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IMPORTANCE: Patients with cutaneous squamous cell carcinoma (SCC) of the head and neck may develop lymph node metastasis; therefore, additional workup of the regional lymph nodes in these patients should be considered. However, there is uncertainty regarding the value of baseline ultrasonographic imaging in addition to clinical examination for the detection of metastasis.OBJECTIVE: To assess the diagnostic accuracy of clinical examination and baseline ultrasonography for the detection of metastasis among patients with high-risk cutaneous SCC of the head and neck and to assess the accuracy of ultrasonography when baseline clinical examination produces negative results.DESIGN, SETTING, AND PARTICIPANTS: This diagnostic study was conducted among a retrospective cohort of 233 patients with 246 high-risk cutaneous SCC tumors of the head and neck. The study included all patients with high-risk cutaneous SCC of the head and neck who received clinical examination and baseline ultrasonographic imaging of their lymph nodes at the Erasmus Medical Center Cancer Institute, a tertiary referral hospital for patients with skin cancer in Rotterdam, the Netherlands, between January 1, 2015, and December 31, 2017. Data were analyzed from October 13, 2020, to September 29, 2021.MAIN OUTCOMES AND MEASURES: Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Fine-needle aspiration cytologic biopsy and 6 months of follow-up per patient were used as the reference standards.RESULTS: Among 233 patients (176 men [75.5%]; median age, 79.1 years [IQR, 71.5-83.7 years]; data on race and ethnicity were not collected) with 246 high-risk cutaneous SCC tumors of the head and neck, 20 metastases were cytologically confirmed at baseline, and 2 metastases were detected during 6 months of follow-up, yielding a 9% metastasis rate. The sensitivity of clinical examination was 50% (95% CI, 28%-72%), and the specificity was 96% (95% CI, 93%-98%). The PPV and NPV were 55% (95% CI, 36%-72%) and 95% (95% CI, 93%-97%), respectively. In the total cohort, ultrasonography had a sensitivity of 91% (95% CI, 71%-99%) and a specificity of 78% (95% CI, 72%-83%), with a PPV of 29% (95% CI, 23%-35%) and an NPV of 99% (95% CI, 96%-100%). In the group of patients with negative results at baseline clinical examination, 9 of 11 metastases were detected by ultrasonography, with 82% sensitivity (95% CI, 48%-98%); specificity was 79% (95% CI, 73%-84%), PPV was 17% (95% CI, 12%-23%), and NPV was 99% (95% CI, 96%-100%).CONCLUSIONS AND RELEVANCE: In this diagnostic study, among a cohort of patients with high-risk cutaneous SCC of the head and neck, baseline ultrasonography was more sensitive than clinical examination alone for the detection of lymph node metastasis. In the setting of a negative result at baseline clinical examination, ultrasonography had high sensitivity for detecting nodal metastases, but this sensitivity should be evaluated against the high rate of false-positive findings.

Simple Summary Melanoma of the skin is the most lethal form of skin cancer. Almost 40% of the patients who die of metastatic melanoma did not have metastases at first diagnosis. More knowledge about patient and tumour characteristics as well as patterns of disease progression is needed. We described the characteristics and disease patterns of early-stage melanomas that progress into metastatic disease. We observed that more than half of the patients with metastases were initially diagnosed with early-stage disease. Additionally, we found that melanomas in some specific body sites were likely to metastasize to certain organs. Our finding that a substantial proportion of patients with metastases were initially diagnosed with early-stage disease highlights the need to investigate who these high-risk patients are. Abstract The characteristics and disease patterns of primary stage I and II cutaneous melanomas that progress to stage III or IV disease were investigated based on data from the Netherlands Cancer Registry (NCR). Data on stage III or IV melanomas at first diagnosis or during follow-up between 2017 and 2019 were retrieved. Patient and primary tumour characteristics were investigated in relation to time to disease progression and the number of organ sites with metastatic disease using regression models. In total, 2763 patients were included, of whom 1613 were diagnosed with stage IV disease. Among the patients with stage IV disease, 60% (n = 963) were initially diagnosed with stage I or II disease. The proportion of patients who received a sentinel lymph node biopsy increased after the introduction of adjuvant therapy in 2019 from 61% to 87%. Among all patients with stage III disease who were eligible for adjuvant systemic therapy (n = 453) after 2019, 37% were not treated with this therapy. Among patients with stage IV disease, lung metastases were most often detected as the first metastatic site and females presented with more metastatic sites than males. Most patient and primary tumour characteristics were not associated with the distant metastatic organ site, except melanoma localisation in the lower extremities and the head or neck. Our observation that most stage IV patients were initially diagnosed with early-stage disease highlights the need for more accurate risk prediction models.

OBJECTIVE: . To compare the screening performance of the Psoriasis Epidemiology Screening Tool (PEST), Psoriatic Arthritis Screening and Evaluation (PASE) and Early Arthritis for Psoriatic Patients (EARP) questionnaires for detecting PsA among psoriasis patients in a primary care setting.METHODS: In a cross-sectional study, 473 primary care psoriasis patients at risk for PsA completed the PEST, PASE and EARP questionnaires and were clinically evaluated by a trained research nurse. A PsA case was defined by a rheumatologist according to the CASPAR criteria. Sensitivity and specificity were determined for the PEST and EARP cut-offs (⩾3) and the PASE cut-offs (⩾44 and ⩾47).RESULTS: PsA was diagnosed in 53 patients. The PEST had a sensitivity of 0.68 and a specificity of 0.71. The PASE was validated for two different cut-offs. The cut-off of 47 led to a sensitivity of 0.59 and a specificity of 0.66, whereas the lower cut-off of 44 led to a sensitivity of 0.66 and a specificity of 0.57. For the EARP we found a sensitivity of 0.87 with a specificity of 0.34.CONCLUSION: The PEST questionnaire has the most favourable trade-off between sensitivity and specificity to screen for PsA. However, as the prevalence of psoriasis and PsA is fairly low in primary care, screening only psoriasis patients with musculoskeletal complaints may be a better allocation of resources.

