The Chronicle of Skin & Allergy - August

HS Adalimumab treatment improves HS QoL measures

Psoriasis Tx update

◼ New options for treating psoriasis, fewer injections

to needle-phobic patients

Ixekizumab shows clearance of PsO, PsA

Up to 30% of PsO patients

by JOHN EVANS, Senior Editor, The Chronicle

In a head-to-head study, pa tients with both psoriatic arthritis (PsA) and moderateto-severe psoriasis (PsO) had bet ter simultaneous improvement of their joint and skin disease after 52 weeks when treated with ixek izumab compared to those treated with adalimumab.

These findings come from a study of data from the SPIRIT-H2H trial and were published in Derma tology Practical & Conceptual (Apr.

Estimating

1, 2022; 12(2):e2022104).

by JOHN EVANS, Senior Editor, The Chronicle

Treatment with adali mumab meaningfully im proved health-related quality of life measures (HRQoL), work productivity, and activity im pairment in patients with moderateto-severe hidradenitis suppurativa (HS), findings from a 52-week realworld study show.

These results were published online in the Journal of Cutaneous Medicine and Surgery (Mar. 24, 2022; 12034754221088584).

satisfaction

The study’s authors note that as many as 30% of patients with PsO will develop PsA, increasing disease burden and reduc ing quality of life (QoL). Therefore, successfully treat ing both skin and joint symptoms is important to opti mally improve health-related QoL in patients with both conditions, they write.

“If there is a treatment that can help manage both conditions more effectively, many patients are going to want that option,” said the study’s senior author Dr. Melinda Gooderham in an interview with THE CHRONICLE OF SKIN & ALLERGY

Dr. Melinda Gooderham

surgery scar outcomes

by JEREMY VISSER, Assistant Editor, The Chronicle

Researchers have determined that patients who undergo Mohs micrographic surgery (MMS) for facial skin cancer have unrealistic expectations for scar outcomes. The crosssectional study, which was published online in JAMA Network Open (Mar. 11, 2020), was performed at the University of Pennsylvania in Philadelphia.

Dr. Gooderham is the Medical Director at the SKiN Centre for Der matology and the Principal Investi gator for the SKiN Research Centre in Peterborough, Ont. Biologic outcomes compared The SPIRIT-H2H study was a 52week, multicenter, randomized, open-label, assessor-blinded, paral

Dermatologists recognize that HS can have a profound impact on patient HRQoL, said the study’s lead author Dr. Wayne Gulliver in an in terview with THE CHRONICLE OF SKIN & ALLERGY. However, while studies have investigated how treatment of HS can impact scores on the Der matology Life Qual ity Index (DLQI) there has been lit tle study of the im pact of HS on work productivity, sexual health or similar as pects of patient life, he said.

Dr. Wayne Gulliver

Dr. Gulliver is a Professor of Medicine at Memorial University in St. John's, NL, and has been in prac tice as a dermatologist for more

More treatments for HS expected to continue to develop

Tough on Dirt, Mild on Skin

perceptions, their correlation to de mographics, and AK/skin cancer history and how this influences sun screen use. . . . . . . . . . . . . . . . . . .23

Research Melanoma rates rising in Canada

A new study from McGill University in Montreal shows that the inci dence of melanoma is increasing in southern and coastal areas of Canada. However, the researchers also note although more cases have been diagnosed, mortality rates are on the decrease for the first time since 2013, likely due to new, tar geted immunotherapy treatments.

According to the report pub Frontiers in Medicine, Prince Edward Island and Nova Sco tia had the highest incidence rates of melanoma in the country, even after adjusting for other factors such as age. Rates in New Brunswick, Ontario, and British Columbia were also high but comparable to the na tional average of 20.75 cases per 100,000 people per year. The prairie provinces and Newfoundland and

Labrador had lower rates than the Canadian average.

The authors found that melanoma incidence was higher in males (54%) than females (46%), al though acral lentiginous melanoma was more frequent in women. For men, skin cancer was more com mon on the trunk and in the head and neck areas. For women, it was more common in the legs and arms. Rates of melanoma were also higher in people over the age of 60 years. Melanoma rates are likely to increase with climate change and the thinning of the Earth’s ozone layer, said lead author Dr. Ivan Litvi nov. He stressed the importance of public education campaigns that target people living in high-risk geo graphic areas. These campaigns should also target men and women differently.

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A M Message from the Medical Editor

In this issue of THE CHRONICLE OF SKIN & ALLERGY, we again bring to your attention the need for improved dermatological care for Indigenous people.

In the last issue, we reported on Dr. Dana Slape’s pres entation at the 2nd Indigenous Skin Spectrum Summit, where Dr. Slape, the first Indigenous der matologist in Australia, described the poor care available in that coun try’s jails.

In this issue, we highlight In digenous dermatology care in Canada and the research of Dr. Rachel Netahe Asiniwasis, the Regina dermatologist. She reports on the many barriers to high-quality dermatological care, including no access to clean water, the high cost of transportation, long wait times, and cultural barriers, just to name a few.

In the report that begins on page 14, Dr. Asiniwasis also high lights some of the research she has conducted with her colleagues which includes the prevalence of skin disorders in the Indigenous communities of Saskatchewan, where atopic dermatitis is com

Please

to

Dr. Lauren Lam, a dermatologist at Beacon Dermatology, Calgary (see page 4)

Wayne Gulliver, MD, FRCPC Editor, Cosmetic Dermatology

Medical Editor

John P. Arlette, MD, FRCPC

Benjamin Barankin, MD, FRCPC

Marc Bourcier, MD, FRCPC

Eric Goldstein, MD, FRCPC

Peter Hull, MD, FRCPC

Richard Langley, MD, FRCPC

Danielle Marcoux, MD, FRCPC

R.A.W. Miller, MD, FRCPC

Sheldon V. Pollack, MD, FRCPC

H. Eileen Murray, MD, FRCPC

Kim Papp, MD, FRCPC

Yves Poulin, MD, FRCPC

Melanie D. Pratt, MD, FRCPC

Denis Sasseville, MD, FRCPC

Jerry Tan, MD, FRCPC

Ronald B. Vender, MD, FRCPC

Founding Editor Colin A. Ramsay, MD, FRCPC (1936-2003)

Publisher Mitchell Shannon

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“In our [dermatologists’] minds, what is important is longevity of the medication. But in the patient's mind, they just want to get clear as soon as possible ”

s Resources of The Chronicle

Client Engagment Cristela Tello Ruiz

Clinical update N e w o p t i o n s f o r t r e a t i n g p s o r i a s i s

might

by LOUISE GAGNON, Correspondent, The Chronicle

to needle-phobic patients, dermatologist says

The approval of IL-17 inhibitor bimek izumab, the availability of IL-23 in hibitor tildrakizumab, and the emergence of nonsteroidal topical therapies, as well as self-reported pa tient data suggesting even mild psoriasis has an ad verse impact on quality of life, are all developments that are top of mind for Canadian dermatologists.

“It [bimekizumab] offers very high efficacy,” said Dr. Irina Turchin, assistant professor in the Division of Clinical Dermatology & Cutaneous Science, Department of Medicine, Dalhousie University in Halifax and a dermatology consultant for Horizon Health Network in Fredericton, N.B. “It was superior in skin clearance on PASI 90 and PASI 100 [Psoriasis Area & Severity Index] compared to

placebo, adalimumab, and secuk inumab at Week 16.”

Dr. Lauren Lam, a dermatologist at Beacon Derma tology in Calgary and a clinical lec turer at the Univer sity of Alberta in Edmonton, agreed the new biologic agent, approved by Health Canada ear lier this year, repre sents a major advance in psoriasis management.

improvement even when off treat ment.

Dr. Irina Turchin Dr. Ashley O’Toole

“It will be a major player in the field,” said Dr. O’ Toole, who was in volved in bimekizumab clini cal trials. “When the trial ended, a lot of patients maintained clear or almost clear skin, even though they were not re ceiving the drug. That was impressive to see.”

“[Bimek izumab] works re ally quickly and works really well,” said Dr. Lam. “It’s an excellent choice for patients who have failed other biologics, and it’s a good choice for patients who have a really high [disease] burden.”

Dr. Lauren Lam

Dr. Ashley O’Toole, a dermatolo gist at the Skin Centre for Dermatol ogy in Peterborough, Ont., and adjunct professor at Queens Univer sity in Kingston, Ont., noted that pa tients in the trial sustained

Newest IL-23 offers convenient dosing Tildrakizumab, an anti-IL-23 biologic agent, is the newest in that class in dermatology in Canada. Data from pooled analyses of two randomized phase III clinical trials (reSURFACE 1 and reSURFACE 2) through 148 weeks showed that at week 148, 72.6%, 53.8%, and 28.9% of tildrak izumab 100 mg responders and 80.2%, 59.9% and 32.6% of tildrak izumab 200 mg responders, had PASI 75, 90 and 100 responses, respec tively (Br J Dermatol 2020 Mar; 182(3):605–617).

cutaneous signs

For more information:

symptoms

The Product Monograph

also available by

New Tx: Topical agents are demonstrating efficacy

“It has shown efficacy in PASI scores and an improvement in quality of life similar to other agents in the class,” said Dr. O’Toole. “What is unique about tildrakizumab is the low number of needles. In fact, after two starter doses, patients receive 4 yearly doses. That is what sets it apart. It’s good for a needle-phobic patient who wants the lowest number of injections.”

Topical agents of interest Dr. Turchin pointed out some topical agents, such as tapinarof, are demonstrating impressive efficacy in the management of psoriasis. “It is the first agent in its class,” said Dr Turchin. “It is an aryl hydrocar bon receptor (AhR)-modulating agent. It is some thing that we have not had before.”

In one 12-week clinical trial, the physician’s global assessment (PGA) response occurred in 35.4% of the patients in the tapinarof group but in 6% of those in the vehicle group. In the second trial, there was a 40.2% PGA response to tapinarof and a 6.3% response to vehicle. There were sta tistically significant differences in both trials be tween vehicle and tapinarof.

“It’s a big advantage that it is non-steroidal,” said Dr. Turchin. “The patients did really well at Week 12 and entered an extension trial. What is interesting is that when patients were taken off treatment, it took four months for psoriasis to re turn. It is exciting that you could have patients off treatment for as long as four months.”

Another topical therapy, the phosphodi

esterase-4 (PDE-4) inhibitor roflumilast, also demonstrated impressive efficacy. “There was significant improvement in pruritis, and it also worked really well in [skin] folds,” noted Dr. Turchin.

Investigators observed significant improve ments in the roflumilast arm for secondary end points, including Intertriginous-Investigator Global Assessment Success (69.7% vs. 16.1%; p<0.01), PASI-75 (40.3% vs. 6.5%; p<0.0001), and Worst Itching Intensity Numerical Rating Scale (WI-NRS) (68.5% vs. 31.3%; p<0.0001).

Treating special sites

Special sites with psoriasis, such as the nails, scalp, palms, soles, and genitalia, can be chal lenging to manage, noted the dermatologists.

“Special sites can be difficult to treat,” said Dr. O’Toole. “For these sites, we often need to use systemic agents such as biologics or small molecules. As many of the newer biologics offer impressive PASI scores, they are all fairly effective at clearing these more difficult areas to treat.”

