Hidradenitis suppurativa/acne inversa (HS) is a chronic, inflammatory, recurrent, debilitating skin disease of the hair follicle that usually presents after puberty with painful, deep‐seated, ...inflamed lesions in the apocrine gland‐bearing areas of the body, most commonly the axillae, inguinal and anogenital regions. A mean disease incidence of 6.0 per 100 000 person‐years and an average prevalence of 1% has been reported in Europe. HS has the highest impact on patients' quality of life among all assessed dermatological diseases. HS is associated with a variety of concomitant and secondary diseases, such as obesity, metabolic syndrome, inflammatory bowel disease, e.g. Crohn's disease, spondyloarthropathy, follicular occlusion syndrome and other hyperergic diseases. The central pathogenic event in HS is believed to be the occlusion of the upper part of the hair follicle leading to a perifollicular lympho‐histiocytic inflammation. A highly significant association between the prevalence of HS and current smoking (Odds ratio 12.55) and overweight (Odds ratio 1.1 for each body mass index unit) has been documented. The European S1 HS guideline suggests that the disease should be treated based on its individual subjective impact and objective severity. Locally recurring lesions can be treated by classical surgery or LASER techniques, whereas medical treatment either as monotherapy or in combination with radical surgery is more appropriate for widely spread lesions. Medical therapy may include antibiotics (clindamycin plus rifampicine, tetracyclines), acitretin and biologics (adalimumab, infliximab). A Hurley severity grade‐relevant treatment of HS is recommended by the expert group following a treatment algorithm. Adjuvant measurements, such as pain management, treatment of superinfections, weight loss and tobacco abstinence have to be considered.
Summary
Background Hidradenitis suppurativa (HS) is a long‐standing disease with abscess and often fistula formation, predominantly in the axillae and groins. The disease is difficult to treat and ...has a severe impact on quality of life. A clinically relevant system for scoring disease severity is lacking in HS.
Objectives To evaluate the modified Hidradenitis Suppurativa Score (HSS) and to study the impact of body mass index (BMI) and smoking habits on disease severity.
Methods Two hundred and fifty‐one consecutive patients with HS referred to a clinic with special interest in the disease were included, of whom 115 were scored. Points were given for regions involved, types of lesion (nodules, fistulas), total area involved and whether lesions were separated by normal skin. Background characteristics included BMI and smoking habits. Two hundred and forty‐six patients completed the Dermatology Life Quality Index (DLQI).
Results The median (interquartile range, IQR) HSS for all patients was 38 (18–66): women 38 (18–71) and men 37 (19–51). Median (IQR) HSS for smokers was 41 (22–75·5), former smokers 27 (16–53) and nonsmokers 22 (10–57). Median (IQR) HSS for patients with BMI < 25 kg m−2 was 32 (12–54), BMI 25–30 kg m−2 44 (22–56) and BMI ≥ 30 kg m−2 50 (18–86). Mean ± SD DLQI for the whole group of patients was 10·3 ± 7·5, median 9, and showed no significant differences between the groups studied. There was a significant positive correlation of fair degree between HSS and DLQI. There were significant differences in HSS between nonsmokers and smokers as well as between women of normal weight compared with obese women.
Conclusions The modified HSS is simple and practical and it extracts important clinical information. A connection between disease severity and BMI as well as smoking habits in patients with HS is presented. The results suggest that the HSS may be a relevant outcome measure in future therapeutic trials in HS.
Whether machine-learning algorithms can diagnose all pigmented skin lesions as accurately as human experts is unclear. The aim of this study was to compare the diagnostic accuracy of state-of-the-art ...machine-learning algorithms with human readers for all clinically relevant types of benign and malignant pigmented skin lesions.
For this open, web-based, international, diagnostic study, human readers were asked to diagnose dermatoscopic images selected randomly in 30-image batches from a test set of 1511 images. The diagnoses from human readers were compared with those of 139 algorithms created by 77 machine-learning labs, who participated in the International Skin Imaging Collaboration 2018 challenge and received a training set of 10 015 images in advance. The ground truth of each lesion fell into one of seven predefined disease categories: intraepithelial carcinoma including actinic keratoses and Bowen's disease; basal cell carcinoma; benign keratinocytic lesions including solar lentigo, seborrheic keratosis and lichen planus-like keratosis; dermatofibroma; melanoma; melanocytic nevus; and vascular lesions. The two main outcomes were the differences in the number of correct specific diagnoses per batch between all human readers and the top three algorithms, and between human experts and the top three algorithms.