Basal cell carcinoma (BCC) is the most common cancer in white-skinned individuals with increasing incidence rates worldwide. Patients with BCC place a large burden on healthcare systems, because of the high incidence and the increased risk of synchronous and metachronous BCCs and other ultraviolet radiation (UVR) related skin cancers (i.e. field cancerization). As a result, the disability-adjusted life years and healthcare costs have risen significantly in recent decades. BCC is a complex disease, in which the interplay between UVR, phenotype (UVR-sensitive) and genotype (somatic mutations and germline mutations/polymorphisms) fulfils a key role in the aetiopathogenesis. Prevention programmes with continual refinements and improvements could be of major importance in tackling the growing skin cancer problem. To provide the most appropriate BCC care, physicians should engage in shared decision-making and choose their treatments wisely.

UNSTRUCTURED Skin cancer is a growing public health problem. Early and accurate detection is important, since prognosis and cost of treatment are highly dependent on cancer stage at detection. However, access to specialized health care professionals is not always straightforward, and population screening programs are unlikely to become implemented. Furthermore, there is a wide margin for improving the efficiency of skin cancer diagnostics. Specifically, the diagnostic accuracy of general practitioners and family physicians in differentiating benign and malignant skin tumors is relatively low. Both access to care and diagnostic accuracy fuel interest in developing smartphone apps equipped with algorithms for image analyses of suspicious lesions to detect skin cancer. Based on a recent review, seven smartphone apps claim to perform image analysis for skin cancer detection, but as of October 2018, only three seemed to be active. These apps have been criticized in the past due to their lack of diagnostic accuracy. Here, we review the development of the SkinVision smartphone app, which has more than 900,000 users worldwide. The latest version of the SkinVision app (October 2018) has a 95% sensitivity (78% specificity) for detection of skin cancer. The current accuracy of the algorithm may warrant the use of this app as an aid by lay users or general practitioners. Nonetheless, for mobile health apps to become broadly accepted, further research is needed on their health impact on the health system and the user population. Ultimately, mobile health apps could become a powerful tool to reduce health care costs related to skin cancer management and minimize the morbidity of skin cancer in the population.

Summary Background The high prevalence of actinic keratosis (AK) requires the optimal use of healthcare resources. Objectives To gain insight in to the healthcare utilization of people with AK in a population‐based cohort, and the management of AK in a primary and secondary care setting. Methods A retrospective cohort study using three complementary data sources was conducted to describe the use of care, diagnosis, treatment and follow‐up of patients with AK in the Netherlands. Data sources consisted of a population‐based cohort study (Rotterdam Study), routine general practitioner (GP) records (Integrated Primary Care Information) and nationwide claims data (DRG Information System). Results In the population‐based cohort (Rotterdam Study), 69% (918 of 1322) of participants diagnosed with AK during a skin‐screening visit had no previous AK‐related visit in their GP record. This proportion was 50% for participants with extensive AK (i.e. ≥ 10 AKs; n = 270). Cryotherapy was the most used AK treatment by both GPs (78%) and dermatologists (41–56%). Topical agents were the second most used treatment by dermatologists (13–21%) but were rarely applied in primary care (2%). During the first AK‐related GP visit, 31% (171 of 554) were referred to a dermatologist, and the likelihood of being referred was comparable between low‐ and high‐risk patients, which is inconsistent with the Dutch general practitioner guidelines for ‘suspicious skin lesions’ from 2017. Annually, 40 000 new claims representing 13% of all dermatology claims were labelled as cutaneous premalignancy. Extensive follow‐up rates (56%) in secondary care were registered, while only 18% received a claim for a subsequent cutaneous malignancy in 5 years. Conclusions AK management seems to diverge from guidelines in both primary and secondary care. Underutilization of field treatments, inappropriate treatments and high referral rates without proper risk stratification in primary care, combined with extensive follow‐up in secondary care result in the inefficient use of healthcare resources and overburdening in secondary care. Efforts directed to better risk differentiation and guideline adherence may prove useful in increasing the efficiency in AK management. What's already known about this topic? The prevalence of actinic keratosis (AK) is high and, in particular, multiple AKs are a strong skin cancer predictor.The high prevalence of AK requires optimal use of healthcare resources.Nevertheless, (population based) AK healthcare utilization and management data are very rare. What does this study add? Although AK‐related care already consumes substantial resources, about 70% of the AK population has never received care.Primary care AK management demonstrated underutilization of topical therapies and high referral rates without proper risk stratification, while in secondary care the extensive follow‐up schedules were applied.This inefficient use of healthcare resources highlights the need for better harmonization and risk stratification to increase the efficiency of AK care., Linked Comment: https://doi.org/10.1111/bjd.17862. https://doi.org/10.1111/bjd.18269 available online https://www.bjdonline.com/article/

Background High incidence rates of keratinocyte carcinoma (KC) in Western countries put pressure on healthcare systems. The aim of this study was to describe clinical practice in order to identify areas for improvement. Methods A random selection of patients from the Integrated Primary Care Information database who consulted their general practitioner (GP) for suspicious or confirmed KC (n = 1597) was made in the analysis. For secondary care, 1569 patients with histologically confirmed KC were randomly selected from the Netherlands Cancer Registry. All patients were diagnosed between 2009 and 2013 and followed up until 2016. Details on diagnosis, treatment and care during follow-up were described. Results Among 942 patients who consulted their GP, KC was included in the working or differential diagnosis, but two-thirds (629) were not KC. If the GP suspected KC, the GP directly referred to a medical specialist in most cases (548 of 942). In half (470 of 967) of all confirmed KCs, a skin malignancy was not described in the initial working or differential diagnosis of the GP. The medical specialist treated the first primary KC in 86% (1369 of 1596) by excision, 4% (69 of 1596) by Mohs surgery and 10% (158 of 1596) by another treatment. Although follow-up is not recommended for low-risk basal cell carcinoma, 83% (29 of 35) received follow-up care. In contrast, 82% (60 of 73) patients with squamous cell carcinoma received less follow-up than recommended. Conclusions Strengthening the diagnostic pathway for KC in primary care and reduction of low-value follow-up visits in secondary care seem potential areas for improving the efficiency of KC care.

