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Background /objectives: Environmental exposure and personal susceptibility both contribute to the development of hand eczema. Here, we report an investigation on wet work exposure and its influence on the risk of developing hand eczema in apprentice nurses., Methods: A prospective cohort study was performed among 721 Dutch apprentice nurses. Participants recorded wet work exposure and symptoms of hand eczema using specially designed diary cards., Results: For 533 apprentice nurses, a follow-up time of 1-3 years was completed. Diary cards were supplied by 383 students. The 1-year period prevalence of hand eczema was 23% in the first year, 25% in the second year and 31% in the third year of follow-up. Eighty-one new cases of hand eczema developed, most of which occurred during the first year of follow-up. In approximately one-third of the participants, wet work exposure exceeded the national guidelines. Frequent hand washing during traineeships [odds ratio (OR) 1.5; 90% confidence interval (CI) 1.0-2.3], frequent hand washing at home (OR 2.3; 90% CI 1.5-3.7) and having a side job involving wet work (OR 1.6; 90% CI 1.0-2.4) were independent risk factors for hand eczema., Conclusion: As a considerable number of apprentice nurses had already developed hand eczema during traineeships, more attention should be paid to skin protection in vocational education., (© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background/aims: Vitiligo is considered to be an autoimmune disease and is known to be associated with other autoimmune diseases, particularly affecting the thyroid. In children and adolescents this association has been reported in only a few studies, with varying results. The aim of this study was to examine thyroid function and prevalence of thyroid autoimmunity in children and adolescents with vitiligo and to investigate the utility of screening., Methods: Two hundred and sixty patients with vitiligo were enrolled. Plasma TSH, FT4 and anti-thyroid peroxidase (TPO) antibody concentrations were measured. The prevalence of thyroid dysfunction and autoimmunity were compared to the general healthy paediatric population., Results: Autoimmune thyroiditis (AIT) with thyroid hormone disturbances was diagnosed in 16 patients (6.2%). This is significantly higher than the prevalence reported in the general healthy paediatric population. Increased levels of anti-TPO antibodies (= 30 kU/l), without thyroid hormone disturbances, were found in 27 patients (10.5%)., Conclusion: The prevalence of AIT in children and adolescents with vitiligo is significantly higher than in the general population. It may be advantageous to screen thyroid function and antibody levels in all paediatric patients with non-segmental vitiligo. To strengthen recommendations on screening, research on the burden for patients and cost-effectiveness is needed., (Copyright © 2013 S. Karger AG, Basel.)

Background: Vitiligo is a common skin disease characterized by autoimmune melanocyte destruction. Recent genetic studies suggest a lower susceptibility to melanoma in patients with vitiligo; however, lifetime melanoma prevalence in patients with vitiligo has not previously been studied. Nonmelanoma skin cancer (NMSC) prevalence has been studied, but only in small studies and with contradictory results., Objectives: This retrospective, comparative cohort survey was designed to assess lifetime prevalences of melanoma and NMSC in patients with vitiligo compared with nonvitiligo controls., Methods: Patients with nonsegmental vitiligo, who visited our clinic between January 1995 and September 2010, and were aged 50 years or older at the time of the study, were invited to participate in a postal survey. The questions regarded demographics, vitiligo characteristics, phototherapy history, skin cancer risk factors and the number of skin cancers experienced during the patient's lifetime. Patients were asked to have their partner fill in a control questionnaire. All skin cancers were validated by a pathology report. In total 2635 invitations were sent and 1307 eligible questionnaires were returned (50%). Multivariate logistic regression models were used to quantify adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for associations between vitiligo and lifetime prevalences of melanoma and NMSC., Results:  Adjusted for confounders, patients with vitiligo had a threefold lower probability of developing melanoma (adjusted OR 0·32; 95% CI 0·12-0·88) and NMSC (adjusted OR 0·28; 95% CI 0·16-0·50). Subgroup analyses of patients treated with narrowband ultraviolet (UV) B, and psoralen and UVA did not show dose-related trends of increased age-adjusted lifetime prevalence of melanoma or NMSC., Conclusions: Our findings suggest that patients with vitiligo have a decreased risk of both melanoma and NMSC., (© 2012 The Authors. BJD © 2012 British Association of Dermatologists.)

Background: Teledermatology, the application of telemedicine in the field of dermatology, has similar accuracy and reliability as physical dermatology. Teledermatology has been widely used in daily practice in the Netherlands since 2005 and is fully reimbursed., Objectives: This study prospectively investigated the effect of teledermatology on efficiency, quality and costs of care when integrated in daily practice and applied following patient selection by the general practitioner (GP)., Methods: Teledermatology consultations between GP and regional dermatologist were performed in daily GP practice in the Netherlands. Efficiency of care was measured by the decrease in the number of physical referrals to the dermatologist. Quality of care was measured by the percentage of teleconsultations for second opinion, physical referrals resulting from these teleconsultations, the response time of the dermatologists and educational effect experienced by the GP. Costs of conventional healthcare without teledermatology were compared with costs with teledermatology., Results: One thousand, eight hundred and twenty GPs and 166 dermatologists performed teledermatology, and 37,207 teleconsultations performed from March 2007 to September 2010 were included. In the group of patients where the GP used teleconsultation to prevent a referral (n =26,596), 74% of physical referrals were prevented. In the group of patients where the GP used teleconsultation for a second opinion (n =10,611), 16% were physically referred after teleconsultation. The prevented referral rate in the total population was 68%. The mean response time of dermatologists was 4·6 h (median 2·0). GPs indicated that there was a beneficial educational effect in 85% of the teleconsultations. The estimated cost reduction was 18%., Conclusions: Teledermatology can lead to efficient care probably at lower cost. We are therefore of the opinion that teledermatology following GP selection should be considered as a possible pathway of referral to secondary care., (© 2011 The Authors. BJD © 2011 British Association of Dermatologists.)

