A pilot study in discrepancies in quality of life among three cutaneous types of rosacea

A pilot study in discrepancies in quality of life among three cutaneous types of rosacea
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   Eleonora Annichiarico, MD, b   Fabio MariaVecchio, MD, c   Pier Luigi Amerio, MD, a and Clara De Simone, MD  a  Departments of Dermatology, a  Internal Medicine, b  and Pathology, c  Catholic University of the Sacred  Heart, Rome, Italy  Funding sources: None.Conflicts of interest: None declared.Correspondenceto:AndreaParadisi,MD,Department of Dermatology, Catholic University of the Sacred  Heart, Largo A. Gemelli 8, 00168  e  Rome, Italy  E-mail:  REFERENCES 1. Carlin CS, Feldman SR, Krueger JG, Menter A, Krueger GG. A50% reduction in the Psoriasis Area and Severity Index (PASI 50)is a clinically significant endpoint in the assessment of psoriasis.J Am Acad Dermatol 2004;50:859-66.2. Knodell RG, Ishak KG, Black WC, Chen TS, Craig R, Kaplowitz N,et al. Formulation and application of a numerical scoringsystem for assessing histological activity in asymptomaticchronic active hepatitis. Hepatology 1981;1:431-5.3. Peterson JR, Hsu FC, Simkin PA, Wener MH. Effect of tumournecrosis factor a antagonists on serum transaminases andviraemia in patients with rheumatoid arthritis and chronichepatitis C infection. Ann Rheum Dis 2003;62:1078-82.4. Magliocco MA, Gottlieb AB. Etanercept therapy for patientswith psoriatic arthritis and cocncurrent hepatitis C virus infec-tion: report of 3 cases. J Am Acad Dermatol 2004;51:580-4.5. Marotte H, Fontanges E, Bailly F, Zoulim F, Trepo C, Miossec P.Etanercept treatment for three months is safe in patients withrheumatological manifestations associated with hepatitis Cvirus. Rheumatology (Oxford) 2007;46:97-9. doi:10.1016/j.jaad.2009.07.010  A pilot study in discrepancies in quality of lifeamong three cutaneous types of rosacea  To the Editor  : Studies have shown the significant psy-chosocial impact of rosacea, but there has not been an Fig 2.  Liver biopsy specimens obtained before etanercept therapy (  A   and  C ) and 12 monthsinto treatment ( B  and  D ) in patients 1 and 2, respectively. To see the images in greater detail,please visit where you can enlarge them using your Internet browser.(Hematoxylin e eosin stain.) J A  M  A  CAD  D ERMATOL  V  OLUME  62, N UMBER   6  Letters   1069  analysis of burden of disease among the individualrosacea subtypes. The goal of this cross-sectional study  was to determine the quality of life (QOL) impact of rosacea among the erythematotelangiectatic (ET), pap-ulopustularpersistent (PP), and phymatous (PH) rosa-cea subtypes in terms of symptomatic (SX), emotional(EM), and functional (FX) impact. After institutional review board approval, adultsubjects were identified by the  International Classification of Diseases, 9th edition  code for rosa-cea from the Emory Dermatology Clinic and con-tactedforatelephoneinterview.Consentingsubjects were administered the RosaQoL 1 (a validated, rosa-cea-specific QOL instrument), queried about dura-tionofdiseaseanddemographics,andwereassessedfor rosacea subtype. The RosaQol is a 21-questionsurvey containing rosacea-specific items that aregrouped into three subscales: SX, EM, and FX.Questions are scaled from 1 (never) to 5 (all thetime).Thetotalscoreisaveragedsothattherangeforboththetotalscoreandthesubscoresrangefrom1to5, with a higher score translating to a lower QOL.Demographic characteristics and duration of rosacea were compared using analysis of variance for cate-gorical variables and the  x  2 test for categorical variables. A one-way analysis of variance with apost-hoc least significant difference procedure wasused to compare RosaQoL scores among the threesubtypes. Multiple