Dr. Lam agreed that psoriasis localized to special sites can be a particular challenge. “Usu ally, it is more difficult to clear [a patient affected in special sites] than someone who has a lot of psoriasis on the body,” said Dr. Lam. “I have seen some really great success with biologics for spe cial sites. There are some medications where there are data supporting their use for special sites, such as apremilast for the scalp and nails.”

Data from the ADVANCE trial, where investi

gators examined improvement in psoriasis symp toms in special sites, suggested there were de creases in itch and enhanced quality of life at 16 weeks and at 32 weeks with apremilast.

Patient perceptions of psoriasis

A paper published earlier this year offered in sights into the UPLIFT survey, a population-based survey aimed at obtaining perceptions of patients who have psoriasis and treatment-related out comes (Dermatol Ther (Heidelb) 2022; 12:61–78).

The survey suggested there may be a disparity between dermatologists who treat the condition and patients who live with the condition. The sur vey noted differing responses to questions about how bothersome psoriasis is, how much it affects quality of life, and how effective treatment is.

“In our [dermatologists’] minds, what is im portant is longevity of the medication,” said Dr. Lam. “But in the patient's mind, they just want to get clear as soon as possible. Something else that patients care about is how many needles are re quired and whether treatment is one injection or two injections. That may not be something der matologists think about. I think that, overall, our end goals for treatment are the same.”

Non-proprietary and brand names of therapies: bimekizumab (Bimzelx, UCB); tildrakizumab (Ilumya, Sun Pharma); adalimumab (Humira, Ab bVie); secukinumab (Cosentyx, Novartis); tap inarof (not approved in Canada); roflumilast (not approved in Canada); apremilast (Otezla, Amgen)

What T THE LAY PRESS is saying about . . .

THE PARTICULARS OF BUTT ACNE

An article published in Cosmopoli tan (June 02, 2022) summarized some expert advice on how patients can quickly rid themselves of but tock acne. It is possible to have clas sic acne on the derriere, but these breakouts tend to be other skin con ditions such as folliculitis, hidradeni tis suppurativa, or keratosis pilaris masquerading as acne. Consulting a dermatologist before attempting any treatment is recommended. The magazine consulted with four specialists to break down every type of “butt acne” and the best treat ments. Aside from seeing a special ist, the physicians recommend using exfoliants, benzoyl peroxide or salicylic acid body washes, taking showers right after sweating, and wearing light fabrics to reduce irri tation.

Dermatology

I ISOTRETINOIN USERS IN THE U.S. “TERRIFIED ” IN THE WAKE OF ROE V. WADE REVERSAL

According to an article published in Yahoo Lifestyle (July 8, 2022), women across the U.S. fear that the Roe v. Wade reversal might affect their access to birth control and medications such as isotretinoin, which is teratogenic. For this reason, many users are expressing concerns about accidentally getting pregnant while on an isotretinoin regimen and not having access to abortion care. After the recent U.S. Supreme Court ruling, isotretinoin users took to Red dit, questioning their protection and wondering how physicians can ethi cally prescribe this teratogenic med ication in states where abortion is not available. Users are also wonder ing if isotretinoin could be banned due to its potentially abortion-induc ing effect.

may be

W WHY C AN’T SOME PEOPLE GROW THEIR HAIR PAST A CERTAIN LENGTH?

A column published in The Toronto Star (July 22, 2022) contained com ments from a dermatologist and a hair stylist on the reasons hair might not grow long and strong. Ac cording to Dr. Jeff Donovan, medical director at Donovan Hair Clinic in Whistler, B.C., there are 45 potential causes for hair loss, including med ication side effects, conditions such as alopecia and general aging. He also says that the scalp’s health af fects how hair grows and that seb orrheic dermatitis, dandruff, and psoriasis can all affect the growth of hair to some degree. He recom mends seeing a dermatologist if sig nificant hair loss is experienced. The column explains that other fac tors such as diet, constant exposure to heat, and stress can also con tribute to hair loss.

AT-HOME SOLUTIONS TO FOUR COMMON SKIN CONCERNS

In addition to visiting a dermatologist, at-home skin care can control skin is sues and maintain healthy skin. An article published in People Magazine (May 2, 2022) consulted three derma tologists and developed a list of tips for at-home care for three common skin conditions: adult acne, eczema, and psoriasis. According to the arti cle, everyday skincare, including cleansers and moisturizers, should be gentle to effectively treat acne. For eczema and psoriasis, moisturizers that are hypoallergenic, fragrancefree, and made with ingredients such as urea and ceramides are recom mended. Also, essential oils can re duce redness and improve circulation and reduce scarring. Fi nally, the three experts recommend that psoriasis patients wear mineral sunscreen daily to reduce inflamma tion, and to watch out for other trig gers like smoking, emotional stress, and diet.

Improvements in the Dermatology

baseline were observed

with

Week

Quality

patients

TREMFYA

(47/62) of patients achieved PASI 90 at Week 16 with

vs. 0% (0/16) with placebo (co-primary endpoint, p <0.001)

50% (31/62) of patients achieved PASI 100 at Week 16 with TREMFYA ONE-PRESS ® vs. 0% (0/16) with placebo (secondary endpoint, p <0.001)

Indications and clinical use:

TREMFYA®/TREMFYA ONE-PRESS® (guselkumab injection) is indicated for the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

TREMFYA®/TREMFYA ONE-PRESS® is also indicated for the treatment of adult patients with active psoriatic arthritis. TREMFYA®/TREMFYA ONE-PRESS® can be used alone or in combination with a conventional disease-modifying antirheumatic drug (cDMARD) (e.g., methotrexate).

Relevant warnings and precautions:

• Do not initiate treatment in patients with any clinically important active infections until the infection resolves or is adequately treated

• Discontinue treatment if patient develops a serious infection or is not responding to standard therapy for infection

• Evaluate patients for tuberculosis infection prior to therapy and monitor for active tuberculosis during and after treatment

• Consider completion of all immunizations prior to treatment

• Concurrent use with live vaccines is not recommended

• Discontinue treatment in cases of serious hypersensitivity reactions, including anaphylaxis, urticaria and dyspnea, and institute appropriate therapy

• Women of childbearing potential should use adequate contraception

• Use during pregnancy only if clearly needed

• The benefits of breastfeeding should be considered along with the mother’s clinical needs

• Effect on human fertility

not been

and efficacy in pediatric patients

patients

For more information:

not been

years of age

consult the Product Monograph at www.janssen.com/canada/products for important

regarding adverse reactions, drug interactions, and dosing and administration

has not been discussed in this piece.

Product Monograph is also available by calling

Study : Psoriatic arthritis patients may have a higher inflammatory burden

lel-group study that evaluated the effi cacy and safety of ixekizumab versus adalimumab in biologic-naïve patients. For this paper, participants had active PsA and PsO and had not adequately responded to conventional non-bio logic systemic medications. The pa tients were 18 years of age or older, had a confirmed diagnosis of PsA for six months or longer and 3% or more of their body surface involved with PsO.

Participants were randomized evenly into ixekizumab and adali mumab treatment groups. For those in the ixekizumab group, the initial dose at week zero was 160 mg, fol lowed by 80 mg every two weeks from week two to week 12. After week 12, the 80 mg dose was deliv ered every four weeks.

For the adalimumab group, the initial dose was 80 mg, which was then followed by 40 mg every two weeks starting at week one.

Investigators compared the effi cacy and safety of ixekizumab and adalimumab in patients with PsA and moderate-to-severe PsO through 52 weeks of treatment. They evaluated the number of patients who achieved American College of Rheumatology (ACR) 50 scores and Psoriasis Area and Severity Index (PASI) 100, 90, or 75 responses at week 52. Researchers also evaluated Dermatology Life Qual ity Index (DLQI), Itch NRS scores and Nail Psoriasis Severity Index.

More frequent simultaneous clearance with IXE They found that more of the patients treated with ixekizumab simultane ously achieved PASI 100 and ACR 50 compared to the adalimumab group at week 24 (40% vs. 17.6%, p=0.015) and week 52 (38% vs. 17.6%, p=0.026).

“PASI 100 and ACR 50 are high tar gets to reach so it is pretty impressive that we saw 40 per cent of patients reaching both of those deeper levels

of response,” said Dr. Gooderham.

Looking at PsO alone, more pa tients in the ixekizumab group achieved PASI 100 (59.2% vs. 25.5%, p=0.001) and PASI 90 (81.6% vs. 60.8%, p=0.028), as well as nail PsO clearance, through week 24 com pared to the adalimumab group.

The researchers also saw that the improvement in joint symptoms was similar between the two study arms.

Choosing the right medication

“In our mind, we still think from a PsA perspective, that TNF antagonists [such as adalimumab] are still the gold stan dard,” said Dr. Gooderham. She noted that modern IL-17 inhibitors such as ix ekizumab are approaching similar effi cacy for treating PsA. “When you bring in the skin components, the IL-17 in hibitors do provide better skin clear ance. So you get that whole package for the patient.”

She noted that observing the sig nificant rate of nail PsO clearance with ixekizumab is also encouraging, be cause nail involvement is an impor tant factor for some patients.

Dr. Gooderham also noted there were no additional safety signals seen with ixekizumab compared to adali mumab.

“Psoriatic arthritis patients can have a higher inflammatory burden,” she said. “They often have concurrent medications such as methotrexate or prednisone, which might increase their risk [of complications]. So it is important to know the treatment that we are choosing for them will provide safe and effective treatments without adding any new burdens or increasing the risk of anything.”

Looking to the future, Dr. Gooder ham says it would be valuable to con duct more comparative studies between classes of medications for PsO and PsA.

“We need to look at the different classes of medications to help find where they are most beneficial,” she said.

“For example, if a physician does have a psoriatic arthritis patient with a high skin burden, an IL-17 inhibitor would make more sense than a TNF antagonist. However, if a physician has a psoriatic arthritis patient who maybe has some inflammatory bowel dis ease, then they will want to lean more to the TNF option for that patient.”

ILUMYA™ coverage now

Enrol

patients in

Patient

PrILUMYA™ (tildrakizumab injection) is indicated for the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

For more information:

Please consult the Product Monograph at: info.ilumya.ca/Product_Monographfor important information relating to contraindications, warnings, precautions, adverse reactions, interactions, dosing and conditions of clinical use.

The Product Monograph is also available by calling our medical information department at: 1-844-924-0656.

REFERENCE:

Consider for the

Vender on Psoriasis

Ronald B. Vender, MD, FRCPC comments on recent findings and developments, and answers clinicians’ questions

Risk factors for diagnosis of PsA, PsO, RA and AS: A set of parallel case-control studies

In this study from the Journal of Rheumatology (doi: 10.3899/jrheum.210006), the authors compared potential risk factors for the diagnosis of psoriatic arthritis (PsA), psoriasis, rheumatoid arthritis (RA), and ankylosing spondylitis (AS), referencing the results of four parallel case-control studies with data obtained from the Health Improvement Network between 1994 and 2015. Patients with PsA, psoriasis, RA, or AS were identified using validated code lists and matched to controls on age, sex, practice, and year. Risk factors were selected in the time prior to diagnosis.

