Correspondence 1457
condition, the profile of our patients was similar in the three periods. No previous study has investigated treatment of AGEP. Spontaneous evolution is generally seen, and Roujeau et al., in a series of 63 cases, reported a mean pustule duration of 9– 10 days and fever of 75–8 days (maximum duration 23 days), but did not describe treatment.1 Our management of AGEP has changed over the last few years, with significantly more frequent use of topical steroids in the acute phase. Furthermore, the median hospitalization duration significantly decreased, but the global hospitalization duration in our department remained stable. Thus, topical steroids might be effective in accelerating the resolution of AGEP. Indeed, topical steroids were found effective in inhibiting skin vasodilatation and activating neutrophils.8,9 AGEP is a rare disease, and therapeutic controlled trials cannot be easily performed. We report indirect arguments to support the efficacy of topical steroids at the acute phase of AGEP. We recommend treating AGEP with short-term potent or highly potent topical steroids. 1
Dermatology Department, AP-HP, Henri S . I N G E N - H O U S Z - O R O 1 , 2 Mondor Hospital, Creteil, France C. HOTZ1 2 Referral Center for Toxic and L. VALEYRIE-ALLANORE1,2 Autoimmune Disease, Creteil, France E. SBIDIAN1,3 3 Universite Paris Est-Creteil Val de Marne, F. HEMERY4 Creteil, France O. CHOSIDOW1,2,3,5 4 Department of Medical Information, P. WOLKENSTEIN1,2,3,5 AP-HP, Henri Mondor Hospital, Creteil, France 5 INSERM, Centre d’Investigation Clinique 006, AP-HP, Creteil, France Correspondence: S. Ingen-Housz-Oro Email: [email protected]
References 1 Roujeau JC, Bioulac-Sage P, Bourseau C et al. Acute generalized exanthematous pustulosis. Analysis of 63 cases. Arch Dermatol 1991; 127:1333–8. 2 Valeyrie-Allanore L, Sassolas B, Roujeau J-C. Drug-induced skin, nail and hair disorders. Drug Saf Int J Med Toxicol Drug Exp 2007; 30:1011–30. 3 Sidoroff A, Dunant A, Viboud C et al. Risk factors for acute generalized exanthematous pustulosis (AGEP): results of a multinational case–control study (EuroSCAR). Br J Dermatol 2007; 157:989–96. 4 Hotz C, Valeyrie-Allanore L, Haddad C et al. Systemic involvement of acute generalized exanthematous pustulosis: a retrospective study on 58 patients. Br J Dermatol 2013; 169:1223–32. 5 Joly P, Roujeau JC, Benichou J et al. A comparison of oral and topical corticosteroids in patients with bullous pemphigoid. N Engl J Med 2002; 346:321–7. 6 Husain Z, Reddy BY, Schwartz RA. DRESS syndrome: part II. Management and therapeutics. J Am Acad Dermatol 2013; 68:709.e1–9. 7 Funck-Brentano E, Duong TA, Bouvresse S, et al. Therapeutic management of DRESS: a retrospective study of 38 cases. J Am Acad Dermatol 2015; 72:246–52.
© 2014 British Association of Dermatologists
8 Ahluwalia A, Flower RJ. Topical betamethasone-17-valerate inhibits heat-induced vasodilatation in man. Br J Dermatol 1993; 128:45–8. 9 Hellberg L, Samavedam UK, Holdorf K et al. Methylprednisolone blocks autoantibody-induced tissue damage in experimental models of bullous pemphigoid and epidermolysis bullosa acquisita through inhibition of neutrophil activation. J Invest Dermatol 2013; 133:2390–9. Funding sources: none. Conflicts of interest: none declared. O.C. and P.W. contributed equally to this study.
