What's already known about this topic?

• Knowledge of cancer stage is essential for optimal patient management.
• Cancer stage includes tumour characteristics, regional extension to lymph node(s) and the presence of any distant metastasis (termed TNM stage or stage group).
• TNM7, published in 2010, formed the basis of the professional datasets to handle and report skin cancer specimens, published online by the Royal College of Pathologists (www.rcpath.org).

What does this study add?

• TNM8 displays significant changes for skin cancer staging.
• Clinicians must state the maximum clinical dimension of every potential invasive skin cancer and whether involved lymph nodes are clinically detectable or occult in Merkel cell carcinoma and melanoma.
• Anatomical site and tumour differentiation no longer influence squamous cell carcinoma staging.
• Mitotic index does not influence pT in melanoma, but 0·8-mm Breslow thickness is a new criterion for the subdivision. pT1bN0M0 is now stage 1A.

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• Topical vitamin D pretreatment enhances methyl aminolaevulinate (MAL)-induced protoporphyrin IX (PpIX) in hairless mice.
• Topical vitamin D prior to aminolaevulinic acid photodynamic therapy (PDT) enhances treatment efficacy of nonmelanoma skin cancers in mouse skin models.

What does this study add?

• In human skin, calcipotriol (CAL)-assisted MAL-PDT proved to be superior to MAL-PDT alone and was well tolerated.
• Topical preconditioning of actinic keratoses with CAL-assisted MAL induced PpIX formation to a greater extent compared with the side that was not pretreated.

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• Ingenol mebutate gel is used to treat actinic keratosis (AK).
• No clinical study has been conducted to date to investigate the efficacy, local skin responses, cosmetic outcomes, quality of life or other safety issues in Asian populations.

What does this study add?

• Ingenol mebutate gel was more effective and showed higher local skin responses in treating AK in Korean patients, compared with the previous studies.
• Ingenol mebutate is an effective treatment of AK in Asians, with tolerable safety profiles.

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• Genital psoriasis is a common and burdensome form of plaque psoriasis, but there are few controlled studies of effective therapies.

What does this study add?

• Ixekizumab significantly improved the severity of genital psoriasis and associated disease characteristics.
• Ixekizumab may be appropriate for treatment of moderate-to-severe genital psoriasis, even in patients with limited body surface involvement.

Linked Editorial: Becher and Burden. Br J Dermatol 2018; 179:811–812.

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• Tofacitinib is an oral Janus kinase inhibitor. The efficacy and safety of tofacitinib 5 mg and 10 mg twice daily has been reported in phase II and phase III trials in patients with moderate-to-severe plaque psoriasis.
• The management of patients with plaque psoriasis requires long-term maintenance treatment.

What does this study add?

• Final safety and efficacy data from this long-term extension study indicate that tofacitinib has a stable safety profile up to 66 months, which is consistent with that observed in previous tofacitinib studies.
• Improvements in efficacy end points and patient-reported outcomes are sustained up to 54 months.

Linked Comment: Lloyd-Lavery. Br J Dermatol 2018; 179:815–816.

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• Systemic therapies, including biologics, are widely prescribed for patients with moderate-to-severe psoriasis.
• As a result of the immunomodulatory mechanism of biological therapies for psoriasis it is hypothesized that long-term exposure to them may increase the risk of developing cancer.

What does this study add?

• This study suggests that, in current clinical practice, the treatment of patients with psoriasis with biologics is not associated with an increased risk of cancer in the medium term, after a few years of use and latency.
• Given the heterogeneity of the data sources and methodological limitations, it remains unclear if use of biologics may be associated with an increased (albeit small) risk of certain cancer subtypes.

Linked Editorial: Egeberg. Br J Dermatol 2018; 179:809–810.

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• Current pemphigus vulgaris (PV) disease activity indices include the recently validated Pemphigus Disease Area Index (PDAI) and the Autoimmune Bullous Skin Disorder Intensity Score.
• The Oral Disease Severity Score (ODSS) has been demonstrated to have good inter- and intraobserver reliability in both lichen planus (LP) and mucous membrane pemphigoid (MMP).

What does this study add?

• The ODSS is shown to be a thorough and sensitive, yet quick assessment tool for oral involvement in PV.
• Its versatility for use additionally in MMP and LP is an added advantage over previously validated methods.