Patients with incident PsA (n=7,594), psoriasis (n=111,375), RA (n=28,341), and AS (n=3,253) were iden tified and matched to 75,930, 1,113,345, 282,226, and 32,530 controls, respectively. Median age of diagnosis was 48 (IQR 38-59), 41 (31-54), 43 (31-54), and 60 (48-71), respectively. The authors note that in the multivari able models, there were some shared and some differing risk factors across all four diseases: PsA was associated with obesity, pharyngitis, and skin infections; PsA and psoriasis were associated with obesity and moderate al cohol intake; PsA and AS were associated with uveitis; and PsA and RA were associated with preceding gout. According to the investigators, both RA and AS were associated with current smoking, former moderate drinking, anemia, osteoporosis, and inflammatory bowel disease. All shared former or current smoking as a risk factor; statin use was inversely associated with all four diseases.

Psoriasis patients have so many comorbidities to worry about it is possible that reduc ing risk factors associated with the development of skin or joint disease may be bene ficial. Clinical studies would need thousands of patients to see if treating psoriasis or certain types of arthritis with biologics can reduce some of these risk factors. How ever, this paper explores risk factors for different inflammatory diseases. For exam ple, obesity and moderate alcohol intake is associated with psoriatic arthritis and psoriasis, but this may be a chicken and egg observation. As we know, psoriasis and psoriatic arthritis can also lead to obesity and moderate alcohol intake due to a sedentary lifestyle and boredom, leaving one to indulge in alcohol. Psoriatic arthritis alone is associated with obesity and skin infections but also pharyngitis. It is well known that tonsillectomy may reduce severe psoriasis in some cases. Unfortunately, psoriasis patients, whether they have skin or joint involvement, must be aware that a healthy lifestyle of low alcohol, moderate weight reduction, smoking cessation and avoidance of infection may prevent some of these diseases.

Factors that may determine super-response to guselkumab

This study was designed to determine the baseline characteristics of patients with moderate-to-severe psoriasis who achieved super-response (Psoriasis Area and Severity Index [PASI] 100 response at Weeks 20 and 28) fol lowing initiation of guselkumab treatment (Journal of the European Academy of Dermatology and Venereology, https://doi.org/10.1111/jdv.18474).

Pooled data from the VOYAGE-1 and VOYAGE-2 studies identified super-responders. Baseline demo graphics, disease, and pharmacokinetic characteristics were compared to non-super-responders to identify which factors were potentially predictive of super-response status. A subset of patients randomized to guselkumab were analyzed (n=664); 271 patients achieved super-response vs. 393 who had non-super-response. Patient age at study entry and baseline body weight (≤90 kg vs. >90 kg), PASI, and Investigator’s Global

Assessment (IGA) score were significant predictors of super-response status, with odds ratios (95% confi dence intervals) of 0.98 (0.967-0.993; p=0.003), 1.42 (1.026-1.977; p=0.034), 0.97 (0.955-0.993; p=0.007), and 0.66 (0.433-0.997; p=0.048), respectively. More pa tients with super-response also achieved an early re sponse: Week 2 PASI 75 (5.5% vs. 1.8%) and Week 8 PASI 100 (22.5% vs 3.3%) vs. non-super-response. Me dian serum guselkumab concentrations through Week 28 were slightly greater in patients with super-response vs. non-super-response. Patients who were younger, less obese, and who had less severe psoriasis were more likely to achieve early clinical responses (complete skin clearance) with guselkumab, the researchers reported.

The concept of super responder is a new finding that is very interesting and can predict how well a certain individual will respond to a particu lar biologic. In this guselkumab study, certain subtypes of individuals that tend to be super responders are identified. This gives great confi dence to the patient and to the pre scribing physician that the biologic is working well. One may also decide to choose a patient for this biologic based on the factors described in the study. An interesting thing to know would be if the super respon ders have longer drug survival and require less dose optimization. Al though this biologic works well in the majority of individuals, choosing the specific identifying features can act as a biomarker for an excellent and predictable response to this bio logic. Other biologics in this class or from other classes may show a simi lar response if these identifying fea tures are examined statistically. This type of response may not be unique to guselkumab.

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HS: Study one of first to enroll Indigenous patients

than 30 years.

Diverse patient base noted

The study was conducted in 23

Canadian medical centres and in cluded 138 adults with moderate-tosevere HS who needed a change in their ongoing therapy. Notably, sev

eral of the participants were patients with skin of colour. “This is one of the first studies that I'm aware of in HS that enrolled Indigenous pa

tients,” said Dr. Gulliver. A small number of skin of colour patients also participated, he added.

“These patients had pretty se vere disease, similar to the phase three clinical trials, with anywhere from 12 to 15 active lesions, three abscesses, 10 inflammatory nodules or three draining fistula,” said Dr. Gulliver. “Many of them also had as sociated scarring.”

He said that 96% of the partici pants had comorbidities that in cluded depression, diabetes, high blood pressure and psoriasis.

Results evaluated after one year of treatment

Camp Liberté was created by a group of dermatologists dedicated to offering children with moderate to severe skin conditions an opportunity to enjoy a summer camp experience. With locations in eastern and western Canada, Camp Liberté hosts more than 40 children per summer at no cost to parents, thanks to the support of generous donors.

Our camps are fully equipped with volunteer dermatologists, residents and nurses to care for children with a wide range of skin conditions, including atopic dermatitis, epidermolysis bullosa, and alopecia areata.

HOW CAN YOU HELP?

A gift to Camp Liberté provides Canadian children with skin conditions an opportunity to grow in confidence and self-esteem through a multi-cultural outdoor camping experience in a fun, safe, bilingual, environment.

Le Camp Liberté a été créé par un groupe de dermatologues déterminés à offrir à des enfants qui ont des problèmes de peau variant de modérés à graves la possibilité de vivre l’expérience d’un camp d’été. Avec ses emplacements dans l’est et l’ouest du Canada, le Camp Liberté accueille plus de 40 enfants par été sans qu’il en coûte quoi que ce soit aux parents, grâce à l’appui de généreux donateurs. Nos camps bénéficient des services complets de dermatologues, de médecins résidents et d’infirmières bénévoles qui s’occupent d’enfants aux prises avec un vaste éventail de problèmes de peau, y compris la dermatite atopique, l’épidermolyse bulleuse et la pelade.

COMMENT POUVEZ-VOUS AIDER?

Un don au Camp Liberté permet à des enfants canadiens qui ont des problèmes de peau d’accroître leur confiance en soi et leur estime de soi en vivant une expérience multiculturelle de camping en plein air offerte dans un environnement bilingue, sécuritaire et amusant.

Each participant was treated for 52 weeks per their physician’s practice, and the researchers recorded pa tient-reported outcome measures (PROMs) at baseline and at weeks 24 and 52.

“If you look across the patientreported outcomes, there was sig nificant improvement across many of the important aspects, whether it be emotional, ambulation or im

Chronicle Companies is pleased to support Camp Liberté with monetary and in kind donations through Sandi’s Fund, established to honour our late friend and colleague, Sandra Gail Leckie, RN. Sandi was a nurse, pharmaceutical in dustry executive and health educator who had a life long affinity for children and chil dren’s charities.

Chronicle Companies contributes prots from the annual National Pharmaceu tical Congress (www.pharma congress.info) to Sandi’s Fund for Camp Liberté, and has partnered with Camp Liberté to provide communications assistance for this valuable philan thropic undertaking.

/ Faites un don dès maintenant! campliberte.ca

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Indigenous patients face barriers to dermatologic care

n Paucity of data on the incidence of psoriasis in Indigenous populations, clinician reports

by KRISHNA RAU, Correspondent, The Chronicle

Indigenous people in remote parts of Canada face many barriers when being treated for inflammatory skin conditions, Dr. Rachel Netahe Asiniwasis told delegates at the second annual Indigenous Skin Spectrum Summit on June 11, 2022.

Dr. Asiniwasis is a dermatologist in Regina and she and her team serve remote northern First Nations communities through flying visits and teledermatology clinics.

Eczema, or atopic dermatitis (AD), is not “just eczema,” especially for Indigenous patients, said Dr. Asiniwasis.

AD can lead to chronic itching and pain, sec ondary infection, bullying, sleep loss, social avoidance, depression, ADHD and even suicide, said Dr. Asini wasis. The atopic triad—AD, asthma and allergies—are among the most common con ditions in Indigenous popula tions, especially in children, she said. And among Indigenous pa tients, AD is often poorly recog nized. Social determinants of health that are unique to Indige nous populations can have a major effect.

“I call atopic dermatitis the diabetes of der matology, because it is common, it is chronic,” she said. “And if it is poorly controlled, it can have numerous physical, mental, psychosocial and fi nancial impacts and consequences... The major ity of cases start before age five.”

“I do not have any children myself, but I would be deeply concerned if this is what they were living with on a daily basis, and they are not having their health issues addressed.”

There are several barriers to treatment for In digenous patients, she said, including long wait ing lists, inadequate health care services, lack of transportation, cost and lack of clean water. Skin barrier at increased risk for infection in patients with AD AD can mean an increased risk of bacterial infec tion, and diseases such as impetigo, due to de fective skin barrier, immune system dysfunction or even dysfunctional antimicrobial proteins. For Indigenous patients, when “you throw in environ mental barriers and access to care, we are seeing a potential disaster,” said Dr. Asiniwasis.

There are similar issues among Indigenous populations with psoriasis, she said.

“We know that systemic inflammation may be associated with higher risks—and this is doc umented—of diabetes, psoriatic arthritis, metabolic syndrome, cardiovascular disease, in flammatory bowel disease, and severe psoriasis has been shown in population-based studies to be an independent risk factor for death due to cardiovascular disease,” said Dr. Asiniwasis. “So

I ask you, is this just a skin problem? And should we dismiss it as such?”

As with AD, psoriasis can lead to chronic itch ing and pain of the skin, embarrassment and selfconsciousness, anxiety and depression, social rejection and financial disability, she said. Physi cians should not be dismissive of psoriasis in In digenous populations.

Dr. Asiniwasis said that while she was con ducting research, she came across an article claiming that psoriasis was nearly absent in North American Indigenous populations. Such claims can be dangerous, she said.

“I do not really know where that is coming from,” said Dr. Asiniwasis. “I do ask, is the psori

physicians and specialists, extensive skincare in structions for patients, proximity to services, supply and access to treatments and clean water access. There were also cultural barriers such as language and a possible lack of understanding or sensitivity towards Indigenous culture.

A national survey conducted in the summer of 2021 received replies from 50 providers, in cluding general physicians, dermatologists and pediatricians, said Dr. Asiniwasis' research assis tant, Trisha Campbell. Most respondents agreed with the Saskatchewan survey about the barriers to dermatologic care in remote communities and felt those communities were underserved by the currently available dermatology services and re

asis nearly absent in these populations or is it that we do not know much about it? And if medicine believes this, and there is no way to document it, the potential for psoriasis complications and the comorbidities might be ignored and the struggles of the clinicians trying to help them.”

There is a paucity of data on psoriasis and In digenous populations, especially in the US, said Dr. Asiniwasis. She said that other studies that claim a low rate of psoriasis among Indigenous populations, such as one from Greenland, were poorly researched and lacked data.

Data from nurses and nurse practitioners in Saskatchewan and from her own conversations with colleagues in Western Canada show a high incidence of psoriasis among Indigenous popu lations, she said.