An evaluation of the preferences of patients with psoriasis between systemic psoralen plus ultraviolet A and bath psoralen plus ultraviolet A DOI: 10.1111/bjd.13561 DEAR EDITOR, Psoralen plus ultraviolet A (PUVA) is a well-established treatment for psoriasis. It comprises the use of psoralen as a photosensitizer, either orally or topically, before the patient is treated by irradiation with UVA (320–400 nm). It is usually the dermatologist who decides which modality of PUVA is used (i.e. bath PUVA or systemic PUVA). Dermatologists’ preferences for treating psoriasis have been studied, but not in relation to mode of PUVA therapy.1 Furthermore, patient preferences for mode of PUVA delivery have not been addressed in previous research. This study was conducted in order to explore patient preferences regarding mode of PUVA treatment. Ninety-nine patients with generalized psoriasis who attended the phototherapy unit between July 2013 and December 2013 were recruited (51 female, 48 male, age range 18–73 years; mean age 427 years). Seventeen patients had previously received PUVA therapy. Exclusion criteria were age < 18 years, concomitant cataract, liver disease, mobility disorders and patients with only palmoplantar or hand/foot psoriasis. Informed consent was obtained from all patients before they participated in the study. Patients were interviewed to obtain a brief medical history so that selection criteria could be assessed. The patients were given a patient information sheet providing a concise description of the two main modes of PUVA (see Supporting Information). We administer bath PUVA three times every 2 weeks, a common and effective regimen chosen to minimize risks of erythema.2 Systemic PUVA treatments are given twice a week in our department. All patients were provided with this information and interviewed by a single investigator. The investigator then went through each point on the information sheet to ensure that the patients understood what was written. Patients were then given the opportunity to ask questions before being British Journal of Dermatology (2015) 172, pp1436–1461
1458 Correspondence
asked to complete a brief questionnaire regarding their preferences and to explain the reasons for their choice. Psoriasis Area Severity Index (PASI) and Dermatology Life Quality Index (DLQI) were completed for all patients. Of the whole group, 54/99 (55%) expressed a preference for bath PUVA. Among female patients, 31/51 (61%) preferred bath PUVA. Among male patients, 23/48 (48%) preferred bath PUVA. Thus, 61% of women, 13% more [95% confidence limits 7%, 32%] than the 48% of men, favoured bath PUVA, P = 010). The mean DLQI for male patients who preferred bath PUVA was 68 vs. 10 for those who preferred systemic PUVA and this difference was statistically significant (P = 0047). For female patients, DLQI score was the same for both modes of PUVA. Additionally, PASI score did not influence patients’ preferences in either sex. Stated reasons for female patients’ preferences for bath PUVA were as follows: 55% did not like taking tablets; 19% did not like the prospect of possible side-effects of systemic therapy; 13% considered bath PUVA to be more convenient; 6% did not like wearing protective glasses with systemic PUVA; only 3% preferred bath PUVA due to the lower frequency of treatment (once every 5 days in our unit, compared with twice weekly for systemic PUVA). Stated reasons for male patients were as follows: 48% did not like taking tablets; 22% considered bath PUVA more convenient; 17% preferred the idea of bath PUVA due to absence of side-effects from systemic medication; 9% stated that they disliked wearing sunglasses after treatment; 4% preferred bath PUVA due to their previous good experience with this modality. In the group of female patients who preferred systemic PUVA, 50% stated that they preferred the shorter course duration compared with bath PUVA (e.g. treatment given twice weekly takes 8–12 weeks, whereas treatment given every 5 days takes 12–16 weeks); 35% considered systemic PUVA as more convenient as it avoids the need for a bath; 5% preferred systemic due to their previous experience. In the group of male patients who preferred systemic PUVA, 60% considered it more convenient; 20% selected this modality due to the shorter course duration; 12% believed that systemic PUVA was more effective (despite the fact that they had been informed that there was no evidence to support this view); 4% preferred systemic PUVA due to their previous experience. We assessed the influence of previous experience on patient’s preferences. Seventeen of the 99 patients had previously received PUVA (12 bath, 4 systemic and 1 both): 9/12 (75%) who had previously received bath PUVA preferred bath PUVA; 4/4(100%) who had previously received systemic PUVA preferred the same treatment. The one patient who had both modes of PUVA preferred bath PUVA. There was no influence of comorbidities on patient preferences. The results of this questionnaire demonstrate several findings. Firstly, female patients with psoriasis preferred bath PUVA to systemic PUVA while there was no preference either way amongst male patients. Secondly, higher DLQI British Journal of Dermatology (2015) 172, pp1436–1461
