesis that external triggers ately. No data however has demonstrated a link

with CYP polymorphism indicating a possible genetic factor or COVID-19/EBV prevalence.

lation compared to other ethnic individuals.7

Environmental factors implicated in the development of SLE Over time, environmental factors that have

CYPs and OP exposure might induce oxida-

SLE include crystalline silica, cigarette smok-

in the United States, where the mortality rate is

3.6 times higher in the African-American popu-

The gene/environment interaction between

36

been implicated in the development of e.g.

BestPractice Nordic / Dermatology / NO. 3 / 2022


CONCLUSION: To summarize, we have limited understanding of whether diseases such as SLE or other manifestations (child adiposity,16 Gulf War illness (GWI),17 chronic fatigue syndrome18 …) present themselves at an earlier living age following exposure to environmental factors. Likewise, our understanding is limited as to whether environmental factors can alter the body’s natural defense mechanism – “the human intestinal virome” – so it will attack the body instead of defending it, thereby escalating SARS-COV-2 – pathogenicity. ing, environmental pollutants, infections, sex

hormones and other factors. Studies of (NZB 12

x NZW) F1 lupus-prone mice have pointed to

a role of chemicals (silica) in the pathogenesis of SLE and human smoking although 13

14

the evidence in human observational studies has been limited until now. Clear evidence has been missing for ethical reasons.

Further studies are needed to examine any

potential relationship between exposure to pesticides/chemicals via e.g. food intake and

CYP polymorphism as exemplified by the SLE model. Whether or not changes in the human

intestinal virome result in a defense or attack mechanism is just at the beginning of our understanding.15

References: 1. Zhao L, Xie F, Wang T-T, et al. Chlorpyrifos Induces the Expression of the Epstein-Barr Virus Lytic Cycle Activator BZLF-1 via Reactive Oxygen Species. Oxid Med Cell Longev. 2015;2015: 309125. DOI:10.1155/2015/309125. 2. Blank M, Shoenfeld Y, Perl A. Cross-talk of the environment with the host genome and the immune system through endogenous retroviruses in systemic lupus erythematosus. Lupus. 2009 Nov;18(13): 1136-1143. DOI:10.1177/0961203309345728. 3. Murphy D, Hutchinson D. Is Male Rheumatoid Arthritis an Occupational Disease? A Review. Open Rheumatol J. 2017 Jul 27;11: 88-105. DOI:10.2174/1874312901711010088. 4. Abou-Donia MB. Organophosphorus ester-induced chronic neurotoxicity. Arch Environ Health. 2003 Aug;58(8): 484-497. 5. Rajak P, Ganguly A, Sarkar S, et al. Immunotoxic role of organophosphates: An unseen risk escalating SARSCoV-2 pathogenicity. Food Chem Toxicol. 2021 Mar;149: 112007. DOI:10.1016/j.fct.2021.112007. 6. Docea AO, Vassilopoulou L, Fragou D, et al. CYP polymorphisms and pathological conditions related to chronic exposure to organochlorine pesticides. Toxicol Rep. 2017 May 26;4: 335-341. DOI:10.1016/j. toxrep.2017.05.007. 7. Parpia AS, Martinez I, El-Sayed AM, et al. Racial disparities in COVID-19 mortality across Michigan, United States. EClinicalMedicine. 2021 Feb 26;33: 100761. DOI:10.1016/j.eclinm.2021.100761. 8. Krzystyniak K, Tryphonas H, Fournier M. Approaches to the evaluation of chemical-induced immunotoxicity. Environ Health Perspect. 1995 Dec;103 Suppl 9(Suppl 9): 17-22. DOI:10.1289/ehp.95103s917. 9. Filipov NM, Pinchuk LM, Boyd BL, Crittenden PL. Immunotoxic effects of short-term atrazine exposure in young male C57BL/6 mice. Toxicol Sci. 2005 Aug;86(2): 324-332. DOI:10.1093/toxsci/kfi188. 10. Mordor Intelligence. Global organophosphate pesticide market – segmented by active ingredients, product type, application, and geography – growth, trends, COVID-19 impact, and forecasts (2021-2026). https://www.mordorintelligence.com/industry-reports/organophosphate-pesticides-market [Accessed 15.3.2022]. 11. Williams JN, Chang SC, Sinnette C, et al. Pesticide exposure and risk of systemic lupus erythematosus in an urban population of predominantly African-American women. Lupus. 2018 Nov;27(13): 2129-2134. DOI:10.1177/0961203318805844. 12. Barbhaiya M, Costenbader KH. Environmental exposures and the development of systemic lupus erythematosus. Curr Opin Rheumatol. 2016 Sep;28(5): 497-505. DOI:10.1097/BOR.0000000000000318. 13. Bates MA, Brandenberger C, Langohr I, et al. Silica Triggers Inflammation and Ectopic Lymphoid Neogenesis in the Lungs in Parallel with Accelerated Onset of Systemic Autoimmunity and Glomerulonephritis in the Lupus-Prone NZBWF1 Mouse. PLoS One. 2015 May 15;10(5): e0125481. DOI:10.1371/journal.pone.0125481. 14. Leffers HCB, Troldborg A, Voss A, et al. Smoking associates with distinct clinical phenotypes in patients with systemic lupus erythematosus: a nationwide Danish cross-sectional study. Lupus Sci Med. 2021 Apr;8(1): e000474. DOI:10.1136/lupus-2021-000474. 15. Carding SR, Hoyles ND. The human intestinal virome in health and disease. Aliment Pharmacol Ther. 2017 Nov;46(9): 800-815. DOI:10.1111/apt.14280. 16. Warner M, Ye M, Harley K, Kogut K, Bradman A, Eskenazi B. Prenatal DDT exposure and child adiposity at age 12: The CHAMACOS study. Environ Res. 2017 Nov;159: 606-612. DOI:10.1016/j.envres.2017.08.050. 17. Seth RK, Maqsood R, Mondal A, et al. Gut DNA Virome Diversity and Its Association with Host Bacteria Regulate Inflammatory Phenotype and Neuronal Immunotoxicity in Experimental Gulf War Illness. Viruses. 2019 Oct 21;11(10): 968. DOI:10.3390/v11100968. 18. Naviaux RK, Naviaux JC, Li K, et al. Metabolic features of chronic fatigue syndrome. Proc Natl Acad Sci USA. 2016 Sep 13;113(37): E5472-5480. DOI:10.1073/pnas.1607571113.