linear regression analysis wasused to assess rosacea subtype impact on QOLimpact adjusting for subject characteristics.The response rate was 52.1%; of the 135 tele-phone surveys completed, 25.2% of respondents(n  ¼  34) reported ET, 34.8% (n  ¼  47) reported PP,and 40.0% (n  ¼ 54) reported PH. The demographicinformation of all respondents is shown in Table I.PH rosacea had theworstQOL(highest rosacea QOLinstrument score) when compared to both ET or PProsacea for both SX ([PH] vs [ET];  P  \ .001, and vs[PP];  P  ¼ .017) and EM ([PH] vs [ET];  P  ¼ .01, and vs[PP];  P   ¼  .004) constructs and total rosacea QOLinstrumentscore([PH]vs[ET];  P  ¼ .002,andvs[PP];  P  ¼ .007; Table II). There was no significant differencein SX, EM, or FX scores between ET and PP rosacea. We performed multivariate linear regression modelsto elicit predictors for SX and EM with rosaceasubtype and gender significant for SX and rosaceasubtype significant for the EM component.Our study confirms previous studies that haveindicated that rosacea carries a significant QOL bur-den overall comparable to that of leg ulcers, occupa-tional contact dermatitis, and vitiligo. 2 In this smallstudy, wefoundadifferenceinQOL impact betweenthe three cutaneous subtypes of rosacea, suggestingthat patients with the PH subtype may carry thegreatest QOL burden, particularly related to thesymptomatic and emotional effects of the disease.Our data suggest, however, that rosacea has a similarimpact on patient functioning regardless of subtype. Amajorlimitationofthisstudyisthatitwasconductedbefore the development of the standard classificationof rosacea by the National Rosacea Society ExpertCommittee on the Classification and Staging of Rosacea. Future studies can build upon our findingsby integrating a more general rosacea population,  Table I.  Demographic information by rosacea subtype Rosacea subtype Variable ET (n = 34) PP (n = 47) PH (n = 54)  P   Total  Age, mean (SD) 58.7 (12.5) 56.2 (14.9) 55.7 (14.6) .61* 56.6 (14.2)Male, n (%) 8 (24.0) 10 (21.2) 18 (33.3) .35 y 36 (26.7)Married, n (%) 23 (67.6) 34 (72.3) 42 (77.7) .80 y 99 (73.3)Nonwhite, n (%) 0 (0.0) 1 (2.1) 6 (11.1) .04 y 7 (5.2)Graduate education, n (%) 14 (41.2) 20 (42.5) 21 (38.8) .60 y 55 (40.7)Income [ $100000, n (%) 9 (33.3) 14 (38.8) 21 (52.5) .32 y 44 (32.6)Duration of 5 1 years, n (%) 17 (50.0) 15 (32.6) 15 (27.7) .32 y 47 (34.8)Total, n (%) 34 (25.2) 47 (34.8) 54 (40.0) — 135 (100.0) ET  , Erythematotelangiectatic;  PH  , phymatous;  PP  , papulopustularpersistent;  SD , standard deviation.*Analysis of variance. y  x  2 test.  Table II.  Mean (SD) rosacea quality of life instru-ment scores by rosacea subtype Rosacea subtype Variable ET PP PH  P  Symptom 2.42 (0.69) 2.66 (0.81) 3.03 (0.72)  \ .001*Emotion 2.67 (0.84) 2.64 (0.86) 3.10 (0.71) .007*Functioning 2.48 (0.83) 2.34 (1.02) 2.50 (0.90) .659*Total 2.56 (0.64) 2.61 (0.77) 2.99 (0.62) .004* ET  , Erythematotelangiectatic;  PH  , phymatous;  PP  , papulopustular-persistent;  SD , standard deviation.*Analysis of variance. J A  M  A  CAD  D ERMATOL J UNE  2010 1070  Letters   considertakingintoaccountthetherapiesthatpatientshave undergone, and correlating QOL impact with anobjective measure of clinical severity. Seema P. Kini, BA, a  Kim Nicholson, MD, a  Laura K. DeLong, MD, MPH, a Tanya Dannemann, MD, b   Justin Estaris, BA, a  Jovonne Foster, MS, a and Suephy C. Chen, MD, MS  a,c   Departments of Dermatology, Emory University School of Medicine, a  Atlanta; the Medical College of Georgia, b   Augusta; and the Department of   Health Services Research & Development, Divi- sion of Dermatology, c  Veterans Affairs Medical Center, Atlanta, Georgia Dr DeLong is supported by a National Institutes of   Health T32 Ruth L. Kirchstein