According to a survey Dr. Asiniwasis and a re search team conducted between Jan. 2018 and Dec. 2019 among nurses and nurse practitioners in rural and remote Indigenous communities in Saskatchewan, AD was the most common der matologic condition, followed by impetigo. Other encountered conditions include MRSA and other skin infections, scabies, diabetic skin complica tions or ulcers, psoriasis, lice, bed bugs and other infestations.

Reported barriers to care included the cost for treatments, skin cleansers and household cleansers, a lack of transportation and related transportation costs, long waiting times for general

sources. The national survey also found that AD was the most prevalent skin condition in these communities and 87.5% found the condition was generally moderate to severe.

Campbell said respondents suggested in creasing teledermatology and virtual care, in creasing in-person dermatologist visits to remote communities, having an employee or nurse who is dedicated to helping coordinate referrals for skin care conditions and cultural awareness pro grams with regards to skin disease management.

Dr. Asiniwasis concluded by saying that eczema cannot be dismissed when it comes to Indigenous patients, especially children.

“A lot of the communities are calling for help,” she said. “There is an impact being seen. Children are missing school because they are being bullied or even committing suicide. They are thinking about suicide because of their skin condition.”

Bottom Line: Eczema and psoriasis are not just skin problems when it comes to remote Indigenous communities, especially for children. When com bined with a lack of access to treatment and numer ous barriers involving the treatment itself, as well as a lack of basics such as housing, clean water and education, common skin conditions can become major problems. This is especially true among chil dren and youth, which have high rates of AD. The problem can be so severe it can lead to suicide. Ex isting studies are non-existent or misleading, and more information is urgently needed.

Dr. Rachel Asiniwasis

“

I call atopic dermatitis the diabetes of dermatology, because it is common, it is chronic and if it is poorly controlled, it can have numerous physical, mental, psychosocial and financial impacts and consequences... The majority of cases start before age five”

Dr. Rachel Asiniwasis

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Mohs sur gery : Scar outcome most important for pts

Continued

In total, 101 adult participants’ MMS scar esti mates were compared to the estimates made by 86 surgeons, with investigators finding that scars were a median of 2.2 times larger than patient es timates and only 1.1 times larger than surgeon es timates.

Dr. Christian Murray commented on these findings in an interview with THE CHRONICLE. “I think this study is an example of something we all knew and believed but this was a way to put this in data. It’s nice to have some evidence that explains to patients who may be confused about what surgery really results in.”

Dr. Murray is a surgeon at Women’s College Hospital Mohs Centre in Toronto and director of the American College of Mohs Surgery accredited fellowship at the University of Toronto.

Applicable to a Canadian population While the study used an American population, the findings are still applicable to Canadian pa tients, according to Dr. Murray. “The generaliz ability of the study would really be determined by what these patients knew coming in,” he said.

Study participants filled out a survey to col lect information regarding history of MMS, pre-op erative consultation and use of resources prior to their scar estimation. The findings suggested that education through these consultations or re sources did not significantly improve the patients postoperative scar length estimates.

In the U.S., Mohs practices typically retain pa tients and see patients on a regular basis, allow ing them to immediately screen high risk patients into surgery. In Canada, where there is limited ac cess to MMS, patients are typically seen and re ferred by many providers before seeing a Mohs surgeon. In this way, they have had the benefit of several consultations and are able to be informed on the process by multiple physicians.

“It would also be significant [to know] what the referring doctor has conveyed to the patient regarding the surgery,” said Dr. Murray.

The authors describe the importance of the finding that “patients are satisfied when surgical

outcomes meet their expectations.” They suggest that patient dissatisfaction with surgical scars is one of the most common reasons patients in the U.S. pursue litigation against MMS surgeons. However, these findings are less relevant to Cana dian physicians as litigation for MMS surgical out comes is less common, according to Dr. Murray.

“I would say that in Canada, it is a very low risk,” he said. “[Litigation] is very rare and when it does happen, it typically does not have to do with the cosmetic result as much as it has to do with the ability to remove the cancer.”

While cosmetic outcome is important, it is not nearly as important as excision of the cancer. With so few Mohs surgeons in Canada, virtually all have completed accredited fellowships and there are strict criteria on which patients are eligible for MMS. “There haven’t been many cases of litigation re lated to cosmetic outcomes for MSS,” said Dr. Mur ray. “In fact, I’m not aware of any.”

Being realistic regarding both the likelihood of cancer removal and cosmetic outcome are im portant, Dr. Murray said. “We all want the same thing. We all want the cancer removed and the best results. Not only that, but we want to have the same understanding of those two things.”

Setting realistic expectations for surgical outcomes

It is important to be realistic with the patient and explain the range of possible outcomes, accord ing to Dr. Murray. He describes this as the primary role of a Mohs surgeon before surgery takes place. “The most predictive thing that determines patient satisfaction is how well they’re informed of the process and the possible outcome before you begin [surgery],” said Dr. Murray.

As a patient is referred to a Mohs surgeon, they will receive the best estimation for out comes and alternatives from each physician. However, only a Mohs surgeon can be expected to predict something as specialized as scar length outcome.

While it is important to set realistic expecta tions before surgery and discuss outcomes after the procedure, Mohs surgery is unique in that pa

Early microneedling improves scar outcomes

Treating surgical scars with microneedling early during the maturation and remodelling phase appears to lead to better aesthetic outcomes than later microneedling.

These findings come from a paper pub lished in Plastic and Reconstructive Surgery.

“Microneedling, also known as minimally invasive percutaneous collagen induction, has demonstrated impressive improvements in chronic acne scars,” the authors write. “How ever, no evidence exists for treating postsurgical scars during active wound healing.”

To investigate the value and safety of using microneedling in acute postsurgical scars, the researchers recruited 25 surgical patients and

administered three microneedling treatments after surgery.

The research team assessed the scars using the Vancouver Scar Scale, Patient and Observer Scar Assessment Scale, and Global Aesthetic Improvement Scale after each of the three treatments and at a final two-month fol low-up.

All the patients had improvements in their scar scores at the final follow-up compared to initial measurements (p<0.001). There was no statistically significant difference in outcomes seen when the researchers broke the findings down by patient age, location of scars or Fitz patrick skin phototype.

tients are awake during surgery. This allows on going discussion and consent during the proce dure. “I consider [the patient] an equal partner in the decision-making,” said Dr. Murray. “If you don’t partner with them, then I think you set your self up for patient dissatisfaction, even if the re sults are good.”

The authors noted one of the limitations of the paper was that not enough information about wound repair techniques was collected, and the effect of these techniques on patient satisfaction.

“I think the simplest repair method is usually the most effective,” said Dr. Murray.

He described the simplest method as the one most likely to have the least negative effects or complications and easiest to manage if problems arise in the future. Each surgery requires unique approaches, and different reconstruction tech niques must be tailored to each individual’s pref erence to ensure patient satisfaction.

“There is a tendency for all of us, especially in academia, to want to try new techniques that have very artistic repair options,” said Dr. Murray. “I typically will try to do the easiest and most nat ural reconstruction method possible.”

While Dr. Murray will show textbook exam ples of potential scar outcomes to patients, surg eries don’t always go to plan and not every surgery can be predicted. An ongoing dialogue and partnering with the patient should include all of these decisions, risks and backup plans so that patients are aware of all potential facial scar out comes.

“It’s a difficult topic for people to understand and predict in many cases,” said Dr. Murray. “Ex plaining to them in simple terms so they can un derstand what to expect is going to result in better patient outcomes in the end.”

Message from the Medical Editor

Continued from page 3

mon. She notes there are also high rates of MRSA and other skin infections, diabetic ulcers, and psoriasis. With these and other challenging der matological conditions such as HS seen in high rates in Indigenous patients, it is important that we deliver high-quality dermatological care and therapies.

In many of the other articles in this issue, readers will see reports on additional significant advances that have been made in the treatment of psoriasis, psoriatic arthritis, HS, and eczema. It should be the goal of each provincial health care authority to have these advanced, highly ef fective therapies available to all of our patients.

As always, THE CHRONICLE team invites and welcomes your comments on this issue, or any other topic in dermatology, at www.derm.city.

—Wayne P. Gulliver, MD, FRCPC, Medical Editor

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Atopic dermatitis

AD and asthma link

n Childhood AD may be linked to parental AD,

According to a recent study, children are more likely to have atopic der matitis (AD) in the first two years of life if their parents have AD or asthma

The study was a secondary analysis of the BASELINE Birth Cohort study that assessed 1,505 children. Infants that were reported to have AD at two months were further evaluated at six, 12 and 24 months. The find ings were published in Pediatric Dermatology (July 25, 2022).

Data was collected on the children’s skin barrier function, early skin care, parental atopy and AD of the infants. At six months, 18.6% of the participants had AD, with 15.2% at 12 months and 16.5% by 24 months.

Among mothers with AD, their children were 1.57 times more likely to have AD at six months and 1.66 times at 12 months. With paternal AD, chil dren were 1.9 times more likely at six months and 1.85 times at 24 months.

Children of mothers with asthma were 1.76 times more likely to have AD at six months and 1.75 times at 12 months. While paternal asthma was 1.7 times to cause AD in children at 6 months and 1.34 times at 24 months.

The study may help inform early interventions for prevention or early treatment of AD, noted the authors.

Photoaggravated AD

n New study highlights significant QoL impairment

According to a recent study, photoaggravated atopic dermatitis (PAD) severely impacts quality of life for patients. Researchers reviewed data from 120 pa tients diagnosed with PAD at a tertiary center referral unit between 2015 and 2019. The study was published in JAMA Dermatology (July 27, 2022).

Out of the 103 adult participants, 78% had a score greater than 10 on the Dermatology Life Quality Index (DLQI) for the past year. Child partic ipants had a DLQI score of 14 for the past year.

Findings showed that 92% of patients tested positive on the broad band UV radiation provocation test and 69% had vitamin D insufficiency or deficiency.Patients with Fitzpatrick skin types V and VI had an earlier photosensitivity onset, were younger at diagnosis and more commonly female. However, the DLQI scores did not significantly differ from patients with Fitzpatrick skin types I-IV.

According to the authors, the findings suggest that proper knowledge of PAD presentation, photoinvestigation and demographic aspects can help assist patient diagnosis and treatment.

Tr eatment Update

VITAMIN D SUPPLEMENTATION DURING PREGNANCY MAY LOWER RISK OF AD IN INFANTS

According to a new study, taking vi tamin D supplements during preg nancy may reduce the likelihood of infants developing atopic dermatitis (AD) in their first year of life.

The study included more than 700 pregnant females, 352 who took 1,000 international units (IU) of Vita min D from 14 weeks until delivery, while 351 took a placebo. The find ings were published in the British Journal of Dermatology (Jun. 28, 2002).

Investigators also noted that in fants who were breastfed for more than one month had a lower risk of AD than those who were not.

“Our findings showed a positive effect, which was more evident in infants that breastfed. This may re flect supplementation during preg nancy increasing the amount of Vitamin D in breast milk,” said lead author Keith Godfrey, PhD.

Professor Godfrey is Professor of Epidemiology and Human Develop ment at the University of Southamp ton in England.

The study also showed the Vita min D supplements led to lasting benefits for infant bone density at four years of age.

STUDY SHOWS DIETARY CHANGES CAN IMPROVE AD SYMPTOMS

According to a new study, dietary changes may improve symptoms in patients with mild or moderate atopic dermatitis (AD) when used in conjunction with regular treatment. However, the authors note there are risks associated with elimination diets that should be discussed.