CONFLICT OF INTEREST: None. BestPractice Nordic / Dermatology / NO. 3 / 2022

37


FRI ADGANG TIL & MED JULI 2022

E-læringskursus om Atopisk Dermatitis

Dermatologisk behandling af moderat til svær eksem Få fri adgang til MEDucate-kurset: Dermatologisk behandling af moderat til svær eksem, der gennemgår standarderne og nye behandlingsmuligheder for patienter med atopisk dermatitis. Kurset er forankret i danske guidelines og udviklet i samarbejde med fagpersoner. Kurset består af både video, podcast, quizzer og korte artikler.

Du får et overblik over: • • • •

Patofysiologi og komorbiditet Traditionel systemisk behandling Behandlinger med biologiske lægemidler JAK-hæmmere Psykosociale konsekvenser af atopisk dermatitis

Kurset er udviklet i samarbejde med danske specialister:

Nikolaj Dyrberg Kristina Ibler

Overlæge, ph.d. Dermatologisk Afdeling, Universitetssygehus Sjælland, Roskilde

Uffe Nygaard

Læge, ph.d.-studerende, Afdeling for Allergi, Hud- og Kønssygdomme, Gentofte Hospital

Læge, ph.d., Afdeling for Hud- og Kønssygdomme, Aarhus Universitetshospital

Bent Deleuran

Line Brok Nørreslet

Kristina Ibler har været konsulent i relation til planlægning, udarbejdelse og faglig godkendelse af kurset – ligesom hun også selv medvirker i kurset.

Professor, Institut for Biomedicin – Forskning og uddannelse, Aarhus Universitetshospital

38

Ph.d.-studerende, Dermatologisk Afdeling, Bispebjerg Hospital

Tag kurset på www.bpno.dk/meducate BestPractice Nordic / Dermatology / NO. 3 / 2022


AD-quiz

Test dig selv – er du opdateret inden for AD? Biologisk behandling

Hvilket redskab bruges til at vurdere symptombelastningen ved AD?

