admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

Acne is one of the most common disorders treated by dermatologists and other health care providers. While it most often affects adolescents, it is not uncommon in adults and can also be seen in children. This evidence-based guideline addresses important clinical questions that arise in its management. Issues from grading of acne to the topical and systemic management of the disease are reviewed. Suggestions on use are provided based on available evidence.

https://www.jaad.org/article/S0190-9622(15)02614-6/pdf

Guidelines of care for the management of acne vulgaris

The etiology of endemic rickets was discovered a century ago. Vitamin D is the precursor of 25-hydroxyvitamin D and other metabolites, including 1,25(OH)2D, the ligand for the vitamin D receptor (VDR). The effects of the vitamin D endocrine system on bone and its growth plate are primarily indirect and mediated by its effect on intestinal calcium transport and serum calcium and phosphate homeostasis. Rickets and osteomalacia can be prevented by daily supplements of 400 IU of vitamin D. Vitamin D deficiency (serum 25-hydroxyvitamin D <50 nmol/L) accelerates bone turnover, bone loss, and osteoporotic fractures. These risks can be reduced by 800 IU of vitamin D together with an appropriate calcium intake, given to institutionalized or vitamin D-deficient elderly subjects. VDR and vitamin D metabolic enzymes are widely expressed. Numerous genetic, molecular, cellular, and animal studies strongly suggest that vitamin D signaling has many extraskeletal effects. These include regulation of cell proliferation, immune and muscle function, skin differentiation, and reproduction, as well as vascular and metabolic properties. From observational studies in human subjects, poor vitamin D status is associated with nearly all diseases predicted by these extraskeletal actions. Results of randomized controlled trials and Mendelian randomization studies are supportive of vitamin D supplementation in reducing the incidence of some diseases, but, globally, conclusions are mixed. These findings point to a need for continued ongoing and future basic and clinical studies to better define whether vitamin D status can be optimized to improve many aspects of human health. Vitamin D deficiency enhances the risk of osteoporotic fractures and is associated with many diseases. We review what is established and what is plausible regarding the health effects of vitamin D.

/pdf/skeletal-and-extraskeletal-actions-of-vitamin-d-current-16dotycegb.pdf

Skeletal and Extraskeletal Actions of Vitamin D: Current Evidence and Outstanding Questions.

Vitamin D and the skin: Focus on a complex relationship: A review

Psoriasis is a chronic immune-mediated inflammatory skin disease. Psoriasis lesions are characterized by hyper-proliferation of epidermal keratinocytes associated with inflammatory cellular infiltrate in both dermis and epidermis. The epidermis is the natural source of vitamin D synthesis by sunlight action. Recently, a role for vitamin D in the pathogenesis of different skin diseases, including psoriasis, has been reported. Indeed, significant associations between low vitamin D status and psoriasis have been systematically observed. Due to its role in proliferation and maturation of keratinocytes, vitamin D has become an important local therapeutic option in the treatment of psoriasis. To date, the successful treatment based on adequate dietary intake of vitamin D or oral vitamin D supplementation in psoriasis represent an unmet clinical need and the evidence of its beneficial effects remains still controversial. This information is important either for Dermatologists and Nutritionists to increases the knowledge on the possible bi-directional relationships between low vitamin D status and psoriasis and on the potential usefulness of vitamin D in psoriasis with the aim not only to reduce its clinical severity, but also for delineating the risk profile for co-morbidities cardiac risk factors that may result from psoriasis. In the current review, we analyzed the possible bi-directional links between psoriatic disease and vitamin D.