Researchers reviewed data from almost 600 participants across 10 randomized patient trials. The study included both children and adults with AD.

The findings were published in the Journal of Allergy and Clinical Im munology: In Practice (July 18, 2022).

Investigators found that 50% of participants had improved AD symp toms when they removed certain foods such as dairy from their diet while on standard treatments. That’s compared to 41% who had improved AD symptoms by using standard treatments without any di etary changes.

The authors noted that patients eliminating certain foods from pa tients’ diet may increase the risk of developing food allergies and mal nutrition. They recommended care fully considering the risks and benefits of implementing dietary changes to treat AD symptoms.

“With our data, patients, care givers, and clinicians are no longer left guessing about the outlook with or without pursuing a diet for eczema and can now have an in formed conversation together,” said first author Dr. Paul Oykhman.

REDUCING PARENT STRESS TO PREVENT CHILDHOOD AD New findings suggest that combining routine pediatric care with telecon sultation and email newsletters to parents appears to effectively reduce the prevalence of atopic dermatitis (AD) in infants.

In a paper published in JMIR Pe diatric and Parenting, investigators note that mothers of infants are prone to experiencing parenting stress, which can reduce the wellbeing of parents and children.

To investigate how effective pe diatric teleconsultation might be at preventing AD in infants and reduc ing parenting stress in mothers, re searchers in Japan recruited 318 infant-mother pairs.

The pairs were randomly as signed to either an intervention group or a control group. All participants re ceived routine postnatal care. Those in the intervention group had a choice to combine routine care with teleconsultation and email newslet ters from the date of their registration with the study until the infant reached four months of age.

Investigators found that the prevalence of AD was significantly lower in the intervention group than in the control group at the fourmonth checkup (20% vs. 33%, p=0.02). However, no significant dif ferences between the groups were observed in scores on the Parenting Stress Index-Short Form (PSI-SF) and General Health Questionnaire12 (GHQ-12), which were used to measure parenting stress and ma ternal mental health.

CONCOMITANT AD, ASTHMA AND RISK OF HOSPITALIZATION

Patients with both asthma and atopic dermatitis (AD) are at a higher risk of hospitalization than patients with only one of the conditions.

These findings come from a Danish study published in the Jour nal of the European Academy of Dermatology and Venereology

For this study, the investigators looked at all records of patients with a hospital diagnosis of AD (11,590), asthma (65,539), or concomitant AD and asthma (819) in the Danish na tional patient registries.

The researchers assessed health care utilization data at three-month intervals from two years before to five years after the date of each patient’s first hospital diagnosis.

They found that adults with con comitant AD and asthma had a higher risk of hospitalization for AD (Odds ratio (OR) 1.38, 95% Confi dence interval (CI) (1.15–1.67), p=0.001) and asthma (OR 1.16, 95% CI (1.00–1.35), p=0.047) compared to patients with only AD and asthma, respectively.

Patients with both conditions also had fewer visits to outpatient clinics for AD (OR 0.10, 95% CI (0.08–0.12), p<0.001) and asthma (OR 0.34, 95% CI (0.29–0.39), p<0.001) compared to patients with only AD or asthma. Those with both asthma and AD had more outpatient clinic visits for rhinitis as well.

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Medicine"

P O S TG R A D UAT E

SUPPLEMENT

Actinic keratoses (AK): An exploratory questionnairebased study of patients’ illness perceptions

Dimitrios Sgouros,1,*,† Adamantia Milia-Argyti,2,† Dimitrios

K. Arvanitis,1 Eleni Polychronaki,2 Fiori Kousta,2 Antonios

Panagiotopoulos,2 Sofia Theotokoglou,1 Anna Syrmali,1 Konstantinos Theodoropoulos,1 Alexander Stratigos,2 Dimitrios Rigopoulos2 and Alexander Katoulis1

12nd Department of Dermatology-Venereology, “Attikon” General University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece

2 1st Department of Dermatology-Venereology, Andreas Sygros Hospital, Medical School, Na tional and Kapodistrian University of Athens, 16121 Athens, Greece

* Author to whom correspondence should be addressed.

† These authors contributed equally to this work.

ABSTRACT

Background: Decreased illness perception among actinic keratoses (AK) patients is a major barrier to the effective management of AK. .

Objective: We aimed to investigate patients’ illness and treatment perceptions, their correlation to demographics and AK/skin cancer history, and secondarily the influence of these perspectives on treatment and sunscreen use.

Materials and Methods: Participants completed questionnaires based on the Brief Illness Perception Questionnaire and statistical analysis was performed.

Results: In total, 208 AK patients were enrolled. A large proportion were poorly aware of the disease (41.4%), with less than half (43%) being familiar with AK. Pa tients were aware of the chronic nature of the disease and its correlation to sun light regardless of demographic characteristics. The level of education played a role in disease awareness (p=0.006), and treatment plan perception (p=0.002). The increase in sunscreen protection after AK diagnosis was higher in women (p=0.009) and younger patients (p=0.044). Patients’ concerns regarding treatment were mainly related to the duration (30%) and effectivity (25%). Dermatologists’ statements highlighting that AK are precancerous lesions (86.2%) influenced pa tients’ willingness for treatment.

Conclusions: Improved awareness of AK is necessary to increase treatment seek ing and compliance, regarding both treatment and sunscreen use. Dermatolo gists’ statements may have a critical influence on patients’ decisions to receive treatment for AK.

Keywords: actinic keratosis; non-melanoma skin cancer; illness perception; awareness; prevention

INTRODUCTION

Actinic keratoses (AK) are a common skin disease that follows the chronic cumu lative action of ultraviolet radiation. They are intraepi dermal skin neoplasms, which correspond to the focal areas of irregular proliferation and differentia tion of keratinocytes, with a low poten tial of malignant transformation to invasive squamous cell carcinoma (iSCC).1,2 They number among the most common pre-neoplastic lesions and are considered to be a part of the evolu tionary spectrum of SCC, constituting the most common neoplasm within the continuum of keratinocyte skin cancer,

with a considerable impact on patients’ quality of life.3 Their prevalence, etiopathogenesis, risk factors, clinical presentation, dermatoscopic and histopathological features, and avail able treatments are well described in the current literature.4,5 Their incidence, although poorly documented, is higher in the age range of 70 years and is ex pected to gradually increase, along with the aging of the population.6,7 Various treatments have been traditionally pro posed to manage this condition, such as topical imiquimod, sodium-diclofenac, piroxicam, 5-fluorouracil, cryotherapy, photodynamic therapy, and surgery. Topical colchicine has been proposed to manage such conditions since the late

1960s.8

Despite their high frequency, growing incidence and premalignant potential, AK are often underdiagnosed and therefore undertreated, which in creases the burden of the disease and consequently that of non-melanoma skin cancers (NMSC) to patients and healthcare systems. The special chronic nature of this disease, with its indolent clinical behaviour, the not always clearcut perceived need for treatment and the underestimated role of sun protec tion, and treatment barriers (such as cosmetic concerns, adverse events, compliance and treatment cost) are some of the main problems encoun tered in clinical practice and directly bear upon the poor awareness of the disease and the decreased perception of the potentially important conse quences between patients if left un treated. The treatment of AK lesions relies on patients’ perspectives regard ing available treatment modalities and their investigations can correspond ingly optimize adherence and clinical outcomes. Personal reported outcomes (PROs), directly from the patients, help in the investigation of AK treatment per ceptions, especially because of the vari ety of the existing treatment options; instruments for their measurement should be incorporated in studies, as they are helpful for defining patients’ preferences and beliefs.9

Illness perception and its main do mains are confirmed to determine pa tients’ beliefs and therefore behaviour, mainly regarding seeking medical care, and are related to the improvement of patients’ outcomes.10,11,12 Reliable tools for their investigation are the different versions of the Illness Perception Ques tionnaire (IPQ), which assesses patients’ cognitive representations and emo tional responses, revealing their under standing of the condition, physical or psychological impairment and its con trollability.13

Regarding AK, patients’ willingness to seek and receive treatment depends on their perception of the disease, as a potentially malignant condition.14 Pre vious studies have shown that informa tion framing and the format of presentation seriously affects patients’

intention to be treated and delineate compliance.14 The successful treatment of AK should use a patient-centred plan which has a high efficacy with mini mum side effects, also taking into con sideration each patient’s profile, including their perception of the dis ease, to improve adherence.15,16

Our study’s primary objectives were to investigate the perceptions of AK patients with regard to their illnesses (risk factors, chronicity, symptoms, and knowledge of the disease) and treat ment (willingness to start treatment, understanding of treatment plan, and concerns) and the correlation to pa tients’ demographics and related AK or skin cancer history. As a secondary goal, we detected the influence of these per ceptions on treatment compliance and the readiness to use sunscreen.

MATERIALS AND METHODS

This was an exploratory, cross-sectional, questionnaire-based study using selfadministered paper-form structured questionnaires, conducted by the 1st and 2nd Dermatology Departments “A. Syggros” and “Attikon” University Hospi tals (waiver decision by Ethics Commit tee 3555/4-3-2021). The only inclusion criterion was adult patients with AK, older than 18 years, who were able to read independently of medical history, comorbidities, or disease severity.

The questions were based on pre vious research on AK and on the Brief IPQ model, due to its advantages of brevity and the speed of completion.17 Patients were asked to complete a total of 20, mostly close-ended, questions. The part of the questionnaire regarding demographics covered close-ended, one-response questions about gender, age (open-ended question), education level and history of UVR exposure and skin cancer. Questions about illness per ception included both close-ended, multiple-choice questions of one or multiple responses and numerical ones on a 10-point rating scale.

Questions of the first part were used to evaluate illness perception, co herence and knowledge about the identity of the disease, source of infor mation about AK, timeline and personal control, including emotional represen

Reprinted with permission ©2022 Lidholm AG, Inerot A, Gillstedt M, Bergfors E and Trollfors B. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and re production in any medium, provided the original author and source are credited. Content has been edited to conform with the Canadian Press Publication Style Guide Chronicle.Academy develops bespoke structured learning programs for clinicians providing in-depth education to professionals in the healthcare industry.

tation and concern. The causal repre sentation of the disease was evaluated by a multiple-choice question, a variant of a question adopted from the IPQ-R version,18 followed by the prioritization of the three major etiological attribu tions, and sun exposure was evaluated as a causal factor with a 10-point scale rating scale response. Additional ques tions, beyond Brief IPQ, focused on sun screen use before and after AK diagnosis, along with the readiness to increase sunscreen use.

The second part of the question naire concerned illness perception, co herence, controllability by treatment (control, consequences, and concern) and compliance. Regarding compliance, an extra question with two different scenarios was formulated, evaluating the impact of information framing by dermatologists on patients’ intention to receive treatment for AK or not (S1. Questionnaire).

Patients’ enrollment was voluntary. AK patients who attended the special Outpatient Dermato-Oncology Depart ments of the aforementioned hospitals between March and September 2021 were asked to complete the distributed questionnaires in written form, during their waiting time. All patients were first informed about the aim and method of the study, as well as the results being used exclusively for scientific reasons.

After data collection, a statistical analysis of the demographic factors was performed along with the questions of illness perception and perception of treatment.