Lentigo maligna (LM) is considered a precursor to LM melanoma (LMM). We assessed trends in LM and LMM incidence rates between 1989 and 2013 in the Netherlands, and estimated the risk of an LMM after LM. Data on newly diagnosed LM and LMM were obtained from the Netherlands Cancer Registry and PALGA: Dutch Pathology Registry. Age-standardized incidence rates (European standardized rate), estimated annual percentage changes, and the cumulative incidence of LMM after LM were calculated. Between 1989 and 2013, 10,545 patients were diagnosed with a primary LM and 2,898 with a primary LMM in the Netherlands. The age-standardized incidence rate for LM increased from 0.72 to 3.84 per 100,000 person-years, and for LMM from 0.24 to 1.19 between 1989 and 2013. LM incidence increased from 2002 to 2013 with 6.8% annually, before an even steeper rise in LMM incidence from 2007 to 2013 (estimated annual percentage change: 12.4%). The cumulative incidence of LMM after a primary LM after 25-year follow-up was 2.0% for males and 2.6% for females. The increased incidence of LM and LMM in the Netherlands seems, besides increased awareness and increased histological confirmation of LM, to reflect a true increase. The absolute risk of an LMM (at any location) after a histologically confirmed LM was low (2.0-2.6%).

textabstractObjective To estimate the prevalence of psoriatic arthritis (PsA) in primary care patients diagnosed as having psoriasis and to estimate the prevalence of musculoskeletal symptoms in psoriasis patients in primary care. Methods We conducted a cross-sectional study in adult primary care patients with psoriasis. Responding patients reporting pain in joints, entheses, or the lower back were interviewed by telephone to determine eligibility and, if eligible, were invited for clinical evaluation. During clinical evaluation, skin, nails, joints, and entheses were assessed. Additionally, ultrasound of the enthesis was performed by an independent trained examiner if a patient had at least 1 tender enthesis (determined by the Leeds Enthesitis Index and the Maastricht Ankylosing Spondylitis Enthesitis Score). Patients who fulfilled the Classification of Psoriatic Arthritis (CASPAR) Study Group criteria were classified as having PsA. Results We invited 2,564 psoriasis patients from databases of 97 participating general practitioners. Of 1,673 responders (65.2%), 841 (50.3%) were willing to participate. A total of 823 patients (32.1%) reported having musculoskeletal symptoms; 659 of these patients were determined to be eligible, 524 of whom were clinically evaluated. We identified 64 cases of established PsA and another 17 cases of newly diagnosed PsA, leading to a prevalence of 3.2% (95% confidence interval [95% CI] 2.5-3.9) among psoriasis patients in primary care. This prevalence would increase to 4.6% (95% CI 3.8-5.4) if PsA cases based on enthesitis were also taken into account. Conclusion Among psoriasis patients in primary care, the prevalence of PsA is conservatively estimated to be 3.2%, increasing to 4.6% if enthesitis is taken into account. The prevalence of musculoskeletal symptoms among psoriasis patients is comparable with the prevalence of musculoskeletal symptoms in the general population.

Prevalence of non-alcoholic fatty liver disease is increased in patients with psoriasis. However, it is not known how liver fibrosis correlates with psoriasis. This study investigated the association between psoriasis and liver fibrosis compared with participants without psoriasis within the population-based Rotterdam Study. All participants were screened for liver fibrosis using transient elastography. Liver stiffness > 9.5 kPa suggested advanced liver fibrosis. Psoriasis was identified using a validated algorithm. A total of 1,535 participants were included (mean age +/- standard deviation 70.5 +/- 7.9 years; 50.8% female; median body mass index 26.4 kg/m(2) (interquartile range 24.2-28.9)) of whom 74 (4.7%) had psoriasis. Prevalence of advanced liver fibrosis was 8.1% in psoriasis patients compared with 3.6% in the reference group (p = 0.05). The risk of advanced liver fibrosis in psoriasis patients remained comparable after adjustment for demographics, lifestyle characteristics and laboratory findings (odds ratio 2.57 (95% confidence interval 1.00-6.63). This study suggests that elderly people with psoriasis are twice as likely to have advanced liver fibrosis irrespective of common risk factors.

Dusingize et al. used a prospective observational cohort study to demonstrate a decreased risk of basal cell carcinoma and an increased risk of squamous cell carcinoma among smokers. This association disappeared after stratifying for skin screening visits, demonstrating the important role of detection bias. In the absence of randomized clinical trials, well-designed and critically analyzed observational studies can provide similarly valuable evidence.