Between Aug 4, 2018, and Sept 30, 2018, 511 human readers from 63 countries had at least one attempt in the reader study. 283 (55·4%) of 511 human readers were board-certified dermatologists, 118 (23·1%) were dermatology residents, and 83 (16·2%) were general practitioners. When comparing all human readers with all machine-learning algorithms, the algorithms achieved a mean of 2·01 (95% CI 1·97 to 2·04; p<0·0001) more correct diagnoses (17·91 SD 3·42 vs 19·92 4·27). 27 human experts with more than 10 years of experience achieved a mean of 18·78 (SD 3·15) correct answers, compared with 25·43 (1·95) correct answers for the top three machine algorithms (mean difference 6·65, 95% CI 6·06–7·25; p<0·0001). The difference between human experts and the top three algorithms was significantly lower for images in the test set that were collected from sources not included in the training set (human underperformance of 11·4%, 95% CI 9·9–12·9 vs 3·6%, 0·8–6·3; p<0·0001).
State-of-the-art machine-learning classifiers outperformed human experts in the diagnosis of pigmented skin lesions and should have a more important role in clinical practice. However, a possible limitation of these algorithms is their decreased performance for out-of-distribution images, which should be addressed in future research.
None.
Summary
Background
The incidence of cutaneous malignant melanoma (CMM) continues to increase in most countries worldwide and the majority are diagnosed with thin tumours (≤ 1 mm).
Objectives
The aim ...of the present study was to investigate the melanoma‐specific survival (MSS) as well as conditional MSS (CMSS) in patients with thin CMM in Sweden.
Patients and methods
Clinical and histological parameters were obtained from the Swedish Melanoma Registry for patients diagnosed with thin CMM between 1990 and 2017. Patients were followed until the end of 2017. MSS as well as CMSS for different thickness groups were calculated using the Kaplan–Meier method and Cox regression analyses were used to calculate for survival differences between thickness groups.
Results
There were 31 670 patients included for final analyses. The overall 10‐ and 20‐year MSS for thin CMMs was 97% 95% confidence interval (CI) 97–97 and 95% (95% CI 95–96), respectively. From 0·7 mm and above, MSS decreased significantly with increasing thickness level. All thickness groups had an increased survival over time. The lowest CMSS was confirmed for men with 1·0 mm in thickness but their 10‐year CMSS increased steadily over time. Women had overall better MSS as well as CMSS than men. However, the relation between MSS and CMSS was similar for both sexes.
Conclusions
MSS was confirmed as excellent for patients with thin CMMs in Sweden. Although we could show a decreased MSS for patients with 0·7 mm thickness and above, the long‐term survival and, in addition, a very favourable CMSS for those patients do not support more extended follow‐up programmes than the current recommendations in Sweden.
What is already known about this topic?
The majority of patients with cutaneous malignant melanoma are diagnosed with thin melanomas (≤ 1 mm) and the survival is generally reported as favourable.
What does this study add?
Our national population‐based designed study, including 31 670 patients with thin melanomas, is exclusive when it comes to melanoma survival data, as many former studies are based on selected and smaller cohorts of patients (e.g. referral centres/hospital‐based registries).
In addition to an excellent overall melanoma‐specific survival (MSS), we could also report an increasing conditional MSS with time from diagnosis for patients with thin melanomas in Sweden.
Linked Comment: Hollestein and Nijsten. Br J Dermatol 2021; 184:4.