National ResearchService Award training grant that is supervised by Dr Chen.Conflicts of interest: None declared. Reprint requests: Suephy C. Chen, MD, MS, Der-matology Clinical and Outcomes Research Unit, Department of Dermatology, Emory University School of Medicine, Emory Clinic, Building A,1365 Clifton Rd NE, Ste 1100, Atlanta, GA 30322  E-mail: REFERENCES 1. Nicholson K, Abramova L, Chren MM, Yeung J, Chon SY, ChenSC. A pilot quality-of-life instrument for acne rosacea. J AmAcad Dermatol 2007;57:213-21.2. Lewis V, Finlay AY. 10 years experience of the DermatologyLife Quality Index (DLQI). J Investig Dermatol Symp Proc2004;9:169-80. doi:10.1016/j.jaad.2009.08.020 Elevation of serum prolactin levels in patients with pemphigus vulgaris: A novel finding with practical implications To the Editor:  Prolactin, a hormone whose receptorsare distributed throughout immune cells, has multi-ple immunostimulatory effects and promotes auto-immunity. 1 This study was conducted to determine whether serum prolactin levels are elevated in pem-phigus vulgaris (PV) patients and whether there isany correlation between prolactin levels and theextent of cutaneous involvement.Twenty-four PV patients (8 men and 16 women;average age, 45.91  6  3.35 yrs [range, 20-83 yrs]) were included in this study. The control groupconsisted of 24 healthy individuals (13 men and 11 women; average age, 41  6  3.03 yrs [range, 22-70 yrs]). The patientsand controls were matched accord-ing to age and sex, and no statistically significantdifference was noted in the demographic analysis of thetwogroups(  P  ¼ .33and  P  ¼ .24,respectively). Weexcludedpregnant/lactatingindividuals,patientswithrenal and/or hepatic failure, patients and controlstaking drugs that could alter serum prolactin levels,such as antipsychotic medications and opium, andalsothosewithahistoryofabortion.Thesamplesweretaken in the morning after a period of absolute restlasting 30 minutes. Serum prolactin levels were mea-sured using enzyme-linked immunosorbent assay.The parametric Mann e  Whitney   U   test was used toestablish the difference in prolactin levels betweenpatientsandcontrols,andthePearsontestwasusedtodetermine the correlation between the percentage of body surface involvement and prolactin levels. Theinvolved body surface area was calculated using theLund and Browder chart.Characteristics of patients and controls are shownin Tables I and II. Mean serum prolactin levels inpatients were significantly higher than in the controlgroup (21.66  6  3.5 ng/mL vs 11.38  6  0.69 ng/mL;  P  ¼ .048; Fig 1). Six of the patients (25%), who wereall female, had hyperprolactinemia, in contrast to thecontrol group, in which no one had hyperprolacti-nemia. A positive correlation between serum pro-lactin levels and the extent of body surface  Table I.  Patients’ characteristics Patient no. Age, y SexProlactin level (ng/mL) Approximatepercentage of  body surfaceinvolvement Mucosal and/or cutaneousinvolvement  1 74 F 15.72 90 Mucocutaneous2 35 M 20.53 63 Mucocutaneous3 38 M 4.74 10 Mucocutaneous4 53 F 33.47 64 Mucocutaneous5 63 F 73.26 81 Mucocutaneous6 25 F 38.24 81 Mucocutaneous7 20 F 42 72 Mucocutaneous8 32 F 12.33 9 Mucocutaneous9 28 M 18.51 36 Cutaneous10 42 F 20.87 — Mucosal11 43 F 35.12 73 Mucocutaneous12 55 F 12.57 18 Mucocutaneous13 66 F 24.45 45 Mucocutaneous14 83 M 7.71 10 Mucocutaneous15 32 F 23.65 50 Mucocutaneous16 46 M 11.78 — Mucosal17 39 M 4.09 45 Cutaneous18 55 M 3.52 9 Cutaneous19 45 M 10.4 — Mucosal20 28 F 36.71 81 Mucocutaneous21 37 F 12.85 54 Mucocutaneous22 49 F 47.35 — Mucosal23 43 M 4.26 10 Mucocutaneous24 71 F 5.82 — Mucosal F  , Female;  M , male. J A  M  A  CAD  D ERMATOL  V  OLUME  62, N UMBER   6  Letters   1071
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