Content » Vol 90, Issue 1


Moving Towards Open Access: High-quality Research and Publication is Essential, but Visibility of the Work is Critical

Moving Towards Open Access: High-quality Research and Publication is Essential, but Visibility of the Work is Critical

The purpose of a scientific journal is to help disseminate news and views in research. The better the article and the more accessible the journal, the more effectively will the authors’ message reach the scientific community. From the perspective of rapid dissemination of scientific research, immediate open access of an article on the internet is no doubt preferable. However, for the sake of quality and readability, the paper first has to pass a peer review process and undergo at least some type of professional editing, which takes time and money. Although the costs can be reduced by not producing a printed version of the journal and by choosing a non-profit publisher, sufficient income must come from subscriptions, submission fees, page charges or advertisements. Taking on a policy of immediate open access means that all subscription fees will eventually disappear and the interest of advertisers will reduce. Thus, the cost of quality control and editing must be met entirely by the authors who submit the papers (unless institutional funding and/or donations are available). In the case of Acta Dermato-Venereologica, changing the subscription-based economy to author paid publication and open access, would require at least a tripling of the present page charges. This is presently regarded as untenable by the Editorial Board.

As of January 2010 the board has therefore decided – in order to move stepwise toward open access of Acta Dermato-Venereologica – to shorten the embargo time to 6 months from publication until the article is freely accessible to everyone, and to retain a printed version in parallel with the e-version for some years to come. Presumably the process of most scientific journals moving to immediate open access, will accelerate in the future, but nobody knows exactly how this will occur. Meanwhile, in Acta Dermato-Venereologica, all review papers and selected papers that we judge to be of special importance are already made freely accessible at the time of publication. We also encourage all authors to place accepted papers in their university repository in order to promote rapid dissemination of their results.

As far as the peer review process of Acta Dermato-Venereologica is concerned, we are very pleased to announce that the Editorial Board has recently recruited two new prominent Section Editors. Professor Carl-Fredrik Wahlgren, Department of Dermatology, Karolinska Institute, Stockholm, is a specialist in Pediatric Dermatology and Atopy. He will be one of the Clinical Case Editors. Professor Roderick Hay, St John’s Institute of Dermatology, London, is one of the world’s leading specialists in cutaneous infections and will cover all papers submitted in this area. These two co-workers will no doubt help to increase the standard of Acta Dermato-Venereologica further.


Subjective Dermatology Outcomes: How You Frame the Question May Not Be That Important After All

How you frame a question may determine the response. For example, if someone asks me about my mild eczema by preceding the question with certain value-laden phrases indicating that it should be perceived as a negative “medical” problem, then I am perhaps more likely to respond in a stereotypical way that agrees with the researcher – that my condition is a problem that impacts on many aspects of my quality of life (whereas in reality it is a mild problem that I only think about occasionally). Even questions such as “how long have you been suffering from eczema?” implies that I am suffering from a “disease”, a question stem that may colour my subsequent responses about the effects of eczema on my quality of life. And if the questions had been preceded by a film about other people with quite severe eczema, would that have affected the way I then answer a questionnaire about quality of life? You would think that there would be lots of research to show how such influences would affect my responses, but the reality is that very little scientific work has been done to explore the effect of such “framing biases” and how they might affect responses to commonly used patient-reported outcomes in dermatology, such as the Dermatology Life Quality Index (DLQI).

In this issue, Murray & Rees (1) report on some fascinating experiments to test the degree to which affective biases can result in different results for the DLQI, the Global Health Question and the visual analogue scales that seem to be so popular in dermatology studies for assessing symptoms such as pain and itch. They studied an opportunistic sample of 215 patients, mainly with psoriasis, who were attending phototherapy, and conducted three experiments to determine how words or images could affect questionnaire responses. They conducted three experiments that measured responses to subjective health outcome questions after randomizing groups of patients to: (i) mood-affecting words such as “worry”; (ii) watching a film clip (or not) about living with a severe skin problem; and (iii) a reframing of the DLQI questions using more neutral words. The overall hypothesis was that framing biases would change the way people respond to health questions, but the results were surprising.

