An extracellular matrix (ECM) is essential for multicellular life. Apart from being a scaffold, it is an actively signalling unit, orchestrating homo- and heterocellular communication to uphold tissue homeostasis or elicit an appropriate regenerative response after injury. The skin as a barrier organ meeting unremittent physical biological and chemical challenges is dependent on both a specialized ECM and attentive yet balanced immune surveillance. Intriguingly, skin-like ECM composites occur in primary and secondary lymphoid organs. Evolutionary, the expansion of the ECM coincides with development of adaptive immunity. Studies of acquired and genetic skin diseases suggest that the skin and lymphoid ECMs are essential, emerging, but yet-under-appreciated, gatekeepers of dermal immune homeostasis. Here, we summarize knowledge of the dermal and skin-distal lymphoid ECM as a mediator of skin immune homeostasis. We argue that increased awareness of the lymphoid-ECM as a potential regulator of skin immunity will increase our understanding of diseases linked to skin inflammation and allow for improved treatment options of them.
We read with interest the study by Handgretinger and colleagues entitled Rosacea Fulminans: An Anti-inflammatory-based Therapeutic Approach,1 and although the topic addressed is of great clinical relevance, the presentation of the results, particularly concerning the choice of the statistical test, warrants discussion.
The study tracked the evolution of the skin condition in six6 patients diagnosed with Rosacea fulminans before and after treatment with azithromycin. According to the methodological section, a t test for independent samples was used to compare the before and after treatment. This choice seems inappropriate to us, as it overlooks some fundamental assumptions in selecting statistical tests that assess the association between two variables.2, 3
The first issue concerns the independence between observations: The ‘before’ and ‘after’ measurements for the same individual are dependent, as they are related to the same subject. The independent samples t test assumes that the observations in each group are independent, which is not the case here.
The second issue concerns the nature of the variable being studied. The Clinical Erythema Assessment (CEA), for example, is an ordinal categorical variable. For instance, on a scale from 0 to 4, as in this case, the differences between ‘0 and 1’ may not represent the same quantitative change as a difference between ‘3 and 4.’ The t test assumes that the data are numbers, meaning that the differences between the values are consistent and quantifiable. For example, the difference between ages 25 and 20 is the same as the difference between 37 and 32, which is 5 years. The t test works with numerical variables, making it inappropriate for dealing with categorical variables, even if they are represented by numbers and have a natural order.
The third issue pertains to the necessity of a statistical test at all. In this regard, we would like to emphasize that the reason for writing this letter is not merely to criticize the choice of the statistical test, but to highlight that the value of a study like this should not rely on statistical significance. It is much more related to the descriptive and visual nature capable of creating a clear sensorial perception of clinical benefit and generating a relevant hypothesis to be explored more thoroughly in future studies.4 In this regard, in our opinion, the study by Handgretinger and colleagues achieves the goal. It is a beautiful and illustrative case series that does not need p values to demonstrate its importance.
Yung Gonzaga conceived and wrote the article. Ana Luísa Sampaio wrote and reviewed the article.
The authors declare no conflict of interest.
Not applicable.
Management and treatment of atopic dermatitis (AD) are complex and therefore bear the risk of therapeutic failure. Individualised patient action plans for patients and for caregivers have been shown to improve AD management, eczema monitoring and therapy adherence. Little is known about the use of patient action plans in the adult setting.
This project aimed at implementing a patient action plan to improve eczema management and evaluating its effects on disease severity and patient-related outcomes.
This quality improvement project had a pretest–posttest design and evaluated AD severity and patient-related outcomes after implementing a patient action plan. A convenience sample of 20 adult patients with AD was included. Socio-demographic, diagnostic and clinical variables were collected from the electronic health records. Trained staff assessed AD severity using SCORing Atopic Dermatitis (SCORAD) and person-centred dermatology self-care index (PeDeSI-G) pre as well as 1-month postintervention. Patients completed dermatology life quality index (DLQI) and patient benefit index (PBI). For comparison of SCORAD, DLQI, PeDeSI-G, paired t-test was applied. PBI was presented using descriptive statistics.
Upon intervention, a significant decrease of disease severity (p < 0.0001), in parallel with a significant decrease of DLQI (p < 0.001) and PeDeSI-G (p < 0.0001) was observed. A PBI ≥ 1 was reached in 95% of participants (mean 2.73; SD 0.9).
Our findings confirm the importance of providing patient action plans to AD patients to achieve best treatment results. Based on our experience, we plan to modify the action plan by including both topical and systemic therapies, and to translate it into several languages.
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