Commentaries
the need for health behaviour change interventions to be theoretically informed and tailored to indivduals.9,10 Furthermore, a description of the intervention that is sufficient to enable replication has been provided. In all, the study by Larsen et al.8 concludes that MI may be a useful adjunct to medical management, patient education and self-management in psoriasis care. This study has paved the way for larger scale RCTs in this subject area. Funding sources No external funding. Conflicts of interest None declared. Faculty of Health and Social Care, University of Hull, 204, Dearne Building, Hull HU6 7RX, U.K. E-mail: [email protected]
F. COWDELL
References 1 Martınez-Garcıa E, Arias-Santiago S, Valenzuela-Salas I et al. Quality of life in persons living with psoriasis patients. J Am Acad Dermatol 2014; 71:302–7. 2 Pereira M, Brito L, Smith T. Dyadic adjustment, family coping, body image, quality of life and psychological morbidity in patients with psoriasis and their partners. Int J Behav Med 2012; 19:260–9. 3 Ersser SJ, Cowdell FC, Latter SM et al. Self-management experiences in adults with mild-moderate psoriasis: an exploratory study and implications for improved support. Br J Dermatol 2010; 163:1044– 9. 4 Ersser SJ, Cowdell FC, Nicholls PG et al. A pilot randomized controlled trial to examine the feasibility and efficacy of an educational nursing intervention to improve self-management practices in patients with mild-moderate psoriasis. J Eur Acad Dermatol Venereol 2012; 26:738–45. 5 Bandura A. Self-Efficacy: The Exercise of Control. New York: Freeman, 1997. 6 Larsen MH, Hagen KB, Krogstad AL et al. Limited evidence of the effects of patient education and self-management interventions in psoriasis patients: a systematic review. Patient Educ Couns 2014; 94:158–69. 7 Rollnick S, Miller W. What is motivational interviewing? Behav Cogn Psychother 1995; 23:325–34. 8 Larsen MH, Krogstad AL, Aas E et al. A telephone-based motivational interviewing intervention has positive effects on psoriasis severity and self management: a randomized controlled trial. Br J Dermatol 2014; 171:1458–69. 9 Michie S, Johnston M, Francis J et al. From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques. Appl Psychol 2008; 57:660–80. 10 Baker R, Camosso-Stefinovic J, Gillies C et al. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2010; 3: CD005470.
© 2014 British Association of Dermatologists
1297
Vitamin D and photodermatoses DOI: 10.1111/bjd.13479 ORIGINAL ARTICLE, p 1478 Vitamin D is known to be beneficial for musculoskeletal health. While suboptimal vitamin D levels have been also associated with other diseases, the cause and effect relationship is yet to be established.1 The three sources of vitamin D are ultraviolet B (UVB) radiation, diet and vitamin supplementation.2 Specific recommendations for vitamin D intake have been made by the National Institute for Health and Care Excellence (NICE), a UK-based organization, and by the Institute of Medicine (IOM), an independent US-based organization.3,4 Previous studies have demonstrated suboptimal levels of vitamin D (measured as serum 25-hydroxyvitamin D [25(OH) D]) in patients with photosensitivity. However, in previous studies, 25(OH)D levels were determined during various seasons, and no controls were used.2 In the current issue of the BJD, Rhodes et al.5 present a carefully done, prospective, longitudinal 12-month study of the vitamin D status of patients with photosensitivity compared with controls. They found that patients with photosensitivity are at greater risk of vitamin D deficiency all year round compared with healthy individuals, which is attributable to the practice of photoprotection. The study by Rhodes et al. elaborates upon reported observations that individuals who work indoors and healthy individuals who practise photoprotection by wearing long-sleeved shirts and staying in the shade have less than adequate serum 25(OH)D levels.2,5 The study by Rhodes et al.5 contained only seven patients with photosensitivity who had skin phototypes V and VI; none of the controls had photosensitivity. Therefore, a comparison between dark-skinned patients with photosensitivity and controls could not be performed. This is a topic for further investigation, as it has been reported that black Americans have lower serum 25(OH)D levels compared with white Americans; however, the former have lower vitamin D-binding protein levels, resulting in similar levels of bioavailable 25(OH)D.6 Narrowband UVB is commonly used as a treatment for polymorphic light eruption; it simultaneously increases vitamin D serum concentrations. In a study of sunseekers and skiers, a significant positive correlation between cumulative UVB exposure and thymine dimers – biomarkers of DNA damage – in urine and serum was observed.7 This study indicated that UVB induces not only vitamin D synthesis, but also DNA damage. Therefore, suboptimal vitamin D levels are best treated with oral intake of vitamin D.7 A frequently asked question is whether serum vitamin D testing should be done for patients at risk of vitamin D insufficiency. The economic burden to society of large-scale vitamin British Journal of Dermatology (2014) 171, pp1285–1299