Despite their best attempts at influencing the responses by prior visual information or word framing, there were no significant differences between any of the groups in terms of median scores for DLQI, the Global Health Question and visual analogue scales. Thus, although scales such as DLQI might have their limitations (2), perhaps these “subjective” outcomes are more robust than we might imagine. That does not mean that we should endorse blatantly leading questions such as “You are feeling better, aren’t you?”, but it does mean that agonizing over the neutrality of language used in some patient-reported health outcomes may be unnecessary.

What was good about this study was the way in which the authors strove to minimize biases by randomizing groups of patients to the interventions, including the order in which the framing biases were delivered, and by describing them in a sufficiently non-specific way in the patient information so as not to unblind the study hypothesis. The main study limitations, acknowledged by the authors, were the limited power to exclude smaller but important differences, and the fact that the experiment might not have reflected how the questions might be delivered in real life. Hats off to Acta Dermato-Venereologica for publishing what some might incorrectly interpret as a “negative” study – I can just imagine other journals turning down the manuscript because “none of the results were significant”, thereby contributing to the publication bias in favour of “positive” studies, which distorts the scientific record within the biomedical literature.

My own reflection on this interesting paper is that it adds more impetus to the need to ask patients what they think about our treatments in studies. I was recently involved in a review of 125 randomized controlled clinical trials published in five leading dermatology journals that regularly publishes trials, to determine how many trials mention patient-reported outcomes and how prominently they were mentioned (3). Disappointingly, only a quarter of trials mentioned patient outcomes, and even when such information was recorded, it was often poorly and incompletely reported and given low prominence within the trial report. It has always puzzled me why doctors are so reluctant to ask patients what they think of the treatments that we use; perhaps there is a general belief that subjective equates to unreliable and not valid, whereas in reality many of the so called “objective” scales that are used in dermatology are very subjective to elicit and clinically difficult to interpret (4).


Hywel Williams, Professor of Dermato-Epidemiology,

Centre of Evidence-Based Dermatology,

King’s Meadow Campus, University of Nottingham,

Lenton Lane, Nottingham NG7 2NR, United Kingdom


Uppsala, December 2009

Anders Vahlquist Torbjörn Egelrud Agneta Andersson

Editor-in-Chief Co-Editor Editorial Manager

doi: 10.2340/00015555-0795

Fusidic Acid Resistant Staphylococcus aureus and Skin Disease

In this issue Alsterholm et al. (p. 52–57) present data from Sweden on fusidic acid resistant Staphylococcus aureus (FRSA) isolated from cases of impetigo and atopic dermatitis, respectively. They found high numbers of FRSA in impetigo, ranging from 75% in bullous impetigo to 32% in non-bullous impetigo. By contrast, significantly lower numbers of FRSA (6.1%) were detected in secondarily infected atopic dermatitis. Unfortunately, the FRSA strains were not genotyped. The high numbers, especially in bullous impetigo, could be due to infection by the well-described clone that has caused widespread outbreaks of impetigo in several European countries, including Norway, Sweden and Denmark, during the last 10 years. The low number of FRSA in secondarily infected atopic dermatitis may indicate that the impetigo clone is not a frequent colonizer of atopic dermatitis. The small number of other studies, published from other geographical areas, have shown FRSA levels in atopic dermatitis ranging from 6% to 50%.

All cases were seen at a single dermatological department after referral from general practitioners, and only a minority of patients seen in the study period 2004 to 2008 were included. There may therefore be an important selection bias and the results are not necessarily true for impetigo and atopic dermatitis patients in primary care. However, it is important continuously to follow the development of fusidic acid resistance among S. aureus and to remind the medical community that restricted use of this antibiotic seems necessary to keep resistance rates as low as possible.

For atopic dermatitis it is a clinical impression that secondary infection with S. aureus promotes inflammation in flares, and that the addition of antiseptics or antibiotics leads to improved efficiency of treatment in the most severely infected cases. Interestingly, a recent Cochrane Review did not find any evidence that the addition of oral or local antibiotics was of benefit in atopic dermatitis. However, the available data are insufficient for firm conclusions to be drawn.