What are the clinical implications of this work?

• We propose that the ODSS would be a useful supplement for future multicentre studies, as well as for recording sequential disease activity in the clinic.

Linked Comment: Murrell et al. Br J Dermatol 2018; 179:816–817.

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• Cutaneous T-cell lymphoma (CTCL) is a rare cancer with multiple negative impacts on the quality of life of patients and their carers, particularly in advanced disease.
• Care of extensive skin lesions in advanced CTCL is complex and time-consuming.
• A systematic review of the literature on CTCL revealed no exploration of the needs or experiences of family carers.

What does this study add?

• Care for patients with advanced CTCL is complex and challenging, and family caregivers can adopt quasi-professional roles.
• Even in advanced CTCL and despite multiple hospital admissions, family caregivers may not expect their relative's death and experience highly variable bereavement support.
• Healthcare providers should consider the support needs of family caregivers as well as those of patients with advanced CTCL and support should be provided during the course of the disease and into bereavement, whatever the place of care and death.

What are the clinical implications of the work?

• Healthcare providers need to take a flexible, person-centred approach to care, rather than relying on existing organizational systems to meet the needs of complex patients with the extensive skin breakdown present in advanced CTCL.
• CTCL raises specific challenges for caregivers given its initially benign appearance and rarity – adapting to the worsening symptoms and prognosis may require specific support for family caregivers.

Linked Comment: Mitchell. Br J Dermatol 2018; 179:817–818.

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• Previous studies have demonstrated the usefulness of conventional polymerase chain reaction (PCR) in diagnosing scabies but the positive diagnosis rate was too low to obtain satisfactory results.
• Research comparing PCR for scabies diagnosis against microscopy detection did not include dermoscopy; therefore, it is possible that there were high false-negative rates by microscopy and the effectiveness of a PCR assay was overstated.

What does this study add?

• The detection rate of scabies by nested PCR in patients who were microscopy negative (26%, nine of 35 samples) was higher than by conventional PCR (14%, 12 of 83 samples).
• Even though false-negatives were minimized in this study owing to the inclusion of dermoscopy, the microscopy sensitivity was 75·7% (95% confidence interval 58·8–88·2), which was significantly inferior to that of the cox1 nested PCR (P = 0·004).

What is the translational message?

• Nested PCR can be successfully used as an alternative method for diagnosing suspected scabies in patients.
• Infection control measures and treatments can be initiated before significant transmission occurs, minimizing the risk of outbreaks.

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• CD73⁺ regulatory T cells (Tregs) were markedly reduced in patients with psoriasis vulgaris compared with healthy controls.
• Methotrexate (MTX) is widely used to treat psoriasis and has also been reported to upregulate the expression of CD73 in melanoma.

What does this study add?

• We investigated the effect and mechanism of MTX on Treg function and its relationship to the CD73/AMPK/mTOR pathway in psoriasis therapy.

What is the translational message?

• These findings may partly explain the mechanism by which MTX treats psoriasis.

Linked Comment: Chen. Br J Dermatol 2018; 179:818–819.

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• Early activation of innate immunity was observed in clinically normal skin of patients with acne prone to atrophic scarring.
• Inflammation is stronger and lasts longer in 1-week-old papules in patients prone to scarring.

What does this study add?

• The inflammatory response in papules of scar-prone (SP) patients with acne can last > 3 weeks.
• Plasma cells are specifically involved in the immune response of evolved-lesions in SP patients only.
• Downregulation of sebaceous gland markers associated with the long-term inflammatory response in SP patients suggests destruction of sebaceous glands.

What is the translational message?

• Inflammatory immune processes persist for at least 3 weeks in the lesions of SP patients with acne. New early and sustained treatment regimens preventing or at least reducing the duration of inflammatory processes in SP patients with acne are required.

Linked Comment: Wang and Saedi. Br J Dermatol 2018; 179:819.

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• Serum levels of immunoglobulin (Ig)G autoantibodies against BP180 correlate with disease activity in bullous pemphigoid (BP).
• Reports about the correlation of serum anti-BP180 IgE with disease severity are inconclusive.
• Karnofsky score is a predictor of death in BP but to date has not been shown to be related to serum autoantibody levels.