scores in male patients may influence their preference toward systemic PUVA. Thirdly, previous experience with PUVA may influence patient preferences and this issue could be explored in subsequent studies. Finally, there is no influence of PASI score or comorbidities on patient preference for mode of PUVA in either sex. We recommend the inclusion of patients in the decision-making process when prescribing PUVA, for units that offer both bath and systemic PUVA. 1
Department of Dermatology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan 2 Department of Dermatology, University Hospital of Wales, Cardiff, U.K. 3 Academic Dermatology Unit, St Woolos Hospital, Newport, U.K. 4 Cardiff University, Cardiff, U.K. Correspondence: Alexander V. Anstey. E-mail: [email protected]
D. ALSHIYAB1 M.F. CHIN2 C. EDWARDS3 A . V . A N S T E Y 3,4
References 1 Wan J, Abuabara K, Andra B et al. Dermatologist preferences for first-line therapy of moderate to severe psoriasis in healthy adult patients. J Am Acad Dermatol 2010; 66:376–86. 2 Man I, Kwok YK, Dawe RS et al. The time course of topical PUVA erythema following 15- and 5-minute methoxsalen immersion. Arch Dermatol 2003; 139:331–4.
Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s website: Data S1. Patient information sheet S1. Funding sources: none. Conflicts of interest: none declared.
Arthritis possibly induced and exacerbated by a tumour necrosis factor antagonist in a patient with psoriasis vulgaris DOI: 10.1111/bjd.13587 DEAR EDITOR, We report a case in which tumour necrosis factor (TNF) inhibitor treatment possibly induced new-onset arthritis. A 71-year-old Japanese man with psoriasis vulgaris had been treated with etretinate. In July 2013, treatment with biweekly 40-mg injections of adalimumab was started. At that time, the patient’s Psoriasis Area and Severity Index (PASI) score was 111; on physical examination, he had no history of © 2014 British Association of Dermatologists
condition, the profile of our patients was similar in the three periods. No previous study has investigated treatment of AGEP. Spontaneous evolution is generally seen, and Roujeau et al., in a series of 63 cases, reported a mean pustule duration of 9– 10 days and fever of 75–8 days (maximum duration 23 days), but did not describe treatment.1 Our management of AGEP has changed over the last few years, with significantly more frequent use of topical steroids in the acute phase. Furthermore, the median hospitalization duration significantly decreased, but the global hospitalization duration in our department remained stable. Thus, topical steroids might be effective in accelerating the resolution of AGEP. Indeed, topical steroids were found effective in inhibiting skin vasodilatation and activating neutrophils.8,9 AGEP is a rare disease, and therapeutic controlled trials cannot be easily performed. We report indirect arguments to support the efficacy of topical steroids at the acute phase of AGEP. We recommend treating AGEP with short-term potent or highly potent topical steroids. 1
Dermatology Department, AP-HP, Henri S . I N G E N - H O U S Z - O R O 1 , 2 Mondor Hospital, Creteil, France C. HOTZ1 2 Referral Center for Toxic and L. VALEYRIE-ALLANORE1,2 Autoimmune Disease, Creteil, France E. SBIDIAN1,3 3 Universite Paris Est-Creteil Val de Marne, F. HEMERY4 Creteil, France O. CHOSIDOW1,2,3,5 4 Department of Medical Information, P. WOLKENSTEIN1,2,3,5 AP-HP, Henri Mondor Hospital, Creteil, France 5 INSERM, Centre d’Investigation Clinique 006, AP-HP, Creteil, France Correspondence: S. Ingen-Housz-Oro Email: [email protected]
References 1 Roujeau JC, Bioulac-Sage P, Bourseau C et al. Acute generalized exanthematous pustulosis. Analysis of 63 cases. Arch Dermatol 1991; 127:1333–8. 2 Valeyrie-Allanore L, Sassolas B, Roujeau J-C. Drug-induced skin, nail and hair disorders. Drug Saf Int J Med Toxicol Drug Exp 2007; 30:1011–30. 3 Sidoroff A, Dunant A, Viboud C et al. Risk factors for acute generalized exanthematous pustulosis (AGEP): results of a multinational case–control study (EuroSCAR). Br J Dermatol 2007; 157:989–96. 4 Hotz C, Valeyrie-Allanore L, Haddad C et al. Systemic involvement of acute generalized exanthematous pustulosis: a retrospective study on 58 patients. Br J Dermatol 2013; 169:1223–32. 5 Joly P, Roujeau JC, Benichou J et al. A comparison of oral and topical corticosteroids in patients with bullous pemphigoid. N Engl J Med 2002; 346:321–7. 6 Husain Z, Reddy BY, Schwartz RA. DRESS syndrome: part II. Management and therapeutics. J Am Acad Dermatol 2013; 68:709.e1–9. 7 Funck-Brentano E, Duong TA, Bouvresse S, et al. Therapeutic management of DRESS: a retrospective study of 38 cases. J Am Acad Dermatol 2015; 72:246–52.