1298 Commentaries
D testing is not inconsequential. In view of the recommendations of NICE and the IOM, and of the fact that vitamin D supplementation can be obtained inexpensively over the counter, it would be reasonable to advise vitamin D supplementation, without serum testing, for at-risk patients. Conflicts of interest None declared. 1
Department of Dermatology, Henry Ford Hospital, Detroit, MI, USA 2 Department of Dermatology, Jan Palfijn Hospital, Merksem, Belgium 3 University Hospital Leuven, Leuven, Belgium E-mail: [email protected]
H.W. LIM1 J . J . L . S N A U W A E R T 2,3
References 1 Bischoff-Ferrari HA, Orav EJ, Willett WC et al. The effect of vitamin D supplementation on skeletal, vascular, or cancer outcomes. Lancet Diabetes Endocrinol 2014; 2:363–4. 2 Kannan S, Lim HW. Photoprotection and vitamin D: a review. Photodermatol Photoimmunol Photomed 2014; 30:137–45. 3 Jacqui W. NICE advises certain groups to take daily vitamin D supplement. BMJ 2014; 348:3349. 4 Ross AC, Manson JE, Abrams SA et al. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab 2011; 96:53–8. 5 Rhodes LE, Webb AR, Berry JL et al. Sunlight exposure behaviour and vitamin D status in photosensitive patients: longitudinal comparative study with healthy individuals at UK latitude. Br J Dermatol 2014; 171:1478–86. 6 Powe CE, Karumanchi SA, Thadhani R et al. Vitamin D-binding protein and vitamin D in blacks and whites. N Engl J Med 2014; 370:880–1. 7 Petersen B, Wulf H, Triguero-Mas M et al. Sun and ski holidays improve vitamin D status, but are associated with high levels of DNA damage. J Invest Dermatol 2014; 134:2806–13.
Photodynamic therapy: increasing acceptance through reduction of adverse reactions DOI: 10.1111/bjd.13395 ORIGINAL ARTICLE, p 1487 Topical photodynamic therapy (PDT) is an established, widely used and effective therapy for nonmelanoma skin cancer including actinic keratosis.1,2 The procedure involves application of a prodrug – aminolaevulinic acid (ALA) or methyl aminolaevulinate (MAL) – which is then converted in the
British Journal of Dermatology (2014) 171, pp1285–1299
cancer cells through the haem biosynthetic pathway to photoactive porphyrins, mainly protoporphyrin IX. On illumination with light of the same wavelengths as the absorption spectrum of the porphyrin, reactive oxygen species, in particular singlet oxygen, are produced, resulting in apoptosis and necrosis of the target tissue.3 The mechanism of action is thus a phototoxic reaction with all its skin symptoms. The two major limiting factors for the use of conventional PDT are the pain during illumination and the severity of the skin reactions. Some patients experience excruciating pain burns, resulting in stopping the illumination and the use of various pain-reducing measures. With the introduction of daylight-PDT (D-PDT) the pain issue is solved.4–7 Exposing the treatment area to 15–2 h of daylight starting within 30 min of application of the prodrugs ALA or MAL, the patients rarely report pain, but merely itching, and the clinical efficacy is similar to that of conventional PDT. D-PDT cannot be used in the wintertime in northern and southern latitudes due to lack of sufficient daylight intensity,8 but in near-equatorial areas it can be used the whole year round, making investment in a lamp superfluous. The remaining major limiting factor of PDT is phototoxic skin reaction, varying in intensity from erythema and oedema to development of sterile pustules and crusts, which in some patients is also accompanied by pain. As actinic keratosis usually develops at the bald scalp, in the face and at the dorsum of hands and underarms, the PDT skin reactions are visible to others and thus are socially disadvantageous, often leading to self-determined restriction of normal participation in social and working life. Most of the severe reaction subsides within 11–12 days, but erythema can persist for months. Scarring is unusual after PDT of actinic keratosis. In this issue of BJD, the same group that introduced D-PDT is now publishing another new, innovative and clinically very important variation of the PDT procedure.9 By using a strong topical corticosteroid before and immediately after PDT for actinic keratosis, the erythema 24 h after treatment was significantly reduced, without reducing the complete response rate at 3 months. The latter finding is contrary to the widespread, but not documented, belief that using topical corticosteroids to reduce the phototoxic skin reaction would also reduce the response rate. After solving the pain issue using DPDT, Wiegell et al. remove the remaining limiting factor of PDT, the severity of the skin reaction, which is reduced significantly by using a topical corticosteroid, potentially increasing patient acceptance and satisfaction. It is now important to investigate whether the response rate of the combination of PDT with topical corticosteroids for actinic keratosis holds over time, by measuring the long-term response rate vs. conventional PDT. Funding sources None.