Skin cancer is the most common type of cancer and its incidence is increasing. The objective of this study was to describe the trends in reimbursed drug and hospital costs of benign and (pre)malignant skin tumours, and to present future projections. Therefore, nationwide hospital and drug reimbursement data (for the period 2007-17) were used. In 2017, malignant skin tumours were the 4th most costly cancer in the Netherlands (after breast, colorectal, and lung cancer). The total costs for skin tumours increased from €278 million for 384,390 patients (in 2007) to €465 million for 578,355 patients (in 2017). Drug costs increased from €0.7 million to €121 million (over the period 2007-17), resulting in a 26% share of overall costs in 2017. Future costs are projected to reach €1.35 billion in 2030. In conclusion, the increasing costs of skin cancer are strongly affected by the increasing incidence and introduction of expensive drugs, and future projections are for an alarming increase.

ObjectiveAutoimmune thyroid disease (AITD) and psoriatic disease share auto-immunological components. Few studies have investigated the link between both, yielding inconclusive results.DesignWe assessed the association of AITD with psoriatic disease in a prospective cohort study and performed a systematic review and meta-analysis.Methods8214 participants of the Rotterdam Study (RS) with thyroid peroxidase antibodies (TPO-Abs), thyroid-stimulating hormone (TSH) and/or free thyroxine (FT4) measurements and information on psoriatic disease were included. We performed logistic and Cox regression analyses and a systematic literature search in several electronic databases on AITD and psoriatic disease. We pooled odds ratios (ORs) of included studies using the Mantel-Haenszel method, while adding RS data on prevalent psoriatic disease.ResultsWithin the RS, we found no association between TPO-Ab positivity and psoriatic disease. There was a positive trend between TSH and prevalent psoriatic disease, and between FT4 and incident psoriatic disease, although not significant. Out of 1850 articles identified, seven were included in the systematic review and four in the meta-analysis. The risk of psoriatic disease (pooled OR) was 1.71 (confidence interval (CI): 1.27–2.31) for TPO-Ab positivity, 1.25 (CI: 1.14–1.37) for AITD and 1.34 (CI: 1.16–1.54) respectively, and 1.17 (CI: 1.03–1.32) for hypothyroidism and hyperthyroidism.ConclusionsOur meta-analysis suggests that TPO-Ab positivity, hypothyroidism and hyperthyroidism might be associated with prevalent psoriatic disease. However, there are only few studies with large heterogeneity regarding psoriatic disease definition and indication of publication bias. Additional prospective data are needed to assess the association of AITD with incident psoriatic disease.

BACKGROUND: Medication use in patients with psoriasis has been studied mostly in the context of psoriasis comorbidities. OBJECTIVES: To investigate detailed drug utilization in patients with psoriasis compared with controls in a population-based sample. METHODS: This was a case-control study based on drug prescriptions derived from a Dutch general practitioner database where patients with psoriasis and controls without psoriasis were matched 1 : 1 for age, sex, general practitioner and duration of follow-up, between 2002 and 2012. We calculated Mantel-Haenszel odds ratios (ORs) and 95% confidence intervals (CIs) for all therapeutic groups and chemical substances. RESULTS: In total 17 627 patients with psoriasis and 17 627 controls were followed for > 4 years. Overall 20% of patients with psoriasis received no psoriasis treatment and 8% had moderate-to-severe disease. During the entire follow-up a mean of nine unique drugs were prescribed in patients with psoriasis; this was significantly higher than in controls (mean of seven). Drug use did not peak around the date of diagnosis for psoriasis, but remained constant over time. All of the most commonly prescribed therapeutic groups were significantly more often prescribed in patients with psoriasis than in controls. These included drugs associated with psoriasis symptoms and treatment (OR 2.17, 95% CI 2.07-2.28 and OR 22, 95% CI 21-25, respectively), drugs related to psoriasis comorbidities (1.46, 95% CI 1.39-1.53) and a proportion of drugs that were a priori not expected to be increased in patients with psoriasis, such as nasal preparations and laxatives. CONCLUSIONS: Patients with psoriasis received more prescriptions for all drugs, regardless of associated comorbidities. This overall increased use of drugs suggests an increased healthcare utilization in patients with psoriasis identified in routine databases.

The reported prevalence of depression in psoriasis varies substantially. This study aims to determine the prevalence and odds of depressive symptoms and clinical depression in psoriasis. A systematic literature search was conducted. Mean questionnaire values and proportions for depressive symptoms and clinical depression were pooled according to different assessment methods. In controlled studies, standardized mean differences (SMDs) and odds ratio (OR) compared depression in psoriasis patients with controls using the random-effect model. The majority of the 98 eligible studies were conducted in tertiary centers without a control group. The prevalence of depressive symptoms was 28% using questionnaires and the prevalence of clinical depression was 12% using International Classification of Diseases codes, 19% using Diagnostic and Statistical Manual of Mental Disorders IV, and 9% for antidepressant use. Psoriasis patients had significantly more depressive symptoms (SMD 1.16; 95% confidence interval (CI) 0.67-1.66), and population-based studies showed that they were at least one and a half times more likely to experience depression (OR 1.57; 95% CI 1.40-1.76) and used more antidepressants than did controls (OR 4.24, 95% CI 1.53-11.76). More than 10% of psoriasis patients suffer from clinical depression, and twice as many have depressive symptoms. The high prevalence of these symptoms is likely to be affected by the tertiary study populations and differential misclassification using questionnaires, where psoriasis-related symptoms may be detected as depressive symptoms.

