Search

IMPORTANCE: Inconsistent reporting of outcomes in clinical trials of rosacea is impeding and likely preventing accurate data pooling and meta-analyses. There is a need for standardization of outcomes assessed during intervention trials of rosacea. OBJECTIVE: To develop a rosacea core outcome set (COS) based on key domains that are globally relevant and applicable to all demographic groups to be used as a minimum list of outcomes for reporting by rosacea clinical trials, and when appropriate, in clinical practice. EVIDENCE REVIEW: A systematic literature review of rosacea clinical trials was conducted. Discrete outcomes were extracted and augmented through discussions and focus groups with key stakeholders. The initial list of 192 outcomes was refined to identify 50 unique outcomes that were rated through the Delphi process Round 1 by 88 panelists (63 physicians from 17 countries and 25 patients with rosacea in the US) on 9-point Likert scale. Based on feedback, an additional 11 outcomes were added in Round 2. Outcomes deemed to be critical for inclusion (rated 7-9 by ≥70% of both groups) were discussed in consensus meetings. The outcomes deemed to be most important for inclusion by at least 85% of the participants were incorporated into the final core domain set. FINDINGS: The Delphi process and consensus-building meetings identified a final core set of 8 domains for rosacea clinical trials: ocular signs and symptoms; skin signs of disease; skin symptoms; overall severity; patient satisfaction; quality of life; degree of improvement; and presence and severity of treatment-related adverse events. Recommendations were also made for application in the clinical setting. CONCLUSIONS AND RELEVANCE: This core domain set for rosacea research is now available; its adoption by researchers may improve the usefulness of future trials of rosacea therapies by enabling meta-analyses and other comparisons across studies. This core domain set may also be useful in clinical practice.

IMPORTANCE: Although isotretinoin may rarely be associated with laboratory abnormalities such as hypertriglyceridemia, the optimal approach to laboratory monitoring is uncertain, and there is wide variation in clinical practice. OBJECTIVE: To establish a consensus for isotretinoin laboratory monitoring among a diverse, international cohort of clinical and research experts in acne. DESIGN, SETTING, AND PARTICIPANTS: Using a modified electronic Delphi process, 4 rounds of anonymous electronic surveys were administered from 2021 to 2022. For laboratory tests reaching consensus (≥70% agreement) for inclusion, questions regarding more time-specific monitoring throughout isotretinoin therapy were asked in subsequent rounds. The participants were international board-certified dermatologist acne experts who were selected on a voluntary basis based on involvement in acne-related professional organizations and research. MAIN OUTCOMES AND MEASURES: The primary outcome measured was whether participants could reach consensus on key isotretinoin laboratory monitoring parameters. RESULTS: The 22 participants from 5 continents had a mean (SD) time in practice of 23.7 (11.6) years and represented a variety of practice settings. Throughout the 4-round study, participation rates ranged from 90% to 100%. Consensus was achieved for the following: check alanine aminotransferase within a month prior to initiation (89.5%) and at peak dose (89.5%) but not monthly (76.2%) or after treatment completion (73.7%); check triglycerides within a month prior to initiation (89.5%) and at peak dose (78.9%) but not monthly (84.2%) or after treatment completion (73.7%); do not check complete blood cell count or basic metabolic panel parameters at any point during isotretinoin treatment (all >70%); do not check gamma-glutamyl transferase (78.9%), bilirubin (81.0%), albumin (72.7%), total protein (72.7%), low-density lipoprotein (73.7%), high-density lipoprotein (73.7%), or C-reactive protein (77.3%). CONCLUSIONS AND RELEVANCE: This Delphi study identified a core set of laboratory tests that should be evaluated prior to and during treatment with isotretinoin. These results provide valuable data to guide clinical practice and clinical guideline development to optimize laboratory monitoring in patients treated with isotretinoin.

Acne is a chronic disease with a varying presentation that requires long-term management. Despite this, the clinical guidelines for acne offer limited guidance to facilitate personalized or longitudinal management of patients.