Hvilket af disse cytokiner blokerer dupilumab?

A

POEM

A

IL-13

B

SCORAD

B

IL-4 og IL-13

C

EASI

C

IL- 5, IL- 13

D

PEASI

D

TNF-alfa

JAK-Hæmmere

Livskvalitet

Filaggrin-genet

Hvilket af nedenstående lægemidler er ikke en JAK-hæmmer?

Hvilken hudsygdom har størst negativ indflydelse på QOL?

Hvor hyppigt ser man mutationer ved moderat til svær AD?

A

Abrocitinib

A

Psoriasis

A

10%

B

Upadacitinib

B

AD

B

20%

C

Baricitinib

C

Acne

C

30%

D

Tralokinumab

D

Urticaria

D

40%

POEM IL-4 og IL-13 Tralokinumab AD 30% BestPractice Nordic / Dermatology / NO. 3 / 2022

A C D B C

Symptombelastning

39


The relationship between atopic dermatitis and exposure to antibiotics in early life The increased use of antibiotics has raised the question of their relationship to atopic dermatitis. This study investigated the antibiotic exposure among Swedish children during pregnancy and in the first year of life.

MWENYA MUBANGA is PhD and Postdoctoral researcher at

Department of Medical Epidemiology

and Biostatistics at

Karolinska Institutet in Sweden.

relationship between atopic dermatitis and com-

Theory of antibiotic exposure and risk of atopic dermatitis The challenges in conducting research that investigates the use of antibiotics, specifically in early childhood, include studying small sample sizes, the use of homogenous populations, failure to consider different types of antibiotics and insufficient

to antibiotics.

factors.

Atopic dermatitis is a persistent skin disease that commonly begins in childhood. It is characterized

by intense itching, eczematous and irritating dryness of the skin. Although a predisposition to at-

opic dermatitis may be inherited, there have been

inconsistent findings in studies investigating the mon environmental factors, including exposure

40

information about both maternal and childhood

BestPractice Nordic / Dermatology / NO. 3 / 2022


CONCLUSION: Our findings are interesting in view of the increased use of antibiotics around the world. Further understanding is needed as to how exactly antibiotics affect the pathways that activate the onset of atopic dermatitis. It has been suggested that the effect of antibiotics may vary depending on how antibiotics act on the skin, the gut, duration of use, their mode of action and route of administration. It may also be important to see if the use of multiple drugs at the same time has a different effect than single dosed agents.2

be used for research. The registers contain infor-

Exposure to antibiotics or environmental factors? In the total population which comprised more than 700,000 singleton children aged between 3 and 9 years, we found that exposure to antibiotics during pregnancy or the first year of life was associated with a higher risk of atopic dermatitis during early childhood. However, when we accounted for familial and other environmental factors by sibling analysis, we found that exposure to antibiotics in pregnancy was not associated with a greater risk of atopic dermatitis. However, exposure during the first year of life was still associated with a

residence, income, migration, prescribed medi-

Furthermore, when we consider the association

Against this background, we recently published a scientific article in JAMA network open1 using a

nationwide study to test the theory that the use of antibiotics during pregnancy or during the first

year of life is associated with an increased risk of atopic dermatitis.

We included all children born in Sweden be-

tween March 2006 and December 2012 and fol-

lowed them up to the study end of December 2015. This study is possible in Sweden because individual-level information on every resident is collected in centralized administrative registers that can

mation such as mother-child pairs, age, area of cations and health outcomes.

Additionally, we extended this investigation to

a smaller population of sibling-pairs that we iden-

tified via the birth registers. This was done in order to help us determine whether results obtained in the general population were related to environ-

mental and familial factors, including genetic pre-

moderate risk of atopic dermatitis.

of the number of doses prescribed to each mother during the study period, there was a greater risk

of atopic dermatitis in those who were prescribed

more doses than those with few ones. However, this was not observed when we accounted for familial and environmental factors.

disposition, or could be mainly attributed to antibiotic exposure.