Statistical Analysis Method

For continuous variables the mean, standard deviation and range or me dian, 25th and 75th percentiles and range were calculated after testing for normal distribution. Shapiro–Wilk and Shapiro–Francia tests were applied for normality testing. For categorical vari

ables, the frequencies and percentages were calculated. Chi-squared and Fis cher’s exact tests were used for the com parison of categorical variables while the non-parametric Kruskal–Wallis and Mann–Whitney U tests were also ap plied. Spearman’s Rho correlation coef ficient was used to assess the strength of the relationship.

A p value <0.05 was considered statistically significant. All statistical analyses were performed using Stata/IC version 15.1.

RESULTS Patients’ Demographics

A total of 230 self-report questionnaires were distributed to patients with AK. The response rate was 94.7%, with 218 questionnaires returned. To avoid nonresponse errors, 10 non-completely filled out questionnaires were excluded and our final sample comprises 208 pa tients.

Males prevailed in the group of pa tients with 168/208 (80.8%) members and the median age of the total of pa tients was 70 years. However, 78% of the patients were older than 65 years, both male (77.78%) and female (78.95%) pa tients. Most patients had secondary ed ucation (40.9%, 85/208), while only one to three patients had completed higher education. Taking part in occupational sun exposure or outdoor activities was reported by 46.9% of the patients (97/208). A personal history of any type of skin cancer and solarium use, as inde pendent risk factors, were not prevalent in the group of investigated patients. In total, 163/208 patients (79.1%) reported no history of any type of skin cancer and 194/208 (93.7%) reported no use of so larium ever in the past or at the time of investigation. All the results can be seen in Table 1.

Illness Perception of AK

Regarding the IPQ-R Illness perception

dimensions, 119/208 patients were aware of the identity (title) of the dis ease (48.6%), compared to 84/208 pa tients (41.4%), who did not know the term AK. Most patients (63%) were in formed only by their dermatologist about their disease, while clinicians of other specialties and the media were re ported as a source of information at lower percentages (14.4% and 12%, re spectively). A large proportion of inves tigated patients (45.9%, n=94) knew that they had more than four lesions to be treated, but one in every three pa tients was not aware of the number of their AK lesions. Of note, 46.4% (n=96) had already received treatment for AK more than four times, while 42.5% (n=88) had done so at least once. De spite having multiple treatments, only 42% (n=87) were familiar with the term AK; one in every three patients reported no familiarity with none of the ques tioned diseases (MM, BCC, SCC, AK) and 25% (n=53) were more familiar with MM. At this point, it was deemed neces sary to evaluate the percentage of pa tients with a history of skin cancer that was familiar with MM: beyond AK, only 24.5% (n=13) were aware of MM. Re garding the duration of AK disease, pa tients had a median score of three years after the initial AK diagnosis (25th–75th percentiles 1–3; range: 0–26). All the aforementioned results can be seen in Table 2.

Among the illness perception di mensions, high median scores were gathered for the timeline using the 10point rating scale: chronicity was evalu ated with a median score of 6 (25th–75th perc. 2–10; range: 1–10). Pa tients did not report intensive symp toms from AK (median score: 1; 25th–75th perc. 1–3; range: 1–10) and the feeling of coherence was rated as very good (median score: 8; 25th–75th perc. 3–10; range: 1–10). Emotional rep resentation, investigated as concern, distress or anxiety provoked by AK, was evaluated as less than average (median score: 3; 25th–75th perc. 1–7; range: 1–10) and economic burden as minimal (median score: 1; 25th–75th perc. 1–3; range: 1–10).

Sunlight was highly assessed as a causal factor and most patients blamed it absolutely for their disease (median score: 10; 25th–75th perc. 8–10; range: 1–10). Before AK diagnosis, sunscreen use was poorly reported (median score: 1; 25th–75th perc. 1–5; range: 1–10), while after AK diagnosis the reported use or willingness to increase sunscreen use was very high (median score: 10; 25th–75th perc. 7–10; range: 1–10). These results can be seen in Table 3 and Table S1.

Among causal attribution dimen sions, after the prioritization of the three main factors blamed to be responsible for AK, solar radiation, at 79.9% (n=163), was prominently displayed. In total, 40% (n=64) considered aging as the second

most important factor, followed by stress (21.3%, n=34) and pollution (19.6%, n=26), while the third most im portant cause was also aging (24.1%, n=32), followed by pollution (19.6%, n=26), stress and accident, each at 12% (n=16).

A possible relation of the causal representation of AK with gender, edu cation level and history of skin cancer was also investigated. Male patients blamed serially solar radiation, aging and pollution with 81.1% (n=133), 44.2% (n=57) and 20.4% (n=21), respec tively. Most female patients (75%, n=30) also blamed solar radiation, and rated stress as the second (32.3%, n=10) and ageing as the third (43.3%, n=13) most important causal factors and did not considerably prioritize pollution or acci dent (Table S3).

No differentiation related to educa tion level was noticed, with patients of all education levels indicating that sun light and aging were the most impor tant factors (Table S4). Patients with no skin cancer history prioritized the same main causal factors, likewise with pa tients with a history of skin cancer as well, with the latter blaming solar radia tion more (91% with history; 77% with no history) (Table S5).

Information Framing AK Treatment

Most patients (86.2%, n=175) were likely to want treatment after hearing their dermatologists’ statements that AK are precancers. Equally, 72.7% (n=133) would decide to receive treatment for AK upon hearing the statement that about 0.5% of AK will turn into skin can cer. Regarding concerns related to treat ment, 35.2% (n=72) had no concerns, followed by 30% (n=62) which worried mostly about treatment duration. Treat ment efficacy was the main worry for 24.6% (n=51) of patients, while cost was not a preoccupation for the patients of our study (Table 4). Possible differentia tions based on gender were also inves tigated. A total of 37% of males had no concern with regard to treatment (n=62), treatment duration and effec tiveness; 32% (n=53) and 22% (n=37), 9% (n=15) were preoccupied with safety, while cosmetic outcomes and pain worried 5.4% (n = 9) and 4.8% (n=8) of male patients, respectively. Fe males, in comparison, were more con cerned about the effectiveness of AK treatment (36%, n=14), cosmetic out come and pain (20.5%, n=8, 15.4%, n=6). The percentage of female patients with no concerns about treatment was similar to the male ones though (28%, n=11) (Table S6).

For the rest of the questions re garding AK treatment perceptions, un derstanding of the treatment plan was highly rated (median score: 10; 25th–75th perc. 8–10; range: 1–10), was re ported compliance to the proposed

treatment (median score: 10; 25th–75th perc. 8–10; range: 1–10). Illness control by the followed treatment was signifi cantly highly rated too (median score: 10; 25th–75th perc. 9–10; range: 1–10) (Table 4 and Table S7).

DISCUSSION

Illness Perception of AK Patients

There are very few and heterogenous reports investigating illness perceptions of AK patients. Available literature data include only one study of 200 Turkish patients19 and one of 2,400 patients from western Saudi Arabia.20 The pres ent one is the first attempt, to the best of our knowledge, to investigate the perceptions of AK patients in the Euro pean population.

Considering that most investigated patients (almost 90%) had received treatment for AK at least once and that the median rate was three years after their initial diagnosis, the results show that patients do not have good knowl edge about the identity of their disease: 58.6% knew the title of the disease and one in every three patients did not know their number of AK lesions, indi

cating low coherence, despite the chronicity of their disease. All in all, this could be related to the poor symptoma tology of AK,21,22 which also aligns with the reported rating, and could poten tially be an additional barrier, leading to the underestimation of AK, especially regarding consequences, concerns and emotional representation. The psycho logical impairment of AK patients is re ported in the literature, regarding the impacts on quality of life, self-confi dence and well-being in general.3,23 These are related not only to concern about disease evolution, but also to be havioral recommendations, such as di rect sun exposure.24

Even though AK are one of the most common skin diseases globally, the nature of the disease is widely un known: awareness of AK among the general population of some European countries, Australia and the USA reaches 6 to 7% on average.23,25,26 According to Halpern, et al (2005), there is more awareness and knowledge of a disease in areas of higher incidence. Indeed, in Australia, where NMSC incidence reaches up to 25%, and in the USA (10%), in comparison to <3% of Europe,

patients reported better familiarity with BCC than with AK (30% vs. 7%, respec tively).25 Contrarily, 10% of patients in Saudi Arabia knew BCC; only 1% knew of AK and 8.6% both.20 In our study, with 80% of the patients not having a skin cancer history, one out of three pa tients reported no familiarity with AK, BCC, SCC, and MM, and only one out of four knew MM, even with skin cancer history. Despite multiple reported treat ments, less than half of the patients were familiar with the term AK, further supporting the low overall knowledge of disease identity. The investigation of the familiarity with MM of 25.5% of our patients would be of interest, to define a possible relation with the known higher risk of MM or better information at the state or physician side.26

In the aforementioned study of Halpern, et al, most AK patients (66%) listed media as their main source of in formation about the disease, compared with 12.4% in our study. In the latter, 65% of patients were informed only by attending dermatologists, like in the study of Basyouni, et al, while physicians of other specialties were chosen by 15%. In countries with better knowl

edge and awareness of skin cancer, such as the USA or Australia, the media plays a significant role in public awareness,20 which could be inferentially reinforced. Further, dermatologists should raise awareness not only of treated patients, but also of other physicians to avoid un derdiagnosis and increase appropriate medical advice seeking. Clear commu nication of information about AK, even in written form, could increase the un derstanding of this disease. Even in the skin cancer-related apps era, clinical consultation outclasses the media, i.e., printed or television.27 Dermatologists are mainly responsible for the increase in disease awareness, in the direction of knowledge of skin health, increase in sun protection behaviours and decrease in skin cancer incidence.28

In our study, dimensions of coher ence and disease duration were highly rated, despite the poor knowledge of disease identity. Patients aware of the disease title had better perception of the chronicity (p=0.004), coherence (p<0.001) and treatment plan (p=0.044), while skin cancer history was signifi cantly related only to increased percep tion of disease duration (p=0.002). In a like manner, in Akarsu, et al’s study, pa tients with skin cancer history had a bet ter perception of the disease’s chronicity, including men.19 Skin cancer history was also found to be related to an increased negative perception of consequences and controllability of AK by treatment, which was not confirmed in our study. In the latter, gender was also found to play no role in the timeline perception of the disease.

On the other hand, the level of ed ucation was shown to be an important factor for increased coherence and sun screen use. Patients with higher educa tion surpass primary school graduates with regard to their understanding of the disease (p=0.006). After AK diagno sis, sunscreen use or readiness for in creased use was equally high among patients, in contrast to previous studies,19,29 where it was higher in higher education levels. This could be explained by the fact that patients of lower education levels tend to attribute their disease to psychological or acci dental factors, something that was not proven in our study. Despite the similar willingness of patients with lower edu cation levels to increase sunscreen use, treatment plan perception was higher among patients with higher education levels (p=0.002), who also had better outcomes regarding compliance to the suggested treatment (p=0.039).