Skin cancer is a growing public health problem. Early and accurate detection is important, since prognosis and cost of treatment are highly dependent on cancer stage at detection. However, access to specialized health care professionals is not always straightforward, and population screening programs are unlikely to become implemented. Furthermore, there is a wide margin for improving the efficiency of skin cancer diagnostics. Specifically, the diagnostic accuracy of general practitioners and family physicians in differentiating benign and malignant skin tumors is relatively low. Both access to care and diagnostic accuracy fuel interest in developing smartphone apps equipped with algorithms for image analyses of suspicious lesions to detect skin cancer. Based on a recent review, seven smartphone apps claim to perform image analysis for skin cancer detection, but as of October 2018, only three seemed to be active. These apps have been criticized in the past due to their lack of diagnostic accuracy. Here, we review the development of the SkinVision smartphone app, which has more than 900,000 users worldwide. The latest version of the SkinVision app (October 2018) has a 95% sensitivity (78% specificity) for detection of skin cancer. The current accuracy of the algorithm may warrant the use of this app as an aid by lay users or general practitioners. Nonetheless, for mobile health apps to become broadly accepted, further research is needed on their health impact on the health system and the user population. Ultimately, mobile health apps could become a powerful tool to reduce health care costs related to skin cancer management and minimize the morbidity of skin cancer in the population.

markdownabstractBackground Rising healthcare expenditures places the potential for substitution of hospital care towards primary care high on the political agenda. As low-risk basal cell carcinoma (BCC) care is one of the potential targets for substitution of hospital care towards primary care the objective of this study is to gain insight in the views of healthcare professionals regarding substitution of skin cancer care, and to identify perceived barriers and potential strategies to facilitate substitution. Methods A qualitative study was conducted consisting of 40 interviews with dermatologists and GPs and three focus groups with 18 selected GPs with noted willingness regarding substitution of skin cancer care. The interviews and focus groups focused on general views, perceived barriers and potential strategies to facilitate substitution of skin cancer care, using predefined topic lists. All sessions were audio-taped, transcribed verbatim and analyzed using the program AtlasTi. Results GPs were generally positive regarding substitution of skin care whereas dermatologists expressed more concerns. Lack of trust in GPs to adequately perform skin cancer care and a preference of patients for dermatologists are reported as barriers by dermatologists. The main barriers reported by GPs were a lack of confidence in own skills to perform skin cancer care, a lack of trust from both patients and dermatologists and limited time and financial compensation. Facilitating strategies suggested by both groups mainly focused on improving GPs’ education and improving the collaboration between primary and secondary care. GPs additionally suggested efforts from dermatologists to increase their own and patients’ trust in GPs, and time and financial compensation. The selected group of GPs suggested practical solutions to facilitate substitution focusing on changes in organizational structure including horizontal referring, outreach models and practice size reduction. Conclusions GPs and, to lesser extent, dermatologists are positive regarding substitution of low-risk BCC care, though report substantial barriers that need to be addressed before substitution can be further implemented. Aside from essential strategies such as improving GPs’ skin cancer education and time and financial compensation, rearranging the organizational structure in primary care and between primary and secondary care may facilitate effective and safe substitution of low-risk BCC care.

Lentigo maligna is an in situ melanoma which usually affects sun-damaged skin on the head and neck. In patients with lentigo maligna, the clinically visible demarcation often correlates poorly with the histopathologically confirmed demarcation. The standard treatment for lentigo maligna is excision with at least 5 mm margins. The key disadvantage of regular excision is the lack of histological margin control, resulting in non-radical excisions and a higher risk of recurrence. Micrographic surgery is indicated for patients with lentigo maligna because this technique is tissue-sparing and it offers absolute certainty concerning the presence of clear histological margins.

Lentigo maligna (LM) is considered a precursor to LM melanoma (LMM). We assessed trends in LM and LMM incidence rates between 1989 and 2013 in the Netherlands, and estimated the risk of a LMM after LM. Data on newly diagnosed LM and LMM were obtained from the Netherlands Cancer Registry and PALGA (Dutch Pathology Database). Age-standardized incidence rates (European standardized rate [ESR]), estimated annual percentage changes (EAPC), and the cumulative incidence of LMM after LM were calculated. Between 1989-2013, 10,545 patients were diagnosed with a primary LM and 2,898 with a primary LMM in the Netherlands. The ESR for LM increased from 0.72 to 3.84 per 100,000 person-years, and for LMM from 0.24 to 1.19 between 1989-2013. LM incidence increased from 2002-2013 with 6.8% annually, prior to the – even steeper – rise in LMM incidence from 2007-2013 (EAPC: 12.4%). The cumulative incidence of LMM after a primary LM after 25 years follow-up was 2.0% for males and 2.6% for females. The increased incidence of LM and LMM in the Netherlands seems, besides increased awareness, increased histological confirmation, diagnostic drift and changed market forces, to reflect a true increase. The absolute risk of a LMM (at any location) after a histologically confirmed LM was low (2.0 – 2.6%).

Most studies investigating the association between psoriasis and cardiovascular disease have shown a significant relationship. This comparison study investigated the association between psoriasis and prevalent use of cardiovascular drugs. Drug exposure data for 1998 to 2006 were extracted from the Dutch PHARMO-Record Linkage System database. Psoriasis patients were selected using an algorithm of hospitalization and drug dispensing records specific for psoriasis and matched with controls for gender, age and time-period. From the records of 2.5 million Dutch residents, 9,804 (0.4%) psoriasis patients and 15,288 (0.6%) controls were selected. Psoriasis patients used significantly more anti-hypertensives, anti-coagulant and anti-platelet agents, digoxin, nitrates, lipid-lowering and anti-diabetic drugs than the reference population during a 5-year period observation. In a multiple linear regression model adjusting for the number of unique drugs used, psoriasis was no longer significantly associated with any of these drug classes. Psoriasis patients used more cardiovascular-related drugs, but surveillance bias appears to affect this association considerably.