References: 1. Mubanga M, Lundholm C, D’Onofrio BM, et al. Association of Early Life Exposure to Antibiotics With Risk of Atopic Dermatitis in Sweden. JAMA Netw Open. 2021;4(4): e215245-e45. DOI:10.1001/jamanetworkopen.2021.5245. 2. Grada A, Bunick CG. Spectrum of Antibiotic Activity and Its Relevance to the Microbiome. JAMA Netw Open. 2021;4(4): e215357. DOI:10.1001/jamanetworkopen.2021.5357.

CONFLICT OF INTEREST: None. BestPractice Nordic / Dermatology / NO. 3 / 2022

41


Low prevalence of patients diagnosed with psoriasis in Nuuk: a call for increased awareness of chronic skin disease in Greenland This study set out to estimate the age- and gender-specific prevalence of psoriasis in Nuuk, Greenland. No overall gender-specific difference in prevalence was observed. Further, the study showed a low prevalence of patients diagnosed with psoriasis in Nuuk. However, we speculate that the prevalence found in this study is underestimated, and further research should be conducted. SOFIA HEDVIG CHRISTENSEN BOTVID is MD, currently a Ph.D. student at

Greenland is the largest island in the world, with

lergy, Dermatology, and Venereology at Gentofte Hospital, Denmark.

by ice. Approximately 56,500 people live along the

National Research Center for Allergy as part of the Department of Al-

She has recently finished working as a doctor in Nuuk and Paamiut, Greenland, for 15 months. CARSTEN SAUER MIKKELSEN is MD and specialist in dermato-venereology. He is a private practitioner in Brønderslev and is part of the research unit at the Department of Dermatology, Aalborg University Hospital, Denmark.

85% of its 2.2 million square kilometers covered

ice-free coastline in Greenland, of which 19,261 live

in the capital, Nuuk. The majority of the population is of Greenlandic origin (90%). 10% are immi-

grants, mostly from Denmark, but also including 2.4% from the Philippines, Thailand, and Iceland.1

Psoriasis around the world Psoriasis is a multifactorial polygenic chronic, immune-mediated inflammatory skin disease characterized by the formation of sharply demarcated, scaly erythematous plaques.2 Psoriasis is estimated to affect 125 million people worldwide. In Europe, it is estimated that approximately 5 million people suffer from psoriasis, while 7 million people in the US have psoriasis.

In western countries, the prevalence of psoria-

sis is believed to be around 2–4%,3-5 while the highest prevalence of psoriasis is found in the Scandinavian population. In Denmark, approximately

2.2–2.8% of the population suffer from psoriasis.6,7

The self-reported lifetime prevalence of psoriasis in northern Norway increased from 4.8% in 1979–

1980 to 11.4% in 2007–2008, indicating an increased

awareness of the disease over the last 40 years.8 Due to difficulties in accurately identifying and

documenting the disease, psoriasis is believed to be underdiagnosed and undertreated in many countries around the world.5

Psoriasis in Inuit populations Very few studies describe the prevalence and incidence of psoriasis among Inuit populations.9-11 Higher prevalence rates have been reported at

42

BestPractice Nordic / Dermatology / NO. 3 / 2022


CONCLUSION: High prevalence rates of psoriasis have previously been reported among Inuit populations. However, this study found a low number of patients diagnosed with psoriasis in Nuuk, Greenland. Furthermore, no overall gender-specific difference was observed. Hence, we suggest that the prevalence found in this study is underestimated, and further research should be conducted. higher latitudes, and also in Caucasians compared

Results

est mention of psoriasis stems from a book from

(0.9%) were diagnosed with psoriasis in Nuuk, of

with other ethnic groups.12 In Greenland, the earli-

During the study period of 12 months, 175 patients

1940 based on observations done over 30 years

which 79 (45%) were females and 96 (55%) were

by a doctor.10 Here, a girl in 1912 was described

as having psoriasis. Furthermore, an epidemiological study from 1980 found a low incidence of

chronic diseases, including psoriasis, in the Uper-

navik district in northern Greenland in the years of

males. The prevalence of patients diagnosed with psoriasis in the adult population aged 20 years old

or more in Nuuk was 1.1%. No overall gender-specific difference in prevalence was observed.

Chronic diseases including diabetes, hyperten-

1950-1974.11 The current prevalence of psoriasis in

sion, and obstructive lung disease were observed

The objective of this study was to estimate the

psoriasis (28.6%) in Nuuk compared to controls

Greenland is unknown.

age- and gender-specific prevalence of psoria-

sis in Nuuk. Furthermore, we aimed to explore the

more frequently among patients with diagnosed (20.9%) (p < 0.05).