Based on previous reports, the readiness to increase sun protection be haviour is associated with gender and age.19,25,26,29,30,31 Women tend to worry more about changes in their appear ance and are more affected by AK diag nosis; they show, therefore, better adherence to treatment recommenda tions.19,25,26,32 Emotional impairment also

seems to be higher in women than in men, according to other studies of other skin diseases too.33,34,35 Changes in ap pearance are of great importance to AK patients, and especially when located on the face, they lead to a psychological burden, which should not be underesti mated.36 Outcomes regarding emo tional representation in our study, did not confirm the above-mentioned ob servations. Concern was overall rated lowly; it was positively associated with gender and knowledge of the disease identity. Female patients were found to have greater psychological (p=0.048) and financial (p=0.030) burdens after AK diagnosis in comparison to male ones, like in Akarsu, et al’s study, but contrarily were shown to use more sunscreen than men before (p<0.001) and to be more willing to increase sunscreen use after diagnosis (p=0.009), not equally with males.19

Sunscreen use was nevertheless negatively associated with a higher age: the older the patients, the less sun screen use reported before (p=0.017) and after (p=0.044) AK diagnosis, even though average overall readiness was high, independently of age and other demographics. Before AK diagnosis, sunscreen use was rated as rare, some

thing that has also been observed in countries with increased public aware ness toward NMSC.20,26 Skin cancer his tory was not found to differentiate the perception of etiological attributions though, as found in previous studies.

Exposure to solar radiation was blamed clearly as the first cause of AK by 80% of patients, who have a good perception of the causative factors over all. Stress was prioritized as the second factor by patients of both genders, 21%. Gender and a lower level of education seemed to play a role in the attribution of the disease to psychological causes in the available literature data.19 In our study, besides female gender, stress was prioritized more highly, which was not statistically significant, by patients with higher education levels.

Information Framing—Treatment Perceptions of AK Patients

Previous studies have already demon strated the impact of information fram ing about a disease on a patient’s intention to be treated.37,38,39,40 Regard ing AK, patients are more likely to choose treatment when the disease is presented as precancerous, a common expression used by the attending clini

of a positive outcome are underlined, a lower proportion of patients are willing to receive treatment.39 Changes in pa tients’ responses about treatment ac cording to the presentation of the information about AK emphasizes the importance of clinicians’ statements. The framing of information about the disease has been shown to be more im portant than age, gender or skin cancer history, but most patients would choose to receive treatment anyway.39

Likewise, in our study, nine out of 10 patients were willing to receive treat ment if AK was presented as a precan cerous condition. With a lower but comparable percentage (73%), patients would receive treatment if their derma tologist stated that the risk for AK turn ing into skin cancer is about 0.5%. Patients with positive responses in at least one scenario were found to have more concerns about AK (p=0.042) in any relation, regardless of general de mographics or education level. Those who wanted treatment, even if in formed of the risk of transformation of an AK being lower than 1%, had better treatment plan perception (p=0.04) and a higher feeling of disease control by treatment (p=0.087). AK are not consid ered a life-threatening disease, but

seeking medical treatment for them is crucial. Using the appropriate terminol ogy, adapted to each patient’s knowl edge and educational background, as part of a patient-centred disease man agement is essential because it deter mines patients’ decision-making.40

Emphasis should be placed not only on the need for treatment, but also on the therapeutic options available, with discussions of patients’ expecta tions, regarding efficacy, adverse events, cost and cosmetic outcomes, improving compliance.19,22,41 Compliance is directly connected with treatment and illness perceptions in general, but is also asso ciated with treatment duration, conven ience, associated concerns and cost. AK patients tend to poorly comply with suggested treatments, as described in an observational study of Shergill, et al, with percentages of non-compliance reaching up to 88%.41 The duration of treatment is the main decisive factor. Patient-applied, shorter regimens, re quiring less frequent application, are re lated to better adherence rates.42 A shorter duration and better tolerance influence patients’ perceptions of treat ment outcome and therefore satisfac tion and adherence; even if a treatment is inferior in terms of effectiveness, it is preferred by patients when better toler able.11,43

In our study, AK patients were shown to perceive treatment quite suc cessfully and have no difficulty follow ing the treatment. Of note, due to the use of the self-report method, there is possibly a non-factual, increased feeling of adherence and therefore disease con trol by treatment, which does not corre spond to the real monitoring, as also described in other studies of AK.43,44

Not to disregard this, the overrid ing majority of patients were treated with cryosurgery and only two patients had undergone PDT. This could have had an influence on the answers regard ing compliance, as each treatment op tion was accompanied by a different duration, application and adverse events profile, determining factors of adherence and therapy persistence. Sur prisingly, the median rates of disease control by treatment perceptions were very high, even if 46% of patients had received multiple, more than four, treat ments already. In total, 35% of patients had no concerns regarding treatment parameters; the duration and efficacy of treatment are a matter of concern for 30% and 25% of patients though. Pain, skin reaction and cosmetic outcome were rated as lower in importance (7% and 8%, respectively). Cryosurgery can often lead to hypopigmentation or scar formation, which justifies cosmetic out come concerns.45 PDT on the other hand, is more connected with pain and local skin reactions.46 These adverse events are considerable treatment bar riers and influence patients’ daily activi

ties or social lives, especially when AK are located on visible sites, such as the face or hands.22,31 PDT is found to have equivalent or even better recovery times and cosmetic outcomes and is often overall preferred for AK patients.47

In our study, these adverse events were not found to have a considerable im pact; the dominance of male gender in our sample could be a reasonable expla nation, as females are mostly concerned about them, according to the common est AK patients’ profiles. The classifica tion of AK patients in different profiles allows for the better management of the disease; patients of our study fall rather into the category of unengaged (with low medical engagement).48

The cost of treatment is another important factor affecting treatment adherence, the cost of daily sunscreen use included.16 Previous studies support the idea that the cost related to NMSC is significantly higher than AK treat ment- and sunscreen-related costs28,49 and is therefore important not only to treat AK, but also investigate the impact of cost-related perceptions on compli ance. Only one patient in our study was concerned about cost, and financial burden was overall rated as minimal. This can be related to the fact that pa tients in public hospitals do not have to pay for their treatment and any medica tion is covered by public health insur ance. Further, sunscreen use was limited and possibly not considered as part of treatment cost. In conclusion, educating patients on the meaning of treatment cost is essential and should include both the appropriate dosage of medica tion to ensure efficacy and daily sun screen use, as the basis of each treatment approach. Cost should not be a barrier to patients’ willingness to in crease sunscreen use, which in our study was high.

LIMITATIONS

Our study is the first one trying to inves tigate the illness perceptions of AK pa tients and the connection between demographic characteristics, sunscreen use and treatment in a large sample of Greek patients. However, it has certain limitations: it is a cross-sectional study, rather than a longitudinal one, and so long-term conclusions cannot be drawn. Further, the participants were patients from special departments of two tertiary hospitals, who already had an AK diagnosis and were, therefore, not naïve with regard to the disease, and represent only a proportion of the Greek AK population. A study of a wider scale with a bigger sample of patients, eventually also over a longer period, would be of interest. Sampling was based on patients’ availability and a big part of different AK patient profiles may be underrepresented. It would be, therefore, wise to also include patients that receive other treatment modalities

or emphasize inclusion criteria more precisely in future studies. All collected data were based on the self-report method and, considering the median age of participants, recalled information may be subjective. Finally, external va lidity may be restricted and results can not be generalized due to the risk of sampling bias. Studies using personal interviews are suggested to overcome this risk.

CONCLUSIONS

In conclusion, the illness perception of AK patients is low, even in patients who receive treatment regularly. Despite the long duration of AK diagnosis, patients do not perceive the disease’s identity well. Familiarity with skin cancers and AK is overall low, even in patients with skin cancer history. Knowledge about AK comes mostly from seeing dermatol ogists, while doctors of other specialties and the media contribute less to pa tients’ information. Patients feel they un derstand their condition well and level of education seems to play a role here. The chronicity and timeline of AK are well perceived. Despite decreased co herence, AK patients feel that they are helped by treatment and report no dif ficulty in adherence, with low levels of reported concerns. Overall, they evalu ated control by treatment as greater than the personal control of the disease. Concern about AK is below average, while concern about treatment, regard less of gender, pertains to duration and efficacy. The readiness to follow a sug gested treatment and increase sun screen use is at a high level. Although sunlight seen as clearly responsible for AK, younger patients are more likely to use sunscreen and 15% use no sun screen regardless of age, education level and skin cancer history. Demo graphic characteristics and skin cancer history are associated with AK illness perceptions, but do not differentiate the understanding of causative factors. Der matologists are proved to form patients’ illness perceptions. Not only are they the main source of information about AK, but also their wording affects pa tients’ decisions to receive treatment. In creased awareness of AK is needed for the successful management of this dis ease. To the best of our knowledge, this is one of the first attempts to investigate the illness perceptions of AK patients. We strongly support the need for fur ther studies to unveil important factors which impact AK illness perceptions.

SUPPLEMENTARY MATERIALS

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ curroncol29070408/s1: S1. Question naire. Table S1: Illness perception di mensions. Table S2: Treatment perception dimensions. Table S3: Treat ment concerns according to gender.

Table S4: Prioritization of causal attribu tions. Table S5: Causal attributions ac cording to gender n (%). Table S6: Causal attributions according to educa tional level n (%). Table S7: Causal attri butions according to skin cancer history n (%). Table S8: Statistically significant correlations. Table S9: Statistically signif icant correlations of knowledge of the term AK. Table S10: Statistically signifi cant correlations of readiness for treat ment, if positive in one of the two questions of information framing.

AUTHOR CONTRIBUTIONS

Conceptualization, D.S., A.M.-A., D.R. and A.K.; formal analysis, D.S. and A.M.-A., In vestigation, D.S., A.M.-A., E.P., F.K., A.P., S.T., A.S. (Anna Syrmali), K.T., A.S. (Alexander Stratigos), D.R. and A.K.; methodology, D.S., A.M.-A., D.K.A. and A.K.; project administration, D.S., A.M.A., D.R. and A.K.; supervision; D.S., E.P., A.S. (Alexander Stratigos), D.R. and A.K.; writing—original draft; A.M.-A. and D.S.; writing—review and editing; D.S., A.M.A. and A.K. All authors have read and agreed to the published version of the manuscript.

FUNDING

This research received no external fund ing.

Institutional Review Board Statement

This study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of “A.Syggros” and “ATTIKON” University Hospitals of Athens (3555/43-2021).

INFORMED CONSENT STATEMENT

Informed consent was obtained from all subjects involved in the study.

DATA AVAILABILITY STATEMENT

The data presented in this study are available on request from the corre sponding author.

CONFLICTS OF INTEREST

The authors declare no conflict of interest

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20. Basyouni R, Alshamrani HM, Al-Faqih S, Alnajjar S, Alghamdi F: Aware ness, knowledge, and attitude to ward nonmelanoma skin cancer and actinic keratosis among the general population of western Saudi Arabia. J Fam Med Prim Care 2020; 9:374.

21. Schmitt JV, Miot HA: Actinic kerato sis: A clinical and epidemiological revision. An Bras Dermatol 2012; 87:425–434.

22. Ceilley RI, Jorizzo JL: Current issues in the management of actinic kerato sis. J Am Acad Dermatol 2013; 68:S28–S38

23. Rosen T, Lebwohl M: Prevalence and awareness of actinic keratosis: Bar riers and opportunities. J Am Acad Der matol 2013; 68(Suppl. S1):S2–S9.

24. Cramer P, Stockfleth E: Actinic ker atosis: Where do we stand and where is the future going to take

us? Expert Opin Emerg Drugs 2020; 25:49–58.

