Residents’corner February 2015. Editorial: What’s new this month? Axel-Patrice VILLANI1 , Valeria BEHLE2 , Joana CABETE3 , Alana DURACK4 , Franc¸ois KUONEN5 , Alejandro MARTIN-GORGOJO6 1
Dermatology department, hôpital Edouard Herriot. 5 place d’Arsonval, 69003 Lyon, France e-mail: [email protected] 2 Department of Dermatology, Venereology and Allergology, University Hospital Wuerzburg, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany e-mail: [email protected] 3 Dermatology Department. Hospital de Santo António dos Capuchos Centro Hospitalar de Lisboa Central. Alameda Santo António dos Capuchos 1169-050, Lisbon, Portugal e-mail: [email protected] 4 Dermatology department, Box 46, Addenbrooke’s Hospital, Hills road, Cambridge, CB2 0QQ, UK e-mail: [email protected] 5 Department of Dermatology and Venereology, Hôpital de Beaumont, Lausanne University Hospital Center, Av. de Beaumont 29, CH-1011 Lausanne, Switzerland e-mail: [email protected] 6 Dermatology Department. General University Hospital Gregorio Mara˜non. C/ Doctor Esquerdo 46, 28007 Madrid, Spain. Dermatology Department. Clinica Dermatologica Internacional and Clinica Ruber. Madrid, Spain e-mail: [email protected]
T
he poor outcomes associated with psoriatic arthritis (PsA) have triggered recent efforts aimed at improving treatment strategies. Among these is the interest of tight control of the disease at an early stage [1]. Therefore, early detection of PsA may be critical to improving optimal PsA management and outcome. Since, in the majority of cases, cutaneous lesions precede arthritic involvement, dermatologists are likely to be at the forefront of early PsA detection and several PsA screening questionnaires have been developed to aid in this process. Currently, the three most widely used questionnaires (PASE -Psoriatic Arthritis Screening and Evaluation-, PEST Psoriasis Epidemiology Screening Tool-, ToPAS -Toronto Psoriatic Arthritis Screening questionnaire-) have shown adequate results in selected populations, but this is not reflected on a larger scale. In this issue of the European Journal of Dermatology, Lopez-Estebaranz et al. [2] report a study evaluating PsA prevalence among psoriasis patients in Spain and the performance of one of these screening tools: the PASE questionnaire. Among their results, the authors found this questionnaire to have a low sensitivity (51%) and a low predictive value (over half of patients diagnosed with PsA by rheumatologists in the study did not have a positive PASE). Though imperfect, PsA screening questionnaires (which ideally should have the highest negative predictive value rather than the highest positive predictive value) can be useful tools that can help dermatologists to rule out PsA. In order not to miss any early PsA, it is also important to remember that the most sensitive PsA symptom is ‘inflammatory pain’. This is in accordance with the CASPAR criteria, which consider inflammatory arthritis as an absolute prerequisite.
94
Chronic spontaneous urticaria (CSU) is associated with a mild inflammatory response. It has been proposed that chronic inflammatory disorders may be associated with an increased risk of cardiovascular diseases such as atherosclerosis, myocardial infarction and stroke. A study based on a cohort of Korean patients with severe and uncontrolled chronic urticaria proved a statistically significant association with metabolic syndrome [3], which can lead to atherosclerosis and cardiovascular events. The exact mechanism is yet to be determined, although a chronic inflammatory response might be involved. Atherosclerosis has been correlated to the up-regulation of the calcification marker Matrix Gla protein (MGP). This issue includes a study by Grzanka et al. [4] assessing systemic inflammatory markers and MGP levels in 17 patients with CSU. They have found that this disease is associated with a mild inflammatory response (increased CRP and interleukin-6), but with no modification in MGP levels. As a chronic inflammatory disease, quality of life among patients with psoriasis is undoubtedly an important issue. Chiricozzi et al. present a study in which they test Psodisk, a recently published psoriasis quality of life assessment tool [5]. They assess the evolution of Psodisk scores on patients receiving TNF␣ inhibitors, correlating clinical improvement with a decrease in this score. Psodisk is a 10-item questionnaire (general health, presence of pain, quality of sleep, peace of mind, social life, work satisfaction, sex life, feeling of shame and skin involvement), presented as a coloured disc, which assesses the burden of psoriasis. Psodisk has shown internal consistency and test-retest reliability. When compared to the Dermatology Life Quality Index (DLQI) and the Skindex-29, no significant differences were found among the different items of these three questionnaires [6]. Psodisk has been designed to be completed jointly by the dermatologist and the patient. It appears to be simple to understand, not very time-consuming and may probably be easily integrated into daily Dermatology practice. Nevertheless, its validation in a broader population, comparing it to other quality of life assessment tools, is necessary.