We found a low prevalence of patients with pso-

common risk factors and co-morbidities for pa-

riasis in Nuuk. We speculate that the prevalence

gender-matched control group. The study was

for an increased awareness of chronic skin dis-

tients with psoriasis compared to an age- and

designed as a cross-sectional case-control study based on national high-quality data from medical records and population registers in Nuuk, from

found in this study is underestimated. Thus, we call

ease in Nuuk, Greenland, particularly since chronic co-morbidity to psoriasis was common.

January 1, 2021, to January 1, 2022.

ORIGINAL PUBLICATION: Botvid SHC, Hove LS, Backe MB, Skovgaard N, Pedersen ML, Mikkelsen CS. Low prevalence of patients diagnosed with psoriasis in Nuuk: a call for increased awareness of chronic skin disease in Greenland, Int. Journal of Circumpolar Health. 2022.81:1. DOI: 10.1080/22423982.2022.2068111

References: 1. Grønlands Statistik. [Online]. [cited 6 Mar 2022]. Available from: https://stat.gl/default.asp?lang=da. 2. Parisi R, Symmons DPM, Griffiths CEM, et al. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol. 2013;133(2): 377–5. 3. Stern RS, Nijsten T, Feldman SR, et al. Psoriasis is common, carries a substantial burden even when not extensive, and is associated with widespread treatment dissatisfaction. J Investig Dermatol Symp Proc. 2004;9(2): 136–139. 4. Gelfand JM, Weinstein R, Porter SB, et al. Prevalence and treatment of psoriasis in the UK: a population-based study. Arch Dermatol. 2005;141(12): 1537–1541. 5. Kurd SK, Gelfand JM. The prevalence of previously diagnosed and undiagnosed psoriasis in US adults: results from NHANES 2003-2004. J Am Acad Dermatol. 2009;60(2): 218-224. 6. Lomholt G. Prevalence of skin diseases in a population: A census study from The Faroe Islands. Dan Med Bull. 1964; 11:1–7. 7. Egeberg A, Skov L, Gislason GH, et al. Incidence and prevalence of psoriasis in Denmark. Acta Derm Venereol. 2017;97(7): 808–812. 8. Danielsen K, Olsen AO, Wilsgaard T, et al. Is the prevalence of psoriasis increasing? A 30-year follow-up of a population-based cohort. Br J Dermatol. 2013 Jun;168(6): 1303-1310. 9. Harvald B. Genetic epidemiology of Greenland. Clin Genet. 1989;36(5): 364-367. 10. Connor WE. Effects of omega-3 fatty acids in hypertriglyceridemic states. Semin Thromb Hemost. 1988;14(3): 271-284. 11. Kromann N, Green A. Epidemiological studies in the Upernavik district, Greenland: incidence of some chronic diseases 1950–1974. Acta Med Scand. 1980;208(1–6): 401-406. 12. Farber EM, Nall ML. The natural history of psoriasis in 5,600 patients. Dermatology. 1974;148(1): 1-18.

