No abstract

We have some issues with the study design and feel the results are distant from everyday practice. Based on the results of several multicentre trials a medical decision tree was designed to compare standard therapy for AK and BCC with MAL-PDT. To achieve this, in the case of BCC the authors have made a combination of the outcome results of two multicentre trials. However, the data in both studies differ largely, not only in type of BCC (superficial vs. nodular) but also in treatment pathway (initial single treatment vs. two PDT cycles) and treatment mode (comparison with surgery in one publication, cryosurgery in the other). Subsequently, the authors have added the conclusions for a virtual second-line treatment of the nonresponders for the AK and BCC group, respectively, based on the expert opinion of 12 Belgian dermatologists who participated in a tworound written questionnaire by mail.The interviews at most only reflect the possibly biased opinions of these 12 dermatologists and not the current consensus or the evidence-based best therapies. Secondly, in order to calculate the cost-benefit ratios 'full responders' were used. If after one session of cryotherapy any AK remained or if the cosmetic result was not excellent it was considered a therapeutic failure and second-line therapies were considered. However, in the case of cryosurgery, cosmetic outcome and response are heavily influenced by the duration and number of freeze-thaw cycles. For instance, in a prospective randomized study comparing MAL-PDT with cryosurgery, 2 two long freeze cycles (24 s) were used, which should influence the cosmetic outcome dramatically. In the randomized study 3 used in this publication by Caekelbergh et al., only one freeze cycle is used which resulted in a response of only 68% for cryosurgery compared with 91% for MAL-PDT. With respect to cosmetic outcome of AK after cryosurgery, in our combined experience of more than 30 years as dermatologists we have never had to refer patients. Moreover, even the suggestion that reconstructive surgery for AK is an option is in our view preposterous and perhaps only reflects the opinion of a plastic surgeon.Thirdly, we found that the results presented in their Tables 1 and 2 diametrically oppose our experience and probably that of many other dermatologists. The authors state that the cosmetic result after successful AK treatment is excellent in only 51% of cases. In the case of BCC, the authors report that this percentage is only 7% after a surgical removal of the tumour. However, in the study of Rhodes et al. 4 which was used for this publication, the cosmetic outcome of surgery was defined as excellent by 75% of the patients (and 41% by a panel). We fear that the figures in the study by Caekelbergh et al. have been mixed because in our opinion too, the majority of patients treated with cryosurgery for AK and surgical excision for BCC are satisfied with the cosmetic result. For MAL-PDT also the cosmetic outcome results should be higher than presented in Tables 1 and 2. Our personal opinio...

The photograph-based M-TAS score requires validation with larger samples but could be a useful research tool for elucidating disease prevalence and determinants of TA as well for monitoring response to treatment.

Traction alopecia (TA) is hair loss caused by prolonged pulling or repetitive tension on scalp hair; it belongs to the biphasic group of primary alopecia. It is non-scarring, typically with preservation of follicular stem cells and the potential for regrowth of early lesions especially if traction hairstyles are stopped. However, the alopecia may become permanent (scarring) and fail to respond to treatment if the traction is excessive and prolonged. Hence, the ability to detect fibrosis early in these lesions could predict patients who respond to treatment. Histopathological diagnosis based on scalp biopsies has been used as a gold standard to delineate various forms of non-scarring alopecia and to differentiate them from scarring ones. However, due to potential discrepant reporting as a result of the type of biopsy, method of sectioning, and site of biopsy, histopathology often tends to be unreliable for the early recognition of fibrosis in TA. In this study, 45 patients were assessed using the marginal TA severity scoring system, and their biopsies (both longitudinal and transverse sections) were systematically assessed by three dermatopathologists, the aim being to correlate histopathological findings with clinical staging. Intraclass correlation coefficients were used to determine the level of agreement between the assessors. We found poor agreement of the identification and grading of perifollicular and interfollicular fibrosis (0.55 [0.23–0.75] and 0.01 [2.20–0.41], respectively), and no correlation could be drawn with the clinical severity score. Better methods of diagnosis are needed for grading and for recognition of early fibrosis in TA.