Plain language summary available online
: Hidradenitis suppurativa (HS) – a rather common, very chronic and debilitating inflammatory skin appendage disorder with a notoriously underestimated burden of disease – has long been a playground ...for the high priests of nomenclature: Ask a bunch of eminent dermatologists and skin pathologists to publicly share their thoughts on what causes HS, and they will soon get entrenched in a heated debate on whether this historical term is a despicable misnomer. Fortunately, the recently founded Hidradenitis Suppurativa Foundation (HSF; http://www.hs‐foundation.org), to which EXP DERMATOL serves as home journal, has broken with this unproductive tradition and has encouraged publication of the current CONTROVERSIES feature. This is exclusively devoted to discussing the pathobiology of this chronic neutrophilic folliculitis of unknown origin. Although traces of terminological bickering remain visible, it does the HS experts in our virtual debate room credit that they engage in a constructive and comprehensive dissection of potential pathogenesis pathways that may culminate in the clinical picture we know under the competing terms HS or acne inversa. These experts sketch more often complementary than mutually exclusive pathogenesis scenarios, and the outlines of a conceivable consensus on the many open pathobiology questions begin to emerge in these CONTROVERSIES. Hopefully, this heralds a welcome new tradition: to get to the molecular heart of HS pathogenesis, which can only be achieved by a renaissance of solid basic HS research, as the key to developing more effective HS therapy.
Summary
Background
The introduction of unclassified new psychoactive substances (NPS) on the recreational drugs market through open online sale (‘legal highs’ or ‘Internet drugs’) continues unabated ...and represents a growing health hazard. The use of NPS has resulted in numerous, severe, adverse events and fatalities, due to unintended overdose or unknown toxic side‐effects.
Objectives
To try to find a possible common underlying cause for the skin–hair–eye symptoms complex observed in three men.
Methods
From late 2013 to mid‐2014, three Swedish men aged 23–34 years with a history of recreational drug use independently presented with similar and very remarkable clinical signs, requiring extensive examination and prolonged treatment.
Results
Common clinical signs included hair depigmentation, hair loss, widespread folliculitis and dermatitis, painful intertriginous dermatitis, dry eyes, and elevated liver enzymes. Two of them also showed transverse white Mees’ lines (leukonychia striata) on the fingernails and toenails, suggesting a temporary, drug‐induced, disorganized keratinization. The clinical signs gradually disappeared over time. However, later on, two developed severe bilateral secondary cataracts requiring surgery. Because drug tests within the Swedish STRIDA project had demonstrated intake of the NPS opioid MT‐45 in all patients, this was suspected to be the common causative agent.
Conclusions
These cases highlight the importance for physicians and health professionals to consider the increasing number of novel, untested recreational drugs, as a potential cause of unusual and otherwise unrecognized clinical signs and symptoms.
What's already known about this topic?
The use of new psychoactive substances (NPS) distributed through open online sale, also referred to as ‘legal highs’ or ‘Internet drugs’, has increased much in recent years.
Intake of NPS has been reported to result in numerous severe adverse events and fatalities, due to unintended overdose or unknown toxic side‐effects.
What does this study add?
This study describes a new complex adverse drug reaction with symptoms involving the hair, skin, nails and eyes, seemingly linked to the intake of the NPS opioid MT‐45.
The study expands the understanding of health hazards associated with the use of novel, untested recreational drugs.
This paper further highlights the importance for health professionals to consider NPS as a potential cause of unusual and otherwise unrecognized clinical signs and symptoms.
Summary Background Previous studies have shown different bacteria in hidradenitis suppurativa (HS) lesions, but the literature regarding bacteria in acute exacerbation of HS is sparse.
Objectives ...To determine the type of bacteria isolated from HS lesions during exacerbations of the disease.
Methods Patients with HS with acute nodules or abscesses were examined and treated by carbon dioxide laser vaporization. Bacterial samples for aerobic and anaerobic cultures were taken from the skin surface (before surgery) and then from the deeper layers (during surgery) of the lesions. At each level two samples were taken, one with a punch biopsy and one by pressing a soft agar gel against the skin. The bacterial findings were typed and quantified.
Results A total of 10 patients (eight women and two men), with a mean age of 37·2 years and a mean HS duration of 14·5 years, were included. All of them had an ongoing exacerbation (mean duration 5·6 days) of their HS, with one inflamed lesion that was treated by carbon dioxide laser vaporization. Coagulase‐negative staphylococci (CNS) were found in the deep layers in all 10 patients. Nine of the patients carried Corynebacterium spp. and two alpha‐haemolytic streptococci at various levels. Among the anaerobic microorganisms, Gram‐positive cocci were the most common bacteria.
Conclusions As found in a previous study, CNS were the most common bacteria, but contrary to what we expected, Staphylococcus aureus was not found in any cultures from acute inflammatory nodules of HS exacerbations.
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