/pdf/vitamin-d-and-its-role-in-psoriasis-an-overview-of-the-2jtov6y95o.pdf

Vitamin D and its role in psoriasis: An overview of the dermatologist and nutritionist

BACKGROUND: Psoriasis negatively impacts sleep, but the factors that cause this sleep disturbance are not well characterized. PURPOSE: To assess sleep quality in subjects with psoriasis. METHODS: 35 outpatients diagnosed with chronic plaque psoriasis affecting at least 10 percent BSA and 44 controls completed the Pittsburgh Sleep Quality Index, Patient Health Questionnaire, Itch Severity Scale, Insomnia Severity Index, and Epworth Sleepiness Scale. For multiple testing, alpha was set at 0.008. RESULTS: Adjusting for age, BMI, and gender, patients with psoriasis had 4.3 times the odds to score in a higher insomnia category (OR 95% CI: 1.7, 11.2; p=0.01), a trend toward experiencing "poor sleep" (p=0.04), and no difference in odds to be "sleepy" (p=0.83). Patients with psoriasis had greater itch than those without psoriasis (mean ISS 8.5 vs. 2.0; p<0.0001). When adjusting for age, BMI, gender, and depression, those with psoriasis were not more likely to experience poor sleep quality (p=0.25), nor to score in a higher insomnia category (p=0.20) or be more "sleepy" (p=0.53). CONCLUSIONS: Patients with psoriasis suffer from sleep disturbances and pruritus more than those without psoriasis. Although sleep disturbances are more prevalent, this may be secondary to depression rather than related to a direct effect of psoriasis.

Sleep disturbances in psoriasis

Background
Most people with psoriasis have limited disease that could be treated with topicals, but topical efficacy is limited by low short term adherence. Psoriasis is a chronic disease, and long term adherence is an even bigger problem.

Objective
To determine how well medication is used in long-term topical treatment of psoriasis and to assess the potential of an Internet-based reporting intervention to improve treatment adherence and outcomes.

Methods
An investigator-blinded, prospective study evaluated topical fluocinonide adherence in 40 mild-to-moderate psoriasis patients over 12 months. Subjects were randomized in a 1:1 ratio to standard-of-care or an Internet-based reporting group. Adherence was objectively monitored with Medication Event Monitoring System caps.

Results
50% of subjects discontinued the treatment. Greater adherence was seen in the intervention group compared to the standard-of-care group (50% vs. 35 %, P=0.08). Psoriasis Area and Severity Index improved more in the intervention group at Month 1 (1.61vs-0.12, p=0.003), Month 3 (2.50vs0.79, p=0.025), and month 12 (3.32vs0.34, p=0.038) than in the standard-of-care group.

Limitations
This study likely underestimates the challenge of long-term adherence, as adherence tends to be better in research studies than in clinical practice. This study also did not fully account for primary non-adherence.

Conclusions
Adherence to topical treatment is low in short term and decreased further in the long term, a considerable challenge for dermatologists to address. A reporting intervention may one of the ways we can improve our patients’ treatment outcomes.

This article is protected by copyright. All rights reserved.

Long-term adherence to topical psoriasis treatment can be abysmal: a 1-year randomized intervention study using objective electronic adherence monitoring.

Importance Treatment outcomes depend on adherence to the prescribed regimen. Primary nonadherence refers to not obtaining and starting to take a prescribed medication. The frequency of primary nonadherence to acne treatment has not been well characterized. The complexity of multidrug acne regimens may add to this problem but, to our knowledge, has not been explored.

Objectives To estimate acne treatment primary nonadherence rates and to determine the relationship between primary nonadherence and the number of acne treatments prescribed.

Design, Setting, and Participants A review of medical records from an outpatient university dermatology clinic identified patients with an acne diagnosis at a dermatology visit in the past 3 months who were prescribed 1, 2, or 3 or more treatments. Patients were excluded if they were not English speakers, were not prescribed treatment for their acne, or did not have an active telephone number. Using randomized lists, these patients were queried via telephone regarding which acne treatments they obtained. The results were analyzed using Fisher exact tests and multivariable logistic regression. For patients who were prescribed 1, 2, or 3 or more treatments, 47, 48, and 48 eligible patients were contacted, respectively.