Truncal acne is common and burdensome for patients; however, there is paucity of evidence and guidance for the management of truncal acne. Currently, clinical practice guidelines provide very little guidance on the assessment or management of truncal acne.

Therapeutic actives for acne have changed little in the last decade. Recognition that acne is an inflammatory condition, not an infectious one, has led to a call for reduction in antibiotic use, which has culminated in a re-evaluation of our nonantibiotic choices. Spironolactone and oral contraceptives have become more acceptable first-line choices, and earlier use of isotretinoin has been proposed.

Therapeutic actives for acne have changed little in the last decade. Recognition that acne is an inflammatory condition, not an infectious one, has led to a call for reduction in antibiotic use. This has culminated in a re-evaluation of highly efficacious combination topical therapy and improved vehicle technology. Laser and light modalities, although not sufficiently studied for first-line use, show promise for the future. The role that diet plays in the initiation and continuation of acne is unclear but remains one of our patients’ most frequently asked questions.

Laboratory monitoring for patients on isotretinoin should include creatinine kinase in athletic males and the more liver-specific gamma glutamyltransferase. There is mounting evidence that acne pathophysiology includes a barrier defect and subsequent microbiome disruption. Avoidance of acne scars with early and aggressive treatment is a more efficient and cost-effective option than subsequent treatment. Laser and light treatments for acne and acne scars are plentiful but poorly supported by evidence-based medicine. The acne pipeline is rich with new chemical entities, new formulations, and combinations of older agents. The gold standard for acne therapy may be changing its face.

Acne, a commonly treated skin disease, requires patient-centered management due to its varying presentations, chronicity, and impact on health-related quality of life (HRQoL). Despite this, evidence-based clinical guidelines focus primarily on clinical severity of facial acne, omitting important patient- and disease-related factors, including ongoing management.

The speaker, Dr. Anna Hyer, considered that it was hardly surprising that developments in education are currently the subject of so much attention, since such changes are at the root of any social development, and opinion in the United States has never looked so frankly at the problems of society.

The physical sequelae of acne include erythema, hyperpigmentation, and scarring, which are highly burdensome for patients. Early, effective treatment can potentially limit and prevent sequelae development, but there is a need for guidance and evidence on prevention-oriented management to improve patient outcomes.

TO THE EDITOR.— A 78-year-old Hispanic man was without previous skin lesions until he sustained a hot oil burn to his left cheek. He was seen in the emergency department at the Brooklyn (NY) Veterans Administration Medical Center, noted to have a small crusted lesion on the left cheek, diagnosed as having a second-degree thermal burn, and treated with topical silver sulfadiazine cream. When seen in the dermatology clinic 1 week later, his lesions were resolving and showed only crusts on an erythematous base with slight scarring. No further care was recommended. One week later, he returned to the clinic with multiple small, tense blisters in a ring around the previously involved area (Fig 1). Tzanck preparation and herpes simplex cultures were negative.Histopathologic findings revealed a subepidermal blister and superficial perivascular lymphohistiocytic infiltrate with multiple eosinophils (Fig 2). Direct immunofluorescence showed heavy fibrillar deposits of IgG at the dermoepidermal

REPORT OF A CASE A 66-year-old white male chemical engineer with a history of type II diabetes, parkinsonism, ankylosing spondylitis, esophageal diverticuli, and major depression presented for evaluation of a pruritic ''rash'' on his back. This rash has been present since the early 1960s. He had received two cycles of radiotherapy to his lower back to treat his ankylosing spondylitis. The first cycle began in 1954 and consisted of radiotherapy two to three times per week for 3 months. The amount and type of radiation the patient received is unknown. The second cycle was performed several years later. Initially, the lesions were reported to disappear with sunlight exposure. In the early 1960s, the patient had a biopsy performed on one of the lesions (results are unknown) and received 1.5 years of UV-B phototherapy. Over the years, the patient sought treatment from other dermatologists, several of whom performed biopsies (results also