© 2014 British Association of Dermatologists
8 Ahluwalia A, Flower RJ. Topical betamethasone-17-valerate inhibits heat-induced vasodilatation in man. Br J Dermatol 1993; 128:45–8. 9 Hellberg L, Samavedam UK, Holdorf K et al. Methylprednisolone blocks autoantibody-induced tissue damage in experimental models of bullous pemphigoid and epidermolysis bullosa acquisita through inhibition of neutrophil activation. J Invest Dermatol 2013; 133:2390–9. Funding sources: none. Conflicts of interest: none declared. O.C. and P.W. contributed equally to this study.
An evaluation of the preferences of patients with psoriasis between systemic psoralen plus ultraviolet A and bath psoralen plus ultraviolet A DOI: 10.1111/bjd.13561 DEAR EDITOR, Psoralen plus ultraviolet A (PUVA) is a well-established treatment for psoriasis. It comprises the use of psoralen as a photosensitizer, either orally or topically, before the patient is treated by irradiation with UVA (320–400 nm). It is usually the dermatologist who decides which modality of PUVA is used (i.e. bath PUVA or systemic PUVA). Dermatologists’ preferences for treating psoriasis have been studied, but not in relation to mode of PUVA therapy.1 Furthermore, patient preferences for mode of PUVA delivery have not been addressed in previous research. This study was conducted in order to explore patient preferences regarding mode of PUVA treatment. Ninety-nine patients with generalized psoriasis who attended the phototherapy unit between July 2013 and December 2013 were recruited (51 female, 48 male, age range 18–73 years; mean age 427 years). Seventeen patients had previously received PUVA therapy. Exclusion criteria were age < 18 years, concomitant cataract, liver disease, mobility disorders and patients with only palmoplantar or hand/foot psoriasis. Informed consent was obtained from all patients before they participated in the study. Patients were interviewed to obtain a brief medical history so that selection criteria could be assessed. The patients were given a patient information sheet providing a concise description of the two main modes of PUVA (see Supporting Information). We administer bath PUVA three times every 2 weeks, a common and effective regimen chosen to minimize risks of erythema.2 Systemic PUVA treatments are given twice a week in our department. All patients were provided with this information and interviewed by a single investigator. The investigator then went through each point on the information sheet to ensure that the patients understood what was written. Patients were then given the opportunity to ask questions before being British Journal of Dermatology (2015) 172, pp1436–1461
1458 Correspondence
asked to complete a brief questionnaire regarding their preferences and to explain the reasons for their choice. Psoriasis Area Severity Index (PASI) and Dermatology Life Quality Index (DLQI) were completed for all patients. Of the whole group, 54/99 (55%) expressed a preference for bath PUVA. Among female patients, 31/51 (61%) preferred bath PUVA. Among male patients, 23/48 (48%) preferred bath PUVA. Thus, 61% of women, 13% more [95% confidence limits 7%, 32%] than the 48% of men, favoured bath PUVA, P = 010). The mean DLQI for male patients who preferred bath PUVA was 68 vs. 10 for those who preferred systemic PUVA and this difference was statistically significant (P = 0047). For female patients, DLQI score was the same for both modes of PUVA. Additionally, PASI score did not influence patients’ preferences in either sex. Stated reasons for female patients’ preferences for bath PUVA were as follows: 55% did not like taking tablets; 19% did not like the prospect of possible side-effects of systemic therapy; 13% considered bath PUVA to be more convenient; 6% did not like wearing protective glasses with systemic PUVA; only 3% preferred bath PUVA due to the lower frequency of