Main Outcomes and Measures The primary study outcomes were the overall rate of primary nonadherence and the rate for each treatment-number subgroup. Secondary outcomes included the association of sex, age, medication type, and electronic prescription status with primary nonadherence.

Results Overall, 27% of patients did not fill all their prescriptions. Of patients who were given 1, 2, or 3 or more treatments, 9%, 40%, and 31%, respectively, did not fill all their prescriptions. There was no statistically significant difference by sex or age for primary nonadherence in any of the 3 treatment-number groups. Based on multivariable analyses, being prescribed a topical retinoid (odds ratio, 2.9; 95% CI, 1.0-8.0) or an over-the-counter product (odds ratio, 3.6; 95% CI, 1.1-12.3) was associated with primary nonadherence. Based on univariate analysis, there was less primary nonadherence with electronic prescriptions compared with paper prescriptions (P < .001).

Conclusions and Relevance Primary adherence to an acne treatment regimen is better when only 1 treatment is prescribed. Some patients may not complete acne treatment because 1 or more of their medications were never obtained.

https://jamanetwork.com/journals/jamadermatology/articlepdf/2174540/doi140060.pdf

Frequency of Primary Nonadherence to Acne Treatment.

Introduction: A variety of acne treatments exist, including topical benzoyl peroxide, topical retinoids, topical antibiotics, oral antibiotics, hormonal therapy, isotretinoin, and procedural therapies, such as light and laser therapies Although each of these treatment modalities confer various benefits for the management of acne, it is important for healthcare providers to be aware of their potential side effects, including ones that are most common and most serious, so that these medications can be prescribed in a safe manner Areas covered: A systematic literature review was performed to identify publications discussing the side effects of the different treatment modalities used for acne vulgaris Acne treatments reviewed included benzoyl peroxide gel, topical retinoids, topical antibiotics, oral antibiotics, hormonal therapy, isotretinoin, and light/laser treatments Expert opinion: A comprehensive overview of acne treatments' side effects is imperative for healthcare professionals and scientists work

Side effects of common acne treatments

Author(s): Hix, Emily; Gustafson, Cheryl J; O'Neill, Jenna L; Huang, Karen; Sandoval, Laura F; Harrison, Jessica; Clark, Adele; Feldman, Stephen R | Abstract: Background: Adherence in the treatment of chronic inflammatory skin diseases such as atopic dermatitis is poor Methods to improve adherence have proven difficultPurpose: To determine whether a short course of treatment with a high-potency corticosteroid will improve adherence compared to longer treatment studies and if improvement in disease and itch continues after treatmentMethods: 10 patients with mild to moderate atopic dermatitis were instructed to apply fluocinonide 01% cream twice daily for 5 days Adherence was self-reported and electronically monitored Treatment outcomes were assessed in terms of Visual Analog Scale of Itch (VAS), Eczema Area and Severity Index (EASI), and Investigator Global Assessment (IGA) scoresResults: The median adherence rate was 40% (range of 0-100) The median percent change in VAS from baseline measures on days 7 and 14 were 90% (range -13, 100, p=002) and 52% (range 0, 100, p=0004) On days 7 and 14, 20% and 70% patients achieved an EASI-75 and 40% and 60% an IGA of 0 or 1Limitations: Small sample size limited subgroup analysesConclusions: Adherence rates with short-term treatment were similar to previously reported rates in longer term treatment studies However, even non-adherent patients had significant improvement in itch and disease severity

/pdf/adherence-to-a-five-day-treatment-course-of-topical-5dlk3xfft5.pdf

Karen E. Huang

Papers

Sleep disturbances in psoriasis

Long-term adherence to topical psoriasis treatment can be abysmal: a 1-year randomized intervention study using objective electronic adherence monitoring.

Frequency of Primary Nonadherence to Acne Treatment.

Side effects of common acne treatments

Adherence to a five day treatment course of topical fluocinonide 0.1% cream in atopic dermatitis.