References
1. Coates LC, Navarro-Coy N, Brown SR, et al. The TICOPA protocol (TIght COntrol of Psoriatic Arthritis): a randomised controlled trial to compare intensive management versus standard care in early psoriatic arthritis. BMC Musculoskelet Disord 2013; 14: 101. 2. Lopez Estebaranz JL, Zarco-Montejo P, Samaniego ML, GarciaCalvo C. Prevalence and clinical features of psoriatic arthritis in psoriasis patients in Spain. Limitations of PASE as a screening tool. Eur J Dermatol 2015; 25: 41-7. 3. Ye YM, Jin HJ, Hwang EK, et al. Co-existence of chronic urticaria and metabolic syndrome: clinical implications. Acta Dermatol Venereol 2013; 93: 156-60. 4. Grzanka A, Machura E, Misiolek M, Polaniak R, Kasperski J, Kasperska-Zajac A. Systemic inflammatory response and calcification markers in patients with long lasting moderate-severe chronic spontaneous urticaria. Eur J Dermatol 2015; 25: 26-8. 5. Chiricozzi A, Bianchi L, Zangrilli A, et al. Quality of life of psoriatic patients evaluated by a new psychometric assessment tool: PsoDisk. Eur J Dermatol 2015; 25: 48-53. EJD, vol. 25, n◦ 1, January-February 2015
6. Sampogna F, Linder D, Romano GV, Gualberti G, Merolla R, di Luzio Paparatti U. Results of the validation study of the Psodisk instrument, and determination of the cut-off scores for varying degrees of impairment. J Eur Acad Dermatol Venereol 2014 (epub ahead of print). doi:10.1684/ejd.2015.2539
Residents’corner February 2015. sQUIZ your knowledge! Jin WEI, Jianzhong ZHANG Department of Dermatology, Peking University People’s Hospital, Beijing, China e-mail: [email protected]
Figure 1. Clinical presentation.
A
42-year-old woman presented with a ten-year history of slightly pruritic brown plaques on the trunk (figure 1). Friction could induce Darier sign. The patient could not recall any previous skin lesions in the past. What is the diagnosis?
EJD, vol. 25, n◦ 1, January-February 2015
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Dermatology department, hôpital Edouard Herriot. 5 place d’Arsonval, 69003 Lyon, France e-mail: [email protected] 2 Department of Dermatology, Venereology and Allergology, University Hospital Wuerzburg, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany e-mail: [email protected] 3 Dermatology Department. Hospital de Santo António dos Capuchos Centro Hospitalar de Lisboa Central. Alameda Santo António dos Capuchos 1169-050, Lisbon, Portugal e-mail: [email protected] 4 Dermatology department, Box 46, Addenbrooke’s Hospital, Hills road, Cambridge, CB2 0QQ, UK e-mail: [email protected] 5 Department of Dermatology and Venereology, Hôpital de Beaumont, Lausanne University Hospital Center, Av. de Beaumont 29, CH-1011 Lausanne, Switzerland e-mail: [email protected] 6 Dermatology Department. General University Hospital Gregorio Mara˜non. C/ Doctor Esquerdo 46, 28007 Madrid, Spain. Dermatology Department. Clinica Dermatologica Internacional and Clinica Ruber. Madrid, Spain e-mail: [email protected]
T
he poor outcomes associated with psoriatic arthritis (PsA) have triggered recent efforts aimed at improving treatment strategies. Among these is the interest of tight control of the disease at an early stage [1]. Therefore, early detection of PsA may be critical to improving optimal PsA management and outcome. Since, in the majority of cases, cutaneous lesions precede arthritic involvement, dermatologists are likely to be at the forefront of early PsA detection and several PsA screening questionnaires have been developed to aid in this process. Currently, the three most widely used questionnaires (PASE -Psoriatic Arthritis Screening and Evaluation-, PEST Psoriasis Epidemiology Screening Tool-, ToPAS -Toronto Psoriatic Arthritis Screening questionnaire-) have shown adequate results in selected populations, but this is not reflected on a larger scale. In this issue of the European Journal of Dermatology, Lopez-Estebaranz et al. [2] report a study evaluating PsA prevalence among psoriasis patients in Spain and the performance of one of these screening tools: the PASE questionnaire. Among their results, the authors found this questionnaire to have a low sensitivity (51%) and a low predictive value (over half of patients diagnosed with PsA by rheumatologists in the study did not have a positive PASE). Though imperfect, PsA screening questionnaires (which ideally should have the highest negative predictive value rather than the highest positive predictive value) can be useful tools that can help dermatologists to rule out PsA. In order not to miss any early PsA, it is also important to remember that the most sensitive PsA symptom is ‘inflammatory pain’. This is in accordance with the CASPAR criteria, which consider inflammatory arthritis as an absolute prerequisite.