Dr med Hans Bredsted Lomholt

Specialist in Dermato-venereology

The Skin Clinic Vesterbro,

Aalborg, Denmark

Bullous Pemphigoid Masquerading as Recurrent Vesicular Hand Eczema

Lupi et al. present, on p. 80–81, an interesting case report of dyshidrosiform palmo-plantar pemphigoid. They describe a 20-year-old man who had had itchy vesicles on his palms and soles for 1 year. Histologically, a subepidermal vesicle was seen, and direct immunofluorescence showed continuous linear deposition of IgG and C3 at the dermal-epidermal junction. An enzyme-linked immunosorbent assay (ELISA) for circulating antibodies against bullous pemphigoid antigen BP 180 was positive.

Based on the figures in their report, the current case was, morphologically, classical recurrent vesicular hand eczema. However, the features that distinguish the current case from recurrent vesicular hand eczema (dyshidrotic eczema or pompholyx) are: (i) that histopathology showed a subepidermal vesicle, while recurrent vesicular hand eczema shows spongiosis and intraepidermal vesicles; (ii) that direct immunofluorescence showed linear deposition of IgG and C3 along the dermal-epidermal junction; and (iii) no improvement was seen after 16 weeks of therapy with 25 mg prednisone daily. Recurrent vesicular hand eczema usually responds well to this treatment.

The terms dyshidrosis, pompholyx and acute and recurrent vesicular hand eczema have been used interchangeably to describe eruptions of tiny vesicles with sparse or no inflammation on the palms and sometimes also on the soles. If vesicles coalesce they may form bullae.

The term dyshidrosis or dyshidrosiform is best avoided. It has been shown repeatedly that there is no connection between the vesicles and the acrosyringium in vesicular hand dermatitis.

The term pompholyx is best reserved for the rare, sudden, severe, self-healing vesicular and/or bullous eruptions on the palms and, occasionally also, on the soles with no or sparse inflammation (1, 2). Indeed, the term “pompholyx” could be replaced by “acute vesicular hand eczema”. The aetiology of this condition is unknown.

Recurrent vesicular hand dermatitis is probably the best term to describe the more common, milder vesicular eruptions on the palms with sharp delineation to palmar skin and with no or moderate inflammation. A multitude of aetiologies have been linked to this eczematous eruption, including allergic and irritant contact dermatitis, systemic contact dermatitis and dermatophytid.

It is probably useful to consider recurrent vesicular hand dermatitis to be a characteristic but non-specific reaction pattern of palmar and plantar skin with many possible causes (3). Thus the title of the current case report could have been “Bullous pemphigoid masquerading as recurrent vesicular hand dermatitis”.


Niels K Veien, MD, PhD

Dermatology Clinic

DK-9000 Aalborg, Denmark

  • Murray CS, Rees JL. How robust are the Dermatology Life Quality Index and other self-reported subjective symptom scores when exposed to a range of experimental biases? Acta Dermatol Venereol 2009; 90: 34–38.
  • Both H, Essink-Bot ML, Busschbach J, Nijsten T. Critical review of generic and dermatology-specific health-related quality of life instruments. J Invest Dermatol 2007; 127: 2726–2739.
  • Townshend AP, Chen CM, Williams HC. How prominent are patient-reported outcomes in clinical trials of dermatological treatments? Br J Dermatol 2008; 159: 1152–1159.
  • Schmitt J, Langan S, Williams HC and the European Dermato-Epidemiology Network. What are the best outcome measurements for atopic eczema? A systematic review. J Allergy Clin Immunol 2007; 120: 1389–1398.
  • Fox T. On dysidrosis. Am J Syphilol Dermatol 1873: 1–7.
  • Hutchinson J. Cheiro-pompholyx. Notes of a clinical lecture on “a recurrent bullous eruption on the hands”. Lancet 1876; 1: 630–631.
  • Veien NK. Acute and recurrent vesicular hand dermatitis. Dermatol Clin 2009; 27: 337–353.