There is no gold standard for a definite diagnosis of atopic dermatitis. For the time being, several lists of diagnostic criteria have been proposed, some of them in actual use. The Millennium Criteria have been proposed to diagnose atopic dermatitis and to differentiate it from atopiform dermatitis. Our aim was to further refine the Millennium Criteria into a manageable set that can differentiate between atopic and atopiform dermatitis and other entities. The hereby refined Millennium Criteria will be compared with the UK Working Party Criteria and the Hanifin & Rajka Criteria. Data of 210 included patients were used. After multiple logistic regression, a minimum set of five criteria was identified as best discriminators: (i) typical morphology; (ii) early age of onset; (iii) Dennie-Morgan fold; (iv) historical and (v) actual flexural involvement. The refined Millennium Criteria were constituted from these criteria. When comparing the different list for validity in diagnosing atopic dermatitis, the refined Millennium Criteria showed a sensitivity of 81.8% and a specificity of 98.8% compared to a sensitivity of 97.7% and specificity of 72.9% of the UK Criteria and a sensitivity of 100% and specificity of 48.8% of the Hanifin & Rajka Criteria. This refinement and validity study shows that the refined Millennium Criteria are a valid tool to diagnose atopic and atopiform dermatitis in a hospital-based setting and therefore could be incorporated in clinical practice and trials., (© 2011 Japanese Dermatological Association.)

Tertiary teledermatology (TTD), where a general dermatologist consults a specialized dermatologist on difficult cases, is a relatively new telemedicine service. We evaluated TTD in a Dutch university hospital, where 13 general dermatologists used TTD to consult 11 specialized dermatologists and two residents at the university medical centre. We measured the avoided referrals to the university centre, the usability of the system and the user acceptance of it. During a three-month study, general dermatologists consulted via TTD 28 times. In 17 of the consultations (61%), the general dermatologists would have referred their patients to the university centre if teledermatology had not been available. Referral was not necessary after teledermatology for 12 of these 17 consultations (71%). The mean usability score (0-100) of all the users was 80. All dermatologists were satisfied with TTD (mean satisfaction of 7.6 on a 10-point scale) and acceptance was high. The baseline measurements showed that half of tertiary referrals were suitable for TTD. These results suggest that TTD reduces unnecessary physical referrals and that users are satisfied with it. A large-scale evaluation is now required.

Objectives: To document and compare the costs of treatment of psoriasis with 2 established systemic agents that differ substantially in their unit costs: methotrexate vs cyclosporine., Design: Cost-minimization analysis within a randomized controlled trial., Setting: Outpatient dermatology department at an academic hospital., Patients: Adults with moderate to severe plaque psoriasis, with no previous methotrexate or cyclosporine treatment., Intervention: Sixteen weeks of treatment with methotrexate or cyclosporine and an additional 36 weeks of follow-up., Main Outcome Measures: Direct and indirect medical and nonmedical costs associated with resource utilization during treatment and follow-up., Results: Average cumulative total costs associated with 16 weeks of treatment were 1593 US dollars for methotrexate and 2114 US dollars for cyclosporine (521 US dollars less for methotrexate); during 36 weeks of follow-up, these costs were 2418 US dollars and 2306 US dollars, respectively. The overall difference in cumulative 1-year costs was 409 US dollars, or approximately 10% of the total costs., Conclusions: After 1 year, the overall difference in total costs between methotrexate and cyclosporine for 16 weeks of treatment and follow-up is relatively small. Systemic medication costs are only a fraction of the costs directly and indirectly generated by utilization of health care resources and associated with individual patients rather than with methotrexate or cyclosporine. Economic arguments can be supportive of but not decisive for individual patient decisions and guidelines for systemic therapy. Rational decision making for the treatment of psoriasis may include costs only within a long-term horizon and may consider the societal and patient benefits of different alternatives.

We carried out a pilot study on the feasibility and accuracy of store-and-forward teledermatology based on patient-provided images and history as a triage tool for outpatient consultation. Patients referred by their general practitioner provided a history and images via the Internet. The information was reviewed by one of 12 teledermatologists and the patient then visited a different dermatologist in person within two days. Three independent dermatologists compared the remote and in-person diagnoses in random order to determine diagnostic agreement. Broader agreement was also measured, by comparing the main disease groups into which the two diagnoses fell. The teledermatologists indicated whether an in-person consultation or further investigations were necessary. There were 105 eligible patients, aged four months to 72 years, who were willing to participate. For the 96 cases included in the analysis, complete diagnostic agreement was found in 41% (n=39), partial diagnostic agreement in 10% (n=10) and no agreement in 49% (n=47). There was disease group agreement in 66% of cases (n=63). Nearly a quarter (23%) of participating patients could have safely been managed without an in-person visit to a dermatologist.