94
Chronic spontaneous urticaria (CSU) is associated with a mild inflammatory response. It has been proposed that chronic inflammatory disorders may be associated with an increased risk of cardiovascular diseases such as atherosclerosis, myocardial infarction and stroke. A study based on a cohort of Korean patients with severe and uncontrolled chronic urticaria proved a statistically significant association with metabolic syndrome [3], which can lead to atherosclerosis and cardiovascular events. The exact mechanism is yet to be determined, although a chronic inflammatory response might be involved. Atherosclerosis has been correlated to the up-regulation of the calcification marker Matrix Gla protein (MGP). This issue includes a study by Grzanka et al. [4] assessing systemic inflammatory markers and MGP levels in 17 patients with CSU. They have found that this disease is associated with a mild inflammatory response (increased CRP and interleukin-6), but with no modification in MGP levels. As a chronic inflammatory disease, quality of life among patients with psoriasis is undoubtedly an important issue. Chiricozzi et al. present a study in which they test Psodisk, a recently published psoriasis quality of life assessment tool [5]. They assess the evolution of Psodisk scores on patients receiving TNF␣ inhibitors, correlating clinical improvement with a decrease in this score. Psodisk is a 10-item questionnaire (general health, presence of pain, quality of sleep, peace of mind, social life, work satisfaction, sex life, feeling of shame and skin involvement), presented as a coloured disc, which assesses the burden of psoriasis. Psodisk has shown internal consistency and test-retest reliability. When compared to the Dermatology Life Quality Index (DLQI) and the Skindex-29, no significant differences were found among the different items of these three questionnaires [6]. Psodisk has been designed to be completed jointly by the dermatologist and the patient. It appears to be simple to understand, not very time-consuming and may probably be easily integrated into daily Dermatology practice. Nevertheless, its validation in a broader population, comparing it to other quality of life assessment tools, is necessary.
References
1. Coates LC, Navarro-Coy N, Brown SR, et al. The TICOPA protocol (TIght COntrol of Psoriatic Arthritis): a randomised controlled trial to compare intensive management versus standard care in early psoriatic arthritis. BMC Musculoskelet Disord 2013; 14: 101. 2. Lopez Estebaranz JL, Zarco-Montejo P, Samaniego ML, GarciaCalvo C. Prevalence and clinical features of psoriatic arthritis in psoriasis patients in Spain. Limitations of PASE as a screening tool. Eur J Dermatol 2015; 25: 41-7. 3. Ye YM, Jin HJ, Hwang EK, et al. Co-existence of chronic urticaria and metabolic syndrome: clinical implications. Acta Dermatol Venereol 2013; 93: 156-60. 4. Grzanka A, Machura E, Misiolek M, Polaniak R, Kasperski J, Kasperska-Zajac A. Systemic inflammatory response and calcification markers in patients with long lasting moderate-severe chronic spontaneous urticaria. Eur J Dermatol 2015; 25: 26-8. 5. Chiricozzi A, Bianchi L, Zangrilli A, et al. Quality of life of psoriatic patients evaluated by a new psychometric assessment tool: PsoDisk. Eur J Dermatol 2015; 25: 48-53. EJD, vol. 25, n◦ 1, January-February 2015
6. Sampogna F, Linder D, Romano GV, Gualberti G, Merolla R, di Luzio Paparatti U. Results of the validation study of the Psodisk instrument, and determination of the cut-off scores for varying degrees of impairment. J Eur Acad Dermatol Venereol 2014 (epub ahead of print). doi:10.1684/ejd.2015.2539
Residents’corner February 2015. sQUIZ your knowledge! Jin WEI, Jianzhong ZHANG Department of Dermatology, Peking University People’s Hospital, Beijing, China e-mail: [email protected]
Figure 1. Clinical presentation.
A
42-year-old woman presented with a ten-year history of slightly pruritic brown plaques on the trunk (figure 1). Friction could induce Darier sign. The patient could not recall any previous skin lesions in the past. What is the diagnosis?
EJD, vol. 25, n◦ 1, January-February 2015
95