© 2014 British Association of Dermatologists
the need for health behaviour change interventions to be theoretically informed and tailored to indivduals.9,10 Furthermore, a description of the intervention that is sufficient to enable replication has been provided. In all, the study by Larsen et al.8 concludes that MI may be a useful adjunct to medical management, patient education and self-management in psoriasis care. This study has paved the way for larger scale RCTs in this subject area. Funding sources No external funding. Conflicts of interest None declared. Faculty of Health and Social Care, University of Hull, 204, Dearne Building, Hull HU6 7RX, U.K. E-mail: [email protected]
F. COWDELL
References 1 Martınez-Garcıa E, Arias-Santiago S, Valenzuela-Salas I et al. Quality of life in persons living with psoriasis patients. J Am Acad Dermatol 2014; 71:302–7. 2 Pereira M, Brito L, Smith T. Dyadic adjustment, family coping, body image, quality of life and psychological morbidity in patients with psoriasis and their partners. Int J Behav Med 2012; 19:260–9. 3 Ersser SJ, Cowdell FC, Latter SM et al. Self-management experiences in adults with mild-moderate psoriasis: an exploratory study and implications for improved support. Br J Dermatol 2010; 163:1044– 9. 4 Ersser SJ, Cowdell FC, Nicholls PG et al. A pilot randomized controlled trial to examine the feasibility and efficacy of an educational nursing intervention to improve self-management practices in patients with mild-moderate psoriasis. J Eur Acad Dermatol Venereol 2012; 26:738–45. 5 Bandura A. Self-Efficacy: The Exercise of Control. New York: Freeman, 1997. 6 Larsen MH, Hagen KB, Krogstad AL et al. Limited evidence of the effects of patient education and self-management interventions in psoriasis patients: a systematic review. Patient Educ Couns 2014; 94:158–69. 7 Rollnick S, Miller W. What is motivational interviewing? Behav Cogn Psychother 1995; 23:325–34. 8 Larsen MH, Krogstad AL, Aas E et al. A telephone-based motivational interviewing intervention has positive effects on psoriasis severity and self management: a randomized controlled trial. Br J Dermatol 2014; 171:1458–69. 9 Michie S, Johnston M, Francis J et al. From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques. Appl Psychol 2008; 57:660–80. 10 Baker R, Camosso-Stefinovic J, Gillies C et al. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2010; 3: CD005470.
© 2014 British Association of Dermatologists
1297
Vitamin D and photodermatoses DOI: 10.1111/bjd.13479 ORIGINAL ARTICLE, p 1478 Vitamin D is known to be beneficial for musculoskeletal health. While suboptimal vitamin D levels have been also associated with other diseases, the cause and effect relationship is yet to be established.1 The three sources of vitamin D are ultraviolet B (UVB) radiation, diet and vitamin supplementation.2 Specific recommendations for vitamin D intake have been made by the National Institute for Health and Care Excellence (NICE), a UK-based organization, and by the Institute of Medicine (IOM), an independent US-based organization.3,4 Previous studies have demonstrated suboptimal levels of vitamin D (measured as serum 25-hydroxyvitamin D [25(OH) D]) in patients with photosensitivity. However, in previous studies, 25(OH)D levels were determined during various seasons, and no controls were used.2 In the current issue of the BJD, Rhodes et al.5 present a carefully done, prospective, longitudinal 12-month study of the vitamin D status of patients with photosensitivity compared with controls. They found that patients with photosensitivity are at greater risk of vitamin D deficiency all year round compared with healthy individuals, which is attributable to the practice of photoprotection. The study by Rhodes et al. elaborates upon reported observations that individuals who work indoors and healthy individuals who practise photoprotection by wearing long-sleeved shirts and staying in the shade have less than adequate serum 25(OH)D levels.2,5 The study by Rhodes et al.5 contained only seven patients with photosensitivity who had skin phototypes V and VI; none of the controls had photosensitivity. Therefore, a comparison between dark-skinned patients with photosensitivity and controls could not be performed. This is a topic for further investigation, as it has been reported that black Americans have lower serum 25(OH)D levels compared with white Americans; however, the former have lower vitamin D-binding protein levels, resulting in similar levels of bioavailable 25(OH)D.6 Narrowband UVB is commonly used as a treatment for polymorphic light eruption; it simultaneously increases vitamin D serum concentrations. In a study of sunseekers and skiers, a significant positive correlation between cumulative UVB exposure and thymine dimers – biomarkers of DNA damage – in urine and serum was observed.7 This study indicated that UVB induces not only vitamin D synthesis, but also DNA damage. Therefore, suboptimal vitamin D levels are best treated with oral intake of vitamin D.7 A frequently asked question is whether serum vitamin D testing should be done for patients at risk of vitamin D insufficiency. The economic burden to society of large-scale vitamin British Journal of Dermatology (2014) 171, pp1285–1299