To estimate the prevalence of psoriatic arthritis (PsA) in primary care patients diagnosed as having psoriasis and to estimate the prevalence of musculoskeletal symptoms in psoriasis patients in primary care.We conducted a cross-sectional study in adult primary care patients with psoriasis. Responding patients reporting pain in joints, entheses, or the lower back were interviewed by telephone to determine eligibility and, if eligible, were invited for clinical evaluation. During clinical evaluation, skin, nails, joints, and entheses were assessed. Additionally, ultrasound of the enthesis was performed by an independent trained examiner if a patient had at least 1 tender enthesis (determined by the Leeds Enthesitis Index and the Maastricht Ankylosing Spondylitis Enthesitis Score). Patients who fulfilled the Classification of Psoriatic Arthritis (CASPAR) Study Group criteria were classified as having PsA.We invited 2,564 psoriasis patients from databases of 97 participating general practitioners. Of 1,673 responders (65.2%), 841 (50.3%) were willing to participate. A total of 823 patients (32.1%) reported having musculoskeletal symptoms; 659 of these patients were determined to be eligible, 524 of whom were clinically evaluated. We identified 64 cases of established PsA and another 17 cases of newly diagnosed PsA, leading to a prevalence of 3.2% (95% confidence interval [95% CI] 2.5-3.9) among psoriasis patients in primary care. This prevalence would increase to 4.6% (95% CI 3.8-5.4) if PsA cases based on enthesitis were also taken into account.Among psoriasis patients in primary care, the prevalence of PsA is conservatively estimated to be 3.2%, increasing to 4.6% if enthesitis is taken into account. The prevalence of musculoskeletal symptoms among psoriasis patients is comparable with the prevalence of musculoskeletal symptoms in the general population.

Multiple observational studies have recently demonstrated associations between psoriasis and several comorbidities--especially metabolic syndrome and cardiovascular disease, and now osteoporosis. It has been hypothesized that elevated levels of tumor necrosis factor-alpha are a biological explanation for the observed associations. In this commentary, we discuss the complexity of associations between psoriasis and comorbidities, possible residual confounding, the limitations of observational studies in proving causality, absolute versus relative risk differences, and the clinical relevance and possible clinical impact of "upgrading" psoriasis to a systemic disease.

Psoriasis has a major impact on health-related quality of life. The present cohort study investigated the use of antidepressant drugs in psoriasis patients and a reference cohort, using pharmacy and hospitalization data from 1998 to 2008 for more than 2.5 million Dutch residents. Multivariate Cox regression was used to compare the risk of first antidepressant use, and Poisson regression to compare the number of episodes of antidepressant use. A total of 25,691 psoriasis cases and 128,573 reference subjects were followed for more than 9 years. The incidence of first antidepressant use was 21 and 9 per 1,000 person years, respectively, and the adjusted hazard ratio (HR) was 1.55 (95% confidence interval (CI) 1.50-1.61). Within the psoriasis cohort, the HR of receiving an antidepressant was significantly higher after the first antipsoriatic treatment (HR 1.07, 95% CI 1.02-1.12). Psoriasis patients have a two-fold increase in antidepressant use, the period after antipsoriatic treatment being characterized by a further increase in antidepressant drug dispenses.

Psoriasis is a chronic inflammatory skin disease that affects approximately 2% of the Dutch population. It has been hypothesized that chronic inflammation occurring in psoriasis patients is more than skin deep, resulting in increased cardiovascular risk. Some observational studies have confirmed this association, although increased cardiovascular risk may also be explained by an increased prevalence of unhealthy life-style factors, systemic medication, the presence of psoriatic arthritis and detection bias. Based on the currently available evidence, we note that the current studies are insufficient to prove that psoriasis has a direct and independent effect on cardiovascular risk. Therefore, suggestions to change the cardiovascular screening and care of psoriasis patients seem to be a step too far. This hypothesis must first be investigated in specifically designed cohort studies or randomized controlled trials.

Background Various screening tools have been developed and validated over the years in order to enhance early recognition of psoriatic arthritis (PsA) among psoriasis patients, but their performance remains suboptimal. In 2014 the CONTEST-group developed a new screening tool consisting of the most discriminating questions from 3 existing tools (PEST, PASE, TOPAS) which was externally validated in 2 psoriasis cohorts from dermatology. Validation in a primary care setting has yet to be performed. Objectives To externally validate the CONTEST questionnaire in psoriasis patients in primary care. Methods Data from the SENSOR study was used, a cross-sectional study in adult psoriasis patients with regular spells of musculoskeletal complaints from primary care. In this study, patients completed the PEST and PASE screening-questionnaires before clinical evaluation. Within CONTEST 3 TOPAS questions are used that were not included in our study. These questions were therefore replaced by similar questions: ToPAS 2A was replaced by PEST 3, ToPAS 2B by nail assessment by a dermatologist and ToPAS 7 by data from the manikin in the PEST. We calculated sensitivity, specificity and area under the curve (AUC) for the CONTEST with a cutoff of 4, as well as the CONTEST-w (weighted version, cutoff of 8) and the CONTEST-jt (including the PEST manikin, cutoff of 5). Performance was also calculated selecting the patients in the same way as the CONTEST study, i.e. only inviting patients with a positive PEST and/or PASE questionnaire for clinical evaluation. As a reference standard we used a clinical diagnosis of PsA made by a rheumatologist and enthesitis confirmed by ultrasound (presence of Power Doppler). Results from our dataset were compared with data from the development cohort and with the performance of the PEST. Results For this analysis 473 psoriasis patients at risk for PsA were available. Compared with the development cohort sensitivity was considerably lower in our dataset (0.30–0.51) than in the development of the CONTEST (0.86). Specificity was higher in our dataset (0.75–0.87) compared with the CONTEST development (0.35–0.48). While AUCs were around 0.7 for all three versions, comparable with the AUCs found in the development of CONTEST. Comparing these results with the performance of the PEST in our population, it shows that the sensitivity is lower for the CONTEST (0.30–0.51) than for the PEST (0.68), while the specificity is slightly higher (0.75–0.87 vs 0.71). Conclusions External validation of the CONTEST questionnaire in primary care psoriasis patients with regular spells of musculoskeletal symptoms resulted in lower sensitivity and higher specificity compared to the development cohort, while AUCs were comparable. When only selecting patients with at least one positive screeningtool, the sensitivity slightly increases while the specificity slightly decreases. However, the performance of the CONTEST questionnaires does not seem to exceed the performance of the PEST in a primary care setting. Acknowledgement This study was financially funded by an investigator-initiated grant from Pfizer bv. Disclosure of Interest None declared