CONFLICT OF INTERESTS: None. BestPractice Nordic / Dermatology / NO. 1 / 2022

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Pligtoplysninger/Forkortet produktresumé Taltz 80 mg injektionsvæske, opløsning i fyldt pen og i fyldt injektionssprøjte (ixekizumab) Indikationsområde: Plaque-psoriasis: Taltz er indiceret til behandling af moderat til svær plaque-psoriasis hos voksne, der er kandidater til systemisk behandling. Pædiatrisk plaque-psoriasis: Taltz er indiceret til behandling af moderat til svær plaque-psoriasis hos børn og unge fra 6 år med en vægt på mindst 25 kg, der er kandidater til systemisk behandling. Psoriasisartrit: Taltz, alene eller i kombination med methotrexat, er indiceret til behandling af aktiv psoriasisartrit hos voksne patienter, der ikke har responderet tilstrækkeligt på eller ikke tåler et eller flere sygdomsmodificerende antireumatiske lægemidler (DMARD) (se SPC pkt. 5.1). Aksial spondylartrit: Ankyloserende spondylitis (radiografisk aksial spondylartrit): Taltz er indiceret til behandling af aktiv ankyloserende spondylitis hos voksne patienter, der ikke har responderet tilstrækkeligt på konventionel behandling. Nonradiografisk aksial spondylartrit: Taltz er indiceret til behandling af aktiv nonradiografisk aksial spondylartrit hos voksne patienter med objektive tegn på inflammation indikeret ved forhøjet C-reaktivt protein (CRP) og/eller magnetisk resonans (MR) scanning, der ikke har responderet tilstrækkeligt på nonsteroide anti-inflammatoriske lægemidler (NSAID’er). Dosering: Taltz skal anvendes under vejledning og supervision af en læge med erfaring i diagnosticering og behandling af sygdomme, for hvilke Taltz er indiceret. Plaque-psoriasis hos voksne: Den anbefalede dosis er 160 mg som subkutan injektion (to injektioner a 80 mg) ved uge 0, efterfulgt af 80 mg (én injektion) ved uge 2, 4, 6, 8, 10 og 12 og herefter vedligeholdelsesdosis på 80 mg (én injektion) hver 4. uge. Pædiatrisk plaque-psoriasis (6 år og derover): Der foreligger ingen data for sikkerhed og virkning hos børn under 6 år (se SPC pkt. 5.1). Tilgængelige data understøtter ikke en dosering ved en vægt under 25 kg. Den anbefalede dosis givet ved subkutan injektion hos børn er baseret på følgende vægtkategorier: Barnets vægt: Højere end 50 kg, anbefalet startdosis (uge 0): 160 mg (to injektioner a 80 mg), og herefter anbefalet dosis hver 4. uge: 80 mg. Barnets vægt: 25 til 50 kg, anbefalet startdosis (uge 0): 80 mg, og herefter anbefalet dosis hver 4. uge: 40 mg. Psoriasisartrit: Den anbefalede dosis er 160 mg som subkutan injektion (to injektioner a 80 mg) ved uge 0 og herefter 80 mg (én injektion) hver 4. uge. For patienter med psoriasisartrit og samtidig moderat til svær plaque-psoriasis, er den anbefalede dosis den samme som for plaque-psoriasis. Aksial spondylartrit (radiografisk og nonradiografisk): Den anbefalede dosis er 160 mg (to injektioner a 80 mg) som subkutan injektion ved uge 0 og herefter 80 mg hver 4. uge (se SPC pkt. 5.1). For alle indikationer (plaque-psoriasis hos børn og voksne, psoriasisartrit, aksial spondylartrit) bør det overvejes at seponere behandlingen hos patienter, der ikke har vist respons efter 16 til 20 ugers behandling. Patienter med partielt respons initialt kan i visse tilfælde efterfølgende opnå bedring ved fortsat behandling ud over 20 uger. Pædiatrisk psoriasisartrit: Taltz’ sikkerhed og virkning hos børn og unge i alderen 2 år til under 18 år i behandlingen af psoriasisartrit (en kategori af juvenil idiopatisk artrit) er endnu ikke klarlagt. Der foreligger ingen data. Det er ikke relevant at anvende Taltz til børn under 2 år for indikationen psoriasisartrit.Taltz skal administreres som subkutan injektion. Bivirkninger: Meget almindelige (≥ 1/10): Infektion i øvre luftveje, reaktioner på injektionsstedet. Almindelige (≥ 1/100 til < 1/10): Tinea-infektion, Herpes Simplex (mukokutan), orofaryngeale smerter, kvalme. Ikke almindelig (≥ 1/1.000 til < 1/100): Influenza, rhinitis, oral candidiasis, konjunktivitis, cellulitis, neutropeni, trombocytopeni, angioødem, urticaria, udslæt, eksem, inflammatorisk