1298 Commentaries
D testing is not inconsequential. In view of the recommendations of NICE and the IOM, and of the fact that vitamin D supplementation can be obtained inexpensively over the counter, it would be reasonable to advise vitamin D supplementation, without serum testing, for at-risk patients. Conflicts of interest None declared. 1
Department of Dermatology, Henry Ford Hospital, Detroit, MI, USA 2 Department of Dermatology, Jan Palfijn Hospital, Merksem, Belgium 3 University Hospital Leuven, Leuven, Belgium E-mail: [email protected]
H.W. LIM1 J . J . L . S N A U W A E R T 2,3
References 1 Bischoff-Ferrari HA, Orav EJ, Willett WC et al. The effect of vitamin D supplementation on skeletal, vascular, or cancer outcomes. Lancet Diabetes Endocrinol 2014; 2:363–4. 2 Kannan S, Lim HW. Photoprotection and vitamin D: a review. Photodermatol Photoimmunol Photomed 2014; 30:137–45. 3 Jacqui W. NICE advises certain groups to take daily vitamin D supplement. BMJ 2014; 348:3349. 4 Ross AC, Manson JE, Abrams SA et al. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab 2011; 96:53–8. 5 Rhodes LE, Webb AR, Berry JL et al. Sunlight exposure behaviour and vitamin D status in photosensitive patients: longitudinal comparative study with healthy individuals at UK latitude. Br J Dermatol 2014; 171:1478–86. 6 Powe CE, Karumanchi SA, Thadhani R et al. Vitamin D-binding protein and vitamin D in blacks and whites. N Engl J Med 2014; 370:880–1. 7 Petersen B, Wulf H, Triguero-Mas M et al. Sun and ski holidays improve vitamin D status, but are associated with high levels of DNA damage. J Invest Dermatol 2014; 134:2806–13.
Photodynamic therapy: increasing acceptance through reduction of adverse reactions DOI: 10.1111/bjd.13395 ORIGINAL ARTICLE, p 1487 Topical photodynamic therapy (PDT) is an established, widely used and effective therapy for nonmelanoma skin cancer including actinic keratosis.1,2 The procedure involves application of a prodrug – aminolaevulinic acid (ALA) or methyl aminolaevulinate (MAL) – which is then converted in the
British Journal of Dermatology (2014) 171, pp1285–1299
cancer cells through the haem biosynthetic pathway to photoactive porphyrins, mainly protoporphyrin IX. On illumination with light of the same wavelengths as the absorption spectrum of the porphyrin, reactive oxygen species, in particular singlet oxygen, are produced, resulting in apoptosis and necrosis of the target tissue.3 The mechanism of action is thus a phototoxic reaction with all its skin symptoms. The two major limiting factors for the use of conventional PDT are the pain during illumination and the severity of the skin reactions. Some patients experience excruciating pain burns, resulting in stopping the illumination and the use of various pain-reducing measures. With the introduction of daylight-PDT (D-PDT) the pain issue is solved.4–7 Exposing the treatment area to 15–2 h of daylight starting within 30 min of application of the prodrugs ALA or MAL, the patients rarely report pain, but merely itching, and the clinical efficacy is similar to that of conventional PDT. D-PDT cannot be used in the wintertime in northern and southern latitudes due to lack of sufficient daylight intensity,8 but in near-equatorial areas it can be used the whole year round, making investment in a lamp superfluous. The remaining major limiting factor of PDT is phototoxic skin reaction, varying in intensity from erythema and oedema to development of sterile pustules and crusts, which in some patients is also accompanied by pain. As actinic keratosis usually develops at the bald scalp, in the face and at the dorsum of hands and underarms, the PDT skin reactions are visible to others and thus are socially disadvantageous, often leading to self-determined restriction of normal participation in social and working life. Most of the severe reaction subsides within 11–12 days, but erythema can persist for months. Scarring is unusual after PDT of actinic keratosis. In this issue of BJD, the same group that introduced D-PDT is now publishing another new, innovative and clinically very important variation of the PDT procedure.9 By using a strong topical corticosteroid before and immediately after PDT for actinic keratosis, the erythema 24 h after treatment was significantly reduced, without reducing the complete response rate at 3 months. The latter finding is contrary to the widespread, but not documented, belief that using topical corticosteroids to reduce the phototoxic skin reaction would also reduce the response rate. After solving the pain issue using DPDT, Wiegell et al. remove the remaining limiting factor of PDT, the severity of the skin reaction, which is reduced significantly by using a topical corticosteroid, potentially increasing patient acceptance and satisfaction. It is now important to investigate whether the response rate of the combination of PDT with topical corticosteroids for actinic keratosis holds over time, by measuring the long-term response rate vs. conventional PDT. Funding sources None.
© 2014 British Association of Dermatologists