25. Halpern AC, Kopp LJ: Awareness, knowledge and attitudes to nonmelanoma skin cancer and actinic keratosis among the general pub lic. Int J Dermatol 2005; 44:107–111.

26. Μackie RM: Awareness, knowledge and attitudes to basal cell carci noma and actinic keratosis among the general public within Europe. . Eur Acad Dermatol Venereol 2004; 18:552–555.

27. Steeb Τ, Wessely A, Mastnik S, Brinker TJ, French LE, Niesert A, Berking C, Heppt M: Patient atti tudes and their awareness towards skin cancer-Related apps: Crosssectional survey. JMIR mHealth uHealth 2019; 7:e13844.

28. Haluza D, Schwab M, Simic S, Cervinka R, Moshammer H: Per ceived relevance of educative in formation on public (skin) health: Results of a representative, popu lation-based telephone survey. Int J Environ Res Public Health 2015; 12:14260–14274.

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30. Bränström R, Kasparian NA, Chang YM, Affleck P, Tibben A, Aspinwall L, Azizi E, Baron-Epel O, Battistuzzi L, Bergman W, et al: Predictors of sun protection behaviors and severe sunburn in an international online study. Cancer Epidemiol Biomark Prev 2010; 19:2199–2210.

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33. Richards HL, Ling TC, Evangelou G, Brooke RCC, Huber K, Gibbs NK, Fortune DG, Rhodes LE: Psycho logic distress in polymorphous light eruption and its relationship to patients’ beliefs about their con dition. J Am Acad Dermatol 2007; 56:426–431.

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36. Esmann, S.; Jemec, G.B.: Manage ment of actinic keratosis patients: A qualitative study. J Dermatolog Treat 2007; 18:53–58.

37. Büchter RB, Fechtelpeter D, Knelan gen M, Ehrlich M, Waltering A: Words or numbers? communicat ing risk of adverse effects in written consumer health information: A systematic review and meta-analy sis. BMC Med Inform Decis Mak 2014; 14:76.

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derm.city

Resear ch of Note

DURATION OF MASK USE DURING COVID 19 A MAJOR RISK FACTOR FOR FACIAL DERMATOSES

This systematic review of cross-sectional studies was conducted to evaluate the association between the use of masks for infection control during the Covid-19 pandemic and various facial dermatoses. The authors also investigated the po tential risk factors for the development of these dermatoses

Investigators identified 37 observational studies with a total of 29,557 study participants.

There was an overall 55% prevalence of facial dermatoses. Individually, acne, facial dermatitis, itch and pressure injuries were consistently reported as facial dermatoses, with a pooled prevalence of 31%, 24%, 30%, and 31% respectively. The most significant risk fac tor was the duration of mask wearing (95% CI: 1.31 – 1.54, p<0.001).

The authors conclude that facial dermatoses associated with mask wear are common and consist of distinct entities. They are related to duration of use. They write that appropriate and tailored treatment is important to improve the outcomes for these affected patients.

LYS Justin, YW Yew: Facial dermatoses induced by face masks: A systematic review and meta-analysis of observational studies, in Contact Dermatitis (Aug. 18, 2022, online ahead of print)

PROJECT IMPROVES MEDIC AL STUDENT CONFIDENCE IN SKIN OF COLOUR SKIN CONDITION RECOGNITION

This paper describes a Quality Improvement Project in the U.K. intended to improve the confidence of medical students and junior doctors in recognizing dermatologic conditions in skin of colour (SoC). The investigators developed two educational interventions to introduce participants to the clinical presentation of dermatologic condi tions in SoC. They used a five-point Likert scale to measure the participants' confidence and an eight-question assessment to quantify differences in knowledge. Results showed that 39% of students and 67% of junior doctors had not received SoC teaching during their undergraduate training.

The authors write that their results confirm the under-representation of SoC in medical education and highlight the need to diversify undergraduate and postgraduate curricula. E Peterknecht, E Reid, K Cheung, A Rajasekaran: Improving the recognition of

Diagnostic Quiz

A . Tinea capitis

B B. Traction alopecia

C C. Androgenetic alopecia

D D. Alopecia areata

THE EDITORS invite your participation in this regular feature of the journal.

Please send all images and correspondence to: Medical Editor, The Chronicle of Skin & Allergy 555 Burnhamthorpe Road, Suite 306, Toronto, Ont. M9C 2Y3.

Telephone: (416) 916-2476 E-mail: health@chronicle.org

Clinical use not mentioned elsewhere in the piece RINVOQ should not be used in combination with other Janus kinase (JAK) inhibitors, immunomodulating biologics (e.g., biologic DMARDs), or with potent immunosuppressants such as azathioprine and cyclosporine.

The safety and e icacy of RINVOQ in adolescents weighing <40 kg and in children aged 0 to less than 12 years with atopic dermatitis have not yet been established. Caution should be used when treating geriatric patients with RINVOQ.

Most serious warnings and precautions

Serious infections: Patients treated with RINVOQ are at increased risk for developing serious infections that may lead to hospitalization or death. Most patients who developed these infections were taking concomitant immunosuppressants such as methotrexate or corticosteroids. If a serious infection develops, interrupt RINVOQ until the infection is controlled. Reported infections include active tuberculosis (TB), which may present with pulmonary or extrapulmonary disease; invasive fungal infections, including cryptococcosis and pneumocystosis; and bacterial, viral (including herpes zoster), and other infections due to opportunistic pathogens. Test patients for latent TB before RINVOQ use and during therapy. Consider treatment for latent infection prior to RINVOQ use. Do not initiate treatment in patients with active infections including chronic or localized infections. Carefully consider the risks and benefits of treatment prior to initiating therapy in patients with chronic or recurrent infections. Closely monitor patients for signs and symptoms of infection during and after treatment, including the possible development of TB in patients who tested negative for latent infection prior to initiating therapy.

Malignancies: Lymphoma and other malignancies have been observed in patients treated with RINVOQ.

Thrombosis: Thrombosis, including deep venous thrombosis, pulmonary embolism, and arterial thrombosis, have occurred in patients treated with JAK inhibitors, including RINVOQ, for inflammatory conditions. Many of these adverse events were serious and some resulted in death. Consider the risks and benefits prior to treating patients who may be at increased risk. Patients with symptoms of thrombosis should discontinue RINVOQ treatment and should be promptly evaluated and treated appropriately.

Other relevant warnings and precautions

• Increases in lipid parameters, including total, low-density lipoprotein, and high-density lipoprotein cholesterol

• Gastrointestinal perforations

• Hematologic events

• Liver enzyme elevation

• Patients with active hepatitis B or C infection

• Patients with severe hepatic impairment

• Concomitant use with other potent immunosuppressants, biologic DMARDs, or other JAK inhibitors

For more information

• Immunizations

• Viral reactivation, including herpes (e.g., herpes zoster) and hepatitis B

• Malignancies

• Increases in creatine phosphokinase

• Monitoring and laboratory tests

• Pregnant women

• Reproductive health

• Breast-feeding

• Geriatrics (≥65 years of age)

• Pediatrics (<12 years of age)

• Asian patients

Please consult the Product Monograph at rinvoq.ca/pm for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-888-704-8271.

Photo courtesy of Wikimedia Commons

POWERFUL EFFICACY DEMONSTRATED in moderate to severe AD

RINVOQ is indicated for the treatment of adults and adolescents 12 years of age and older with refractory moderate to severe atopic dermatitis (AD) who are not adequately controlled with a systemic treatment (e.g., steroid or biologic) or when use of those therapies is inadvisable. RINVOQ can be used with or without topical corticosteroids. Not a real patient, for illustrative purposes only.

In the Measure Up 1 study:‡

RINVOQ 15 mg demonstrated significant improvement in skin clearance (as measured by proportion of patients with EASI 75; co-primary endpoint & EASI 90; secondary endpoint) vs. placebo at Week 161,2

• EASI 75: 69.6% (n/N=196/281) vs. 16.3% (n/N=46/281) of patients achieved EASI 75 with RINVOQ 15 mg vs. placebo ( p<0.0001, multiplicity-controlled).

• EASI 90: 53.1% (n/N=149/281) vs. 8.1% (n/N=23/281) of patients achieved EASI 90 with RINVOQ 15 mg vs. placebo ( p<0.0001, multiplicity-controlled).

A rapid improvement in skin clearance was achieved for RINVOQ 15 mg compared to placebo (defined as EASI 75 by Week 2; secondary endpoint)1,2

• EASI 75: 38.1% (n/N=107/281) vs. 3.6% (n/N=10/281) of patients achieved EASI 75 at Week 2 with RINVOQ 15 mg vs. placebo ( p<0.0001, multiplicity-controlled).

A greater proportion of patients treated with RINVOQ 15 mg achieved clinically meaningful itch reduction (≥4-point reduction in Worst Pruritus NRS; secondary endpoint) compared to placebo treatment group at Week 16

• ≥4-point reduction in Worst Pruritus NRS: 52.2% (n/N=143/274) vs. 11.8% (n/N=32/272) of patients achieved a ≥4-point reduction in Worst Pruritus NRS with RINVOQ 15 mg vs. placebo ( p<0.0001, multiplicity-controlled).

At Week 16, a greater proportion of patients treated with RINVOQ 15 mg achieved clinically meaningful improvement in emotional state (ADerm-IS emotional state domain score improvement from baseline; secondary endpoint) compared to placebo group (RINVOQ 15 mg [n/N=142/227]: 62.6%; placebo [n/N=42/212]: 19.8%; p<0.0001, RINVOQ vs. placebo, multiplicity-controlled).

with

to severe

NOW INDICATED IN ACTIVE PSORIATIC ARTHRITIS

SKYRIZI is indicated for the treatment of adult patients with:

• Moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

• Active psoriatic arthritis. SKYRIZI can be used alone or in combination with a conventional non-biologic disease-modifying antirheumatic drug (cDMARD) (e.g., methotrexate).

In the KEEPsAKE 1 and KEEPsAKE 2 studies, SKYRIZI treatment in patients with PsA demonstrated a statistically significant improvement from baseline in physical function as assessed by HAQ-DI vs. placebo at Week 24. The mean change from baseline was -0.31 (multiplicity-controlled p≤0.001 vs. placebo) and -0.22 (multiplicity-controlled p≤0.001 vs. placebo), respectively, in the SKYRIZI groups, and -0.11 and -0.05, respectively, in the placebo groups.*

Reach out to your AbbVie sales representative for more details.

In the KEEPsAKE 1 and KEEPsAKE 2 studies:1

• Significantly more patients treated with SKYRIZI for PsA achieved ACR 20 vs. placebo at Week 24 (primary endpoint). 57.3% (multiplicity-controlled p≤0.001 vs. placebo) and 51.3% (multiplicity-controlled p≤0.001 vs. placebo) of SKYRIZI patients achieved ACR 20, respectively, in the SKYRIZI groups, and 33.5% and 26.5%, respectively, in the placebo groups.

• An analysis of observed data suggested that ACR 20 response was maintained at Week 52 in both studies.

Clinical use: Efficacy and safety in pediatric population (<18 years of age) have not been evaluated. Limited data available for geriatrics (≥65 years of age).

For more information: Please consult the Product Monograph at www.abbvie.ca/content/dam/ abbviecorp/ca/en/docs/SKYRIZI_PM_EN.pdf for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-888-704-8271.