treatment (once every 5 days in our unit, compared with twice weekly for systemic PUVA). Stated reasons for male patients were as follows: 48% did not like taking tablets; 22% considered bath PUVA more convenient; 17% preferred the idea of bath PUVA due to absence of side-effects from systemic medication; 9% stated that they disliked wearing sunglasses after treatment; 4% preferred bath PUVA due to their previous good experience with this modality. In the group of female patients who preferred systemic PUVA, 50% stated that they preferred the shorter course duration compared with bath PUVA (e.g. treatment given twice weekly takes 8–12 weeks, whereas treatment given every 5 days takes 12–16 weeks); 35% considered systemic PUVA as more convenient as it avoids the need for a bath; 5% preferred systemic due to their previous experience. In the group of male patients who preferred systemic PUVA, 60% considered it more convenient; 20% selected this modality due to the shorter course duration; 12% believed that systemic PUVA was more effective (despite the fact that they had been informed that there was no evidence to support this view); 4% preferred systemic PUVA due to their previous experience. We assessed the influence of previous experience on patient’s preferences. Seventeen of the 99 patients had previously received PUVA (12 bath, 4 systemic and 1 both): 9/12 (75%) who had previously received bath PUVA preferred bath PUVA; 4/4(100%) who had previously received systemic PUVA preferred the same treatment. The one patient who had both modes of PUVA preferred bath PUVA. There was no influence of comorbidities on patient preferences. The results of this questionnaire demonstrate several findings. Firstly, female patients with psoriasis preferred bath PUVA to systemic PUVA while there was no preference either way amongst male patients. Secondly, higher DLQI British Journal of Dermatology (2015) 172, pp1436–1461
scores in male patients may influence their preference toward systemic PUVA. Thirdly, previous experience with PUVA may influence patient preferences and this issue could be explored in subsequent studies. Finally, there is no influence of PASI score or comorbidities on patient preference for mode of PUVA in either sex. We recommend the inclusion of patients in the decision-making process when prescribing PUVA, for units that offer both bath and systemic PUVA. 1
Department of Dermatology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan 2 Department of Dermatology, University Hospital of Wales, Cardiff, U.K. 3 Academic Dermatology Unit, St Woolos Hospital, Newport, U.K. 4 Cardiff University, Cardiff, U.K. Correspondence: Alexander V. Anstey. E-mail: [email protected]
D. ALSHIYAB1 M.F. CHIN2 C. EDWARDS3 A . V . A N S T E Y 3,4
References 1 Wan J, Abuabara K, Andra B et al. Dermatologist preferences for first-line therapy of moderate to severe psoriasis in healthy adult patients. J Am Acad Dermatol 2010; 66:376–86. 2 Man I, Kwok YK, Dawe RS et al. The time course of topical PUVA erythema following 15- and 5-minute methoxsalen immersion. Arch Dermatol 2003; 139:331–4.
Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s website: Data S1. Patient information sheet S1. Funding sources: none. Conflicts of interest: none declared.
Arthritis possibly induced and exacerbated by a tumour necrosis factor antagonist in a patient with psoriasis vulgaris DOI: 10.1111/bjd.13587 DEAR EDITOR, We report a case in which tumour necrosis factor (TNF) inhibitor treatment possibly induced new-onset arthritis. A 71-year-old Japanese man with psoriasis vulgaris had been treated with etretinate. In July 2013, treatment with biweekly 40-mg injections of adalimumab was started. At that time, the patient’s Psoriasis Area and Severity Index (PASI) score was 111; on physical examination, he had no history of © 2014 British Association of Dermatologists