Although psoriasis has been associated with components of the metabolic syndrome, its association with myocardial infarction is less clear. A cohort study was conducted using hospital and pharmacy records of 2.5 million Dutch residents between 1997 and 2008. The risk of ischemic heart disease (IHD) hospitalizations was compared between psoriasis patients and a matched reference cohort. Additional adjustments were made for healthcare consumption and use of cardiovascular drugs. A total of 15,820 psoriasis patients and 27,577 reference subjects were included, showing an incidence rate of 611 and 559 IHD per 100,000 person-years, respectively (P=0.066). The age-and gender-adjusted risk of IHD was comparable between both cohorts (hazard ratio (HR)=1.10, 95% confidence interval 0.99-1.23). Before cohort entry, psoriasis patients used more antihypertensive, antidiabetic, and lipid-lowering drugs and were more often hospitalized. Adjusting for these confounders decreased the HR for IHD, but it remained comparable between both populations. There was no different risk of IHD between the subgroup of patients who only used topicals versus those who received systemic therapies or inpatient care for their psoriasis. This study, therefore, suggests that psoriasis is not a clinically relevant risk factor for IHD hospitalizations on the population level.

Recently, comorbidities have been rediscovered in dermatology. Although numerous associations between skin diseases and other conditions have been reported, only a few are well documented. The association of comorbidities and dermatoses is complex and multifactorial. Life-style factors, impaired health-related quality of life, depression, therapeutic interventions, and several biases may confound the relationship between skin diseases and comorbidities. This article discusses observational studies that assess comorbidities in psoriasis, atopic dermatitis, vitiligo, and nonmelanoma skin cancer, and the likelihood of the observed associations and their clinical consequences.

Contains fulltext : 69550.pdf (Publisher’s version ) (Closed access) BACKGROUND: In 2003, the Dutch psoriasis guidelines were among the first evidence-based medicine guidelines in dermatology. Although pivotal, the implementation of dermatological guidelines has not been assessed. OBJECTIVES: To evaluate various aspects that affect implementation of clinical guidelines such as knowledge, attitudes and practices among dermatologists. METHODS: A cross-sectional anonymous postal survey was conducted among all Dutch dermatologists. In addition to questions about knowledge and practices, 24 items assessed guidelines attitudes. Factor analysis was applied to merge these items into attitudinal scales and multiple linear regression was used to identify predictors for these scales. RESULTS: Of the 353 dermatologists, 161 (46%) completed the questionnaire. Almost all respondents were aware of the guidelines and 60% reported to have a decent knowledge of their content. Factor analysis retained 22 items divided into three scales: usefulness and content, barriers, and reliability. Apart from some disagreement on the user-friendliness and communication facilitating properties, the dermatologists' attitudes were generally positive. A larger volume of patients with psoriasis was associated with more frequent use of the guidelines [adjusted odds ratio (OR) = 2.42; 95% confidence interval (CI) 1.02-5.72]. Good familiarity predicted a more positive attitude towards the guidelines' usefulness and content (P < 0.001), perceived barriers (P < 0.001), and more frequent use in practice (adjusted OR = 8.38; 95% CI 3.08-22.81). CONCLUSIONS: Dutch dermatologists seem to know and appreciate their psoriasis guidelines and use them more often when they have a larger psoriasis population. Enhancing the familiarity of the guidelines among users may result in a more positive attitude towards them and a higher frequency of use.

Contains fulltext : 70341.pdf (Publisher’s version ) (Closed access)

will perform coordinated postmarketing surveillance studies to monitor the effectiveness and safety of system-ic agents, including biologics, in the treatment of psoria-sis. Accordingly, international data can be pooled to reach sufficient power and new drugs can be easily monitored in the future. Established registries try to link to Psonet and new ones are under construction to use the Psocare framework to collect a standardized ‘core set’ of vari-ables. The countries that participate include Italy, France, Israel, Portugal, Spain, Sweden, the Netherlands and the UK. Moreover, the establishment of a multidisciplinary and international group of investigators sharing resourc-es and activities may increase the quality of (pharma-co)epidemiological studies and stimulate the develop-ment of independent pragmatic randomized controlled trials (RCT) that are needed by patients and physicians [4, 5] .I n our opinion, Psocare and Psonet may revolutionize postmarketing and pharmacoepidemiological studies in and outside dermatology. The manufacturers of the pso-riasis drugs should have studied several aims of the these frameworks, but a recent Food and Drug Administration survey showed that only 34% of 2,701 postmarketing commitments were honoured [5, 6] . No such data are available for the European Medicines Agency. Since there is a lack of information about drug behaviour outside the restricted clinical trial population, commercially less in-teresting (hard) outcomes and long-term safety of drugs

Biogen Idec Inc, following its acquisition of Fumapharm AG, is developing BG-12 (Panaclar, BG-00012, FAG-201), an oral second-generation fumarate derivative, for the potential treatment of multiple sclerosis (MS). In January 2007, a phase III program for relapsing-remitting MS patients was initiated. The company was also developing the drug for psoriasis and, in October 2003, Biogen Idec expected to commence phase III trials for psoriasis in the US in the following year. In April 2005, the drug met its European phase III psoriasis trial endpoint, with the data expected to be used to support a market authorization filing in Germany in 2005. It was later disclosed that while an application had been filed, this was subsequently withdrawn based on a joint decision by Fumapharm and Biogen Idec. No further development has been reported on BG-12 for psoriasis in the US and it was not listed as a pursued indication on Biogen Idec's April 2007 pipeline.