What does this study add?

• High serum anti-BP180 IgG levels are associated with an increased mortality in BP.
• Patients with BP with a lower Karnofsky score show higher serum levels of anti-BP180 and anti-BP230 IgG.
• High levels of total serum IgE appear to be related to a lower number of treatment-related adverse events.
• Patients with BP with high anti-BP180 IgG may be at risk of fatal outcomes, while in those with high total IgE, fewer adverse events can be expected.

Linked Comment: Hashimoto and Tsuruta. Br J Dermatol 2018; 179:820–821.

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• The clinical and genetic features and outcomes of mastocytosis differ between the adult and paediatric forms.
• Paediatric mastocytosis is also a clonal disease.
• Spontaneous regression occurs in the majority of cases and no predictive factors have been identified.

What does this study add?

• This prospective study of 53 patients shows that KIT mutation is not a predictor of evolution. However, characteristics such as age at disease onset could be predictors.
• Paediatric mastocytosis evolution is not systematically regressive, and adolescents can experience only partial regression or aggravation, including both cutaneous and mast cell mediator-related symptoms.
• A long-term follow-up study of paediatric patients with mastocytosis is needed.

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• Nonsyndromic X-linked recessive ichthyosis is a relatively common type of ichthyosis.
• Prior studies found a high prevalence of cryptorchidism and attention deficit hyperactivity disorder (ADHD).

What does this study add?

• We identified a high prevalence of epilepsy (13%), confirmed a high frequency of ADHD (30%) and found a 10% prevalence of orchiopexy.
• We also quantified other common findings such palmoplantar hyperlinearity (almost always absent) and pruritus (present in 60% of patients).

Linked Comment: Traupe. Br J Dermatol 2018; 179:821–822.

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• Tenerife and skiing holiday studies in adults have shown an ultraviolet (UV)B-dependent increase in 25-hydroxyvitamin D₃ [25(OH)D₃] and potentially mutagenic cyclobutane pyrimidine dimers (CPD) that may initiate skin cancer.
• Childhood solar UV radiation exposure increases the risk of skin cancer in adulthood, but no study has assessed the risks and benefits of solar UV radiation in children on holiday.

What does this study add?

• Relatively low daily UV radiation doses in children at a Baltic Sea summer camp resulted in a modest but significant improvement in 25(OH)D₃ (24%) but a very much greater increase in CPD (1162%).
• The children had the same level of CPD as adults who had higher UV radiation doses over a shorter holiday in Tenerife.
• These results stress the importance of rigorous photoprotection in the young.

Linked Comment: Webb. Br J Dermatol 2018; 179:822–823.

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• Staphylococcus aureus frequently colonizes individuals with atopic dermatitis (AD), with increasing disease severity correlating with greater bacterial load of the organism.
• Antimicrobial therapies are routinely used in AD for management and prevention of disease flares.

What does this study add?

• Staphylococcus aureus isolates from children with AD differ in their antimicrobial resistance profiles from those in healthy, nonatopic nasally colonized children.
• Fusidic acid resistance is significantly more prevalent in cases of AD, and arises through distinct genetic mechanisms when compared with healthy controls.
• Carriage of plasmid-derived genetic determinants associated with antiseptic resistance also clearly differentiated S. aureus from cases of AD and controls.

Linked Editorial: Leung. Br J Dermatol 2018; 179:807–808.

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• SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome is a disease of unknown cause but genetically several similarities to autoinflammatory diseases have been found.
• Clinically, dermatological and osteoarticular manifestations resemble signs of neutrophil activation.
• Usual treatments include nonsteroidal anti-inflammatory drugs and corticosteroids but treatment with tumour necrosis factor (TNF)-α or interleukin (IL)-1 antagonists have also been previously reported.

What does this study add?

• Given that TNF-α, IL-23 and IL-17 together with activated neutrophils are involved in the pathogenesis of SAPHO syndrome, blocking of these cytokines is a potential strategy in treatment-refractory cases.
• The use of specific cytokine-directed antibodies such as ustekinumab or secukinumab or pan-cytokine inhibition with apremilast provides further therapeutic options in the management of this rare condition.

Linked Comment: Firinu. Br J Dermatol 2018; 179:823.