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A consensus approach to improving patient adherence and persistence with topical treatment for actinic keratosis

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      Abstract

      Background

      Topical therapy is important in the treatment of actinic keratosis, but guidance for improving adherence/persistence during topical therapy is still lacking.

      Objectives

      To utilize expert consensus to generate a list of recommendations to improve real-world efficacy when prescribing topical therapy for actinic keratosis.

      Methods

      An expert panel of eight dermatologists was convened to generate recommendations based on facilitated discussion and consensus generation using a modified Delphi session. The recommendations were ratified with the expert panel.

      Results

      Facilitated discussion generated 31 issues within five themes, which were prioritized using expert voting. Consensus was achieved on the importance of short and simple treatment regimens for maximizing patient compliance, physician awareness of the progression of actinic keratosis to squamous cell carcinoma, provision of appropriate patient information, and the use of effective communication strategies to educate physicians about actinic keratosis. Based on these key findings, eight recommendations were generated.

      Conclusions

      The recommendations will assist physicians when prescribing topical actinic keratosis therapy. Further research should focus on the types of patient outcomes that are influenced by the characteristics of topical field therapy.

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      Most cited references 27

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      Definition of treatment goals for moderate to severe psoriasis: a European consensus

      Patients with moderate to severe psoriasis are undertreated. To solve this persistent problem, the consensus programme was performed to define goals for treatment of plaque psoriasis with systemic therapy and to improve patient care. An expert consensus meeting and a collaborative Delphi procedure were carried out. Nineteen dermatologists from different European countries met for a face-to-face discussion and defined items through a four-round Delphi process. Severity of plaque psoriasis was graded into mild and moderate to severe disease. Mild disease was defined as body surface area (BSA) ≤10 and psoriasis area and severity index (PASI) ≤10 and dermatology life quality index (DLQI) ≤10 and moderate to severe psoriasis as (BSA > 10 or PASI > 10) and DLQI > 10. Special clinical situations may change mild psoriasis to moderate to severe including involvement of visible areas or severe nail involvement. For systemic therapy of plaque psoriasis two treatment phases were defined: (1) induction phase as the treatment period until week 16; however, depending on the type of drug and dose regimen used, this phase may be extended until week 24 and (2) maintenance phase for all drugs was defined as the treatment period after the induction phase. For the definition of treatment goals in plaque psoriasis, the change of PASI from baseline until the time of evaluation (ΔPASI) and the absolute DLQI were used. After induction and during maintenance therapy, treatment can be continued if reduction in PASI is ≥75%. The treatment regimen should be modified if improvement of PASI is 5 but can be continued if the DLQI is ≤5. This programme defines the severity of plaque psoriasis for the first time using a formal consensus of 19 European experts. In addition, treatment goals for moderate to severe disease were established. Implementation of treatment goals in the daily management of psoriasis will improve patient care and mitigate the problem of undertreatment. It is planned to evaluate the implementation of these treatment goals in a subsequent programme involving patients and physicians.
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        Stability of response characteristics of a Delphi panel: application of bootstrap data expansion

        Background Delphi surveys with panels of experts in a particular area of interest have been widely utilized in the fields of clinical medicine, nursing practice, medical education and healthcare services. Despite this wide applicability of the Delphi methodology, there is no clear identification of what constitutes a sufficient number of Delphi survey participants to ensure stability of results. Methods The study analyzed the response characteristics from the first round of a Delphi survey conducted with 23 experts in healthcare quality and patient safety. The panel members had similar training and subject matter understanding of the Malcolm Baldrige Criteria for Performance Excellence in Healthcare. The raw data from the first round sampling, which usually contains the largest diversity of responses, were augmented via bootstrap sampling to obtain computer-generated results for two larger samples obtained by sampling with replacement. Response characteristics (mean, trimmed mean, standard deviation and 95% confidence intervals) for 54 survey items were compared for the responses of the 23 actual study participants and two computer-generated samples of 1000 and 2000 resampling iterations. Results The results from this study indicate that the response characteristics of a small expert panel in a well-defined knowledge area are stable in light of augmented sampling. Conclusion Panels of similarly trained experts (who possess a general understanding in the field of interest) provide effective and reliable utilization of a small sample from a limited number of experts in a field of study to develop reliable criteria that inform judgment and support effective decision-making.
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          Frequency of pre-existing actinic keratosis in cutaneous squamous cell carcinoma.