Objective: To develop and introduce evidence-based guidelines for the treatment of vitiligo in children and in adults., Patients and Setting: Patients, residents, and dermatologists from the Department of Dermatology, Academic Medical Center, University of Amsterdam, and the Netherlands Institute for Pigmentary Disorders in Amsterdam., Design: Scientific evidence obtained from 3 systematic reviews of the literature was combined with the results of 2 questionnaires and interviews of potential users of the guidelines, 3 internal expert meetings, and 1 local expert meeting, during which preliminary guidelines were presented and commented on. A final version of the guidelines was synthesized and disseminated among potential users. Six months after the introduction of these guidelines, their use was evaluated., Results: Before the development of the guidelines, there was no uniformity in treatment selection, and there was a variability in estimates of treatment outcome. The metaanalysis showed class 3 corticosteroids and narrowband UV-B to be the most effective and safest therapies for localized and for generalized vitiligo, respectively. From another systematic review, it could be concluded that patients with segmental, stable, or lip-tip vitiligo could be successfully treated with most autologous transplantation methods. For vitiligo universalis, results of the systematic review showed that depigmentation using monobenzone or a Q-switched ruby laser was equally effective. The final version of the guidelines consisted of a treatment scheme together with detailed treatment protocols. Implementation of the guidelines was evaluated in 5 physicians. After the introduction of these guidelines, they were followed in most adult cases with vitiligo (71% of patients with localized vitiligo, 82% with generalized vitiligo, 100% with stable or segmental vitiligo, and 80% with universal vitiligo). In children with vitiligo, the physicians adhered to the guidelines for 52% of the cases., Conclusions: Guidelines for the treatment of vitiligo can be successfully developed and disseminated for daily clinical practice. The results of the implementation of these guidelines should be confirmed in other centers involving more clinicians.

In only a minority of chronic urticaria patients an underlying cause or illness can be detected. Previous studies demonstrated that detailed history taking is more important than routine laboratory investigations. To improve the process of history taking, the use of a detailed urticaria questionnaire is highly recommended. By using such a history-based diagnostic approach, the costs of laboratory investigations could be reduced from an average of 538 NLG per patient to 84 NLG per patient. The percentage of patients in whom a cause could be found increased from 29% to 53%. No severe underlying illnesses were missed by using this approach.

We report a comparative study of the patch-test results obtained with a corticosteroid series, added to the standard series, in two centres, one in Belgium and the other in the Netherlands. The frequencies of positive reactions to the corticosteroids differed considerably between the two centres, and we suggest several reasons for this.

This is a review of the clinical studies performed so far in The Netherlands of the treatment of psoriasis with cyclosporin A (CyA), a selective immunosuppressive drug that has caused a major breakthrough in transplant medicine. Data derived from a double-blind placebo-controlled study (5 mg/kg/day of CyA), dose-finding studies (2.5 mg vs 5 mg/kg/day and 1 mg, 2 mg or 3 mg/kg/day), and long-term treatment of chronic plaque-type psoriasis (1.1-7.2 mg/kg/day) suggest an initial starting dose of 3 mg/kg/day irrespective of the severity of the disease. Long-term treatment brought about dose- and time-dependent (reversible) side-effects, including renal dysfunction and hypertension. Efforts to reduce the dose included concomitant administration of drugs known to have anti-psoriatic efficacy. Only combination with topical steroids appeared to add to the clinical efficacy of CyA, but did not allow a dose reduction sufficient to restore renal function. Dose reduction through intermittent treatment, however, postponed exacerbations sufficiently to permit at least partial normalization of serum creatinine levels. A similar effect was seen in the treatment of pustular palmoplantar psoriasis, which responded to doses of 1.1-6.1 mg/kg/day.

8 cases of contact dermatitis from toluenesulfonamide formaldehyde resin in a nail hardener are presented. Most patients had used nail lacquers containing this resin for many years without trouble, but became sensitized to the resin shortly after the introduction of this particular nail hardener. A hypothesis concerning the possible mechanism is given.

To determine whether the prevalence of allergic reactions to certain preservatives warrants their inclusion in a routine series for patch testing, a tray of 14 preservatives was tested in 501 consecutive suspected contact dermatitis patients. More than 1% positive reactions were found with DMDM hydantoin, Kathon CG, and alkyl trimethyl ammonium chloride only. The concentration of alkyl trimethyl ammonium chloride (0.1% aqua) was considered too high. Of 6 patients reacting to the formaldehyde releaser DMDM hydantoin, 4 were positive to formaldehyde. Kathon CG may be an important allergen in the Netherlands, and it is worthwhile for dermatologists there to add it to the standard test series. The recent inclusion of quaternium-15 in the ICDRG standard series appears to be of little value to them.