tarmsygdom. Sjælden (1/10.000 til < 1/1.000): Anafylaksi. Kontraindikationer: Alvorlig overfølsomhed over for det aktive stof eller over for et eller flere af hjælpestofferne. Klinisk vigtige aktive infektioner (f.eks. aktiv tuberkulose, se nedenfor). Særlige advarsler og forsigtighedsregler: Behandling med Taltz er forbundet med en øget forekomst af infektioner, f.eks. infektion i øvre luftveje, oral candidiasis, konjunktivitis og tinea-infektioner. Taltz bør anvendes med forsigtighed hos patienter med en klinisk vigtig kronisk infektion eller en anamnese med tilbagevendende infektion. Patienter skal instrueres i at søge læge, hvis der opstår tegn eller symptomer, der tyder på en infektion. Hvis der udvikles en infektion, skal patienten overvåges nøje, og Taltz skal seponeres, hvis patienten ikke responderer på standardbehandling, eller hvis infektionen bliver alvorlig. Behandlingen med Taltz må ikke genoptages, før infektionen er i bedring. Taltz må ikke gives til patienter med aktiv tuberkulose (TB). Hos patienter med latent TB skal behandling mod TB overvejes, før behandling med Taltz indledes. Alvorlige overfølsomhedsreaktioner, herunder tilfælde af anafylaksi, angioødem, urticaria og i sjældne tilfælde sene (10-14 dage efter injektion) overfølsomhedsreaktioner inklusive udbredt urticaria, dyspnø og høje antistoftitre, er rapporteret. Hvis der opstår en alvorlig overfølsomhedsreaktion, skal administration af Taltz omgående ophøre og relevant behandling indledes. Inflammatorisk tarmsygdom (inklusive Chrons sygdom og colitis ulcerosa): Der er blevet rapporteret om tilfælde af nyopstået eller forværret inflammatorisk tarmsygdom hos patienter i behandling med Taltz (se SPC pkt. 4.8). Taltz anbefales ikke til patienter med inflammatorisk tarmsygdom. Hvis en patient udvikler tegn og symptomer på inflammatorisk tarmsygdom eller oplever forværring af en allerede eksisterende inflammatorisk tarmsygdom, skal Taltz seponeres og passende medicinsk behandling bør påbegyndes.Taltz bør ikke anvendes sideløbende med levende vacciner. Interaktion: Resultater fra et lægemiddelinteraktionsstudie hos patienter med moderat til svær psoriasis har vist at 12 ugers administration af ixekizumab i kombination med lægemidler som metaboliseres af CYP3A4 (dvs. midazolam), CYP2C9 (dvs. warfarin), CYP2C19 (dvs. omeprazol), CYP1A2 (dvs. koffein) eller CYP2D6 (dvs. dextromethorfan) ikke har en klinisk signifikant påvirkning på farmakokinetikken af disse lægemidler. Fertilitet, graviditet og amning: Fertile kvinder skal anvende sikker kontraception under behandlingen og i mindst 10 uger efter endt behandling. Som en sikkerhedsforanstaltning bør behandling med Taltz undgås under graviditet. Det skal besluttes, om amning skal ophøre eller behandling med Taltz seponeres, idet der tages højde for fordelene ved amning for barnet i forhold til de terapeutiske fordele for moderen. Virkningen af ixekizumab på fertiliteten hos mennesker er ikke blevet undersøgt. Dyrestudier indikerer hverken direkte eller indirekte skadelige virkninger, hvad angår fertilitet. Overdosering: Doser på op til 180 mg er blevet administreret subkutant i kliniske studier uden dosisbegrænsende toksicitet. I tilfælde af overdosering anbefales det, at patienten monitoreres for tegn eller symptomer på bivirkninger, og at relevant symptomatisk behandling omgående indledes. Lægemiddelformer: Injektionsvæske, opløsning i fyldt injektionssprøjte og i fyldt pen. Pakningsstørrelser og priser: Styrke Pakning 80 mg 1 fyldt pen 80 mg 1 fyldt injektionssprøjte For dagsaktuel pris henvises til medicinpriser.dk Udleveringsgruppe: BEGR Tilskudsstatus: Ingen Indehaver af markedsføringstilladelsen: Eli Lilly and Company (Ireland) Limited, Dunderrow, Kinsale, Co. Cork, Irland.

Produktresumeet er omskrevet og forkortet i henhold til det produktresumé, som er godkendt af det Europæiske Lægemiddelagentur. Det fuldstændige produktresumé kan vederlagsfrit rekvireres hos Eli Lilly Danmark A/S, Lyskær 3E, 2. tv., 2730 Herlev. Telefon: 45 26 60 00. Se annonce side 2.

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