Background Psoriatic Arthritis (PsA) is a progressive inflammatory joint disease that can lead to severe joint damage. New treatment strategies can be very effective in early stages of the disease [1]. This requires early recognition of the symptoms to be PsA. Several screening tools have been developed to enhance early recognition [1-4]. However, most were developed in secondary care [2,3], while early recognition should ideally take place in primary care. Objectives To evaluate the screening performance of the PEST [4], PASE [2,5] and EARP [3] to identify psoriatic arthritis among primary care psoriasis patients with recurrent spells musculoskeletal complaints (MSC). Methods We conducted a cross-sectional study in adult primary care patients with psoriasis who reported recurrent MSC spells. Patients were selected by ICPC code S91 for psoriasis and the presence of recurrent spells of MSC (joints, enthesis or low back pain) was determined by telephone interview. Patients completed the PEST, PASE & EARP questionnaires before clinical evaluation by a trained research nurse. Assessments included PASI, LEI/MASES, 66/68-joint count and the presence of nail-psoriasis. When patients reported a painful enthesis on LEI/MASES, an ultrasound of the entheses was performed. A PsA case fulfilled the CASPAR criteria. Sensitivity and specificity were determined for the PEST and EARP cut off ≥3 and PASE cut off ≥44 as well as ≥47. Results 473 psoriasis patients participated with a mean ± SD age of 55.7±13.9 years and 50.9% being male. Median PASI score was 2.3 (IQR 1-4) and 71 patients (15.0%) had nail abnormalities related to psoriasis. We found 17 new cases of PsA (3.6%) as diagnosed by a rheumatologist. Moreover, we found 36 cases of enthesitis, confirmed by ultrasound. The majority of these refrained from further evaluation by a rheumatologist, however most of them would classify as PsA according to the CASPAR criteria. Looking into all cases, including enthesitis, the EARP had a sensitivity of 87% and a specificity of 33%, for the PEST this was 68% and 71%. The PASE had a sensitivity of 66% and a specificity of 55% at the cut off of ≥44 and 59% and 64% at the cut off of≥47 (Table 2). Similar figures were observed if only axial manifestations and arthritis were taken into account. Conclusions Modest sensitivity was observed for the PEST and PASE with an acceptable specificity for the PEST, while the EARP had high sensitivity and low specificity, which is undesirable for screening. The performance of all screening tools was lower than previously reported in secondary care settings [1-4]. References Coates LC, et al. BMC Musculoskelet Disord, 2013. Husni ME, et al. J Am Acad Dermatol, 2007. Tinazzi I, et al. Rheumatology (Oxford), 2012. Ibrahim GH, et al. Clin Exp Rheumatol, 2009. Dominguez, PL, et al. Arch Dermatol Res, 2009. Acknowledgements This study was financially funded by an investigator-initiated grant from Pfizer bv. Disclosure of Interest None declared

Background Over 25% of the new consultations in primary care is due to musculoskeletal complaints (MSC)(1). In patient with psoriasis, the underlying diagnosis could be psoriatic arthritis (PsA). Prevalence figures of PsA in psoriasis patients vary widely (6-42%) and data in primary care is scarce (2, 3) Objectives To estimate the prevalence of MSC and PsA in primary care patients with psoriasis. Methods We conducted a cross-sectional study in adult primary care patients with psoriasis. Patients were identified from GP records by ICPC code S91 for psoriasis. Responding patients reporting pain in joints, entheses or the lower back were checked on eligibility by a telephone interview and invited for clinical evaluation. Ultrasonoghraphy (US) of the enthesis was performed if a patient had at least one tender enthesis (LEI/MASES) by an independent trained examiner. Patients were referred to a rheumatologist if clinical evaluation suggested the presence of arthritis or axial disease or ultrasonography of the enthesis showed positive Power Doppler (PD) signal. A PsA case was defined by opinion of the rheumatologist or fulfilling the CASPAR criteria with PD signal in an enthesis on US. Results 2564 psoriasis (PsO) patients from 97 GPs were invited. Of the 1673 responders (65.2%), 841 (50.3%) were willing to participate. 823 (32.1%) patients reported suffering from MSC of which eventually 524 were eligible and clinically evaluated. We identified 81 cases of PsA (Figure 1), of which 17 (21%) were newly diagnosed, leading to a prevalence of 3.2% (95%CI 2.5%>3.9%) among primary care psoriasis patients, assuming no additional cases of PsA among the non-responders. Besides these cases, we also identified 36 patients with enthesitis confirmed by ultrasound, which would increase the prevalence of PsA towards 4.6% (95% CI 3.8%>5.4%). Conclusions Among psoriasis patients in primary care the prevalence of PsA is estimated to be 3.2%, which would increase towards 4.6% if you take the enthesitis cases into account. Moreover, 21% of the cases was newly diagnosed. We hereby assumed that no additional cases would be observed in the non-responders. The prevalence of MSC is estimated to be 32.1%, which is comparable with the prevalence in general population (1). References van der Linden MW et al., NIVEL/RIVM2004. Ibrahim G. et al, Arthritis Rheum. 2009. Gelfand JM. et al, Arch Dermatol. 2005 Acknowledgements This study was financially funded by an investigator-initiated grant from Pfizer bv. Disclosure of Interest None declared