          Controversy over the rate of malignant transformation of actinic keratosis (AK) into cutaneous squamous cell carcinoma (SCC) has generated considerable debate regarding the importance of treating all such precancers to preclude their transofrmation. Current changes in US healthcare policy will deny many individuals access to certain simple and effective treatment modalities for precancerous lesions. Our purpose was to determine whether there is a significant association between the presence of cutaneous SCC and pre-existing AK. One hundred and sixty five consecutive cases of cutaneous SCC, retrieved from the files of a university-affiliated dermatopathology laboratory serving north-central Florida, were selected for review by a single dermatopathologist (D.M.). Hematoxylin and eosin stained skin tissue slides were examined under light microscopy for the presence of AK in close proximity to, or giving rise to, cutaneous SCC. Of the 165 cutaneous SCC cases reviewed, 82.4% (136 out of 165) were found to have concomitant AK giving rise to and/or in close proximity to SCC. Of the 136 AK-positive SCC cases, 26.7% (44) were identified as superficial SCC arising within an AK (AKSSCC) and 55.7% (92) had AK in close proximity to SCC (AK + SCC). Close proximity is defined to include AK changes located directly adjacent to (on the shoulder of) SCC, to a maximum distance of 8 mm away. The 82.4% prevalence of concomitant AK and cutaneous SCC in our biopsy population suggests a strong correlation between these two lesions. The fact that 26.7% of these lesions had SCC arising from AK highlights the importance of early recognition and effective treatment for AK.
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            Author and article information

            Affiliations
            [1 ]Klinik für Dermatologie, Venerologie und Allergologie St. Josef-Hospital, Ruhr-Universität Bochum Bochum, Germany
            [2 ]Department of Dermatology, University of L'Aquila L'Aquila, Italy
            [3 ]Instituto Valenciano de Oncologia Valencia, Spain
            [4 ]Skin Centre, St Bartholomew's Hospital and The London NHS Trust London, UK
            [5 ]Hôpital Saint-Louis Paris, France
            [6 ]Department of Medicine (Dermatology), The University of Melbourne, St Vincent's Hospital Melbourne and Skin & Cancer Foundation Inc. Fitzroy, SA, Australia
            [7 ]Universidade de Sao Paulo São Paulo, Brazil
            [8 ]Adelphi Research Bollington, UK
            [9 ]Leo Pharma Copenhagen, Denmark
            [10 ]Mount Sinai Hospital New York, NY, USA
            Author notes
            Eggert Stockfleth, md, phd, Gudrunstraße 56, 44791 Bochum,, Germany E-mail: e.stockfleth@ 123456klinikum-bochum.de

            Funding sources: Leo Pharma.

            Conflicts of interest: E.S. speaker, consultant, advisory board (Meda, Leo, and Almirall). K.P. advisory board (Leo, Roche, Meda). C.G. advisory board (Leo, Meda, Galderma, Almirall). R.C. speaker (Leo, Janssen, MSD/Pfizer). N.B.-S. consultant (Leo). P.F. advisory board, investigator, speaker (Abbvie, Janssen, MSD, Pfizer, CSL, GSK); advisory board, investigator (Amgen, Celgene); advisory board, consultant, investigator (Novartis); consultant, investigator, speaker (Eli Lilly); investigator (BMS); investigator, consultant (Roche); advisory board, consultant, speaker (Galderma); advisory board, consultant, investigator, speaker (Leo). J.S. advisory board (Leo). A.C. consultant (Leo). S.E. employee, speaker (Leo). M.L. consultant (Leo, Valeant); investigator (Leo).

            This work has been presented as a poster at European Academy of Venereology and Dermatology Annual Meeting, October 2013.

            Journal
            Int J Dermatol
            Int. J. Dermatol
            ijd
            International Journal of Dermatology
            Blackwell Publishing Ltd (Oxford, UK )
            0011-9059
            1365-4632
            May 2015
            10 April 2015
            : 54
            : 5
            : 509-515
            25865875
            4437053
            10.1111/ijd.12840
            © 2015 The Authors. International Journal of Dermatology published by John Wiley & Sons Ltd on behalf of International Society of Dermatology

            This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

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