Consensus Conference Management of chronic urticaria Wednesday 8 January 2003 Institut Pasteur Paris, France Recommendations (Short version)

ARTICLE

Auteur(s) :

Promoted by the
Société Française de Dermatologie
with the support of

Association des Enseignants d’Immunologie des Universités de Langue Française
Association Nationale de Formation Continue en Allergologie
Collège des Enseignants de Dermatologie de France
Collège National des Généralistes Enseignants
Fédération Française de Formation Continue en Dermato-Vénéréologie
Groupe d’Études et de Recherche en Dermato-Allergologie
Société Française d’Allergologie et d’Immunologie Clinique
Société Française d’Immunologie
Société Française de Pédiatrie
Société Nationale Française de Médecine Interne

with the participation of:

l’Association Consensus en Dermatologie

Questions put to the panel

Question 1

Which are the factors during questioning and the clinical examination which direct the diagnosis towards that of chronic urticaria?

Question 2

Faced with chronic urticaria, what are the minimum paraclinical investigations necessary? For which patients is a more complete check-up required, and which one?

Question 3

When are allergological examinations necessary, and which ones?

Question 4

In which circumstances does etiological evidence have an effect on the treatment and evolution of chronic urticaria?

Question 5

What treatment modalities are proposed for patients presenting an idiopathic chronic urticaria which is resistant to antihistaminic mono-therapy?

Question 6

When should psychological factors be taken into account and how should they be dealt with?

Introduction

Urticaria is one of the most frequent dermatological conditions: 15 to 20% of the population has at least one acute eruption during his or her lifetime, resulting in 1 to 2% of dermatological and allergological consultations. Chronic urticaria is defined by the persistence of lesions beyond 6 weeks, these can last for years, with the average being 3 to 5 years. Forty percent of urticarias lasting more than 6 months are still present ten years later and 20% are still present after 20 years.
Chronic urticaria can be serious when it is associated with angioedema involving the laryngo-pharynx or the digestive tract. The psychological, and in particular the socio-professional repercussions are often important and can alter the patient’s quality of life and cause anxiety in many cases.
There are many causes classically found in patients, which sometimes results in exhaustive and expensive testing, this often at the insistent demand of patients who want to know the reason’ for their illness. However, the diagnostic value’ of these etiological tests is disappointing, leaving the doctor frustrated and the patient often distraught.
The classic anti-histamine treatments are not always efficient, encouraging the patient to ask for repeat or more extensive testing and leaving the doctor with the problem of chosing the best diagnostic and therapeutic strategy to follow.
The aims of this meeting on the management of chronic urticaria were as follows: to recall the essential factors which should be established by questioning and clinical examination in diagnosing the causes of chronic urticaria, to propose a strategy for appropriate complementary examinations and a coherent treatment programme, taking into account when necessary, any psychological factors.
The recommendations proposed by the Panel were classed as A, B or C in function of the level of scientific proof provided in the literature (Table I). Those which are not explicitly graded in the text should be considered as recommendations of the majority of the Panel. Unfortunately the level of scientific proof provided in the literature is often very poor. In these cases the Panel also took into account normal professional practices while trying to put forward common sense propositions.

Table I. Recommended grading system for clinical studies

Question 1

Which are the factors during questioning and the clinical examination which direct the diagnosis towards that of chronic urticaria?

Urticaria is characterised by the appearance of transient papules, (usually lasting for less than 24 hours), which are pruritic. When oedema reaches the deeper levels of the dermis or hypodermis, the lesions take on the appearance of hard swellings, pale in colour and painful rather than pruritic, lasting for 48 to 72 hours. This is known as deep urticaria or angiœdema. Almost 50% of patients present with an association of the two forms of urticaria.
Urticaria is considered chronic when the eruption lasts for more than 6 weeks (in a permanent or recurrent form).
Diagnosis of the causes of chronic urticaria relies on questioning and clinical examination.

Questionnaire

The history should establish:
– the chronology;
– personal and family antecedents (atopy, urticaria, systemic disease);
– long-term medicines (conversion enzyme inhibitors- CEI), sartans, aspirin and non-steroidal anti-inflammatory drugs NSAIDs), and occasional use of medicines (codeine and morphine);
– dietary habits (overconsumption of histamine- liberating foods);
– the possibility of contact urticaria (particularly latex) and professions at risk;
– the circumstances triggering urticaria due to a physical factor (effort, rubbing, pressure, heat, cold, water, sun exposure, vibrations);
– the role of “stress” as an aggravating factor;
– additional symptoms indicative of a systemic illness.
Chronic urticaria in children is rare and presents few particularities.

Clinical examination

• Dermatological examination: certain localisations are themselves indicative of the cause:
– dermographism (linear lesions reproduced by scratching);
– delayed urticaria due to pressure (deep urticaria at pressure points);
– cholinergic urticaria (brief exposure to heat, to effort or to an emotion);
– facial angio-œdema (caused by food in children, and by drugs in adults).
In small children the appearance is often like that of bruising.
Atypical forms exist in adults: annular, micropapular or purpuric.
A fixed eruption, lasting longer than 24 hours, and not very pruritic suggests urticarial vasculitis.
It is necessary to differentiate chronic urticaria from erythema multiforme (children), and mastocytosis and pre-bullous pemphigoïd.
• General examination: this needs to be complete, and in particular oriented towards auto-immune illnesses in adults.
• Tests to be carried out when there is suspicion of physical urticaria: each type of urticaria is authenticated by specific tests:
– dermographism. The diagnostic test is carried out with a simple pen scratch for a length of about 10 cm;
– cholinergic urticaria or heat-reflex urticaria. The provocation tests consist of physical exercice resulting in sweating;
– cold urticaria. The provocation test consists of ice placed in a plastic bag and applied to the forearm for a period of 20 minutes. In the event of a negative response, it is necessary to immerse the forearm at 5-10 °C for 10 to 15 minutes;
– delayed pressure urticaria. The diagnosis is confirmed by the application of a weight of 2.5 to 7 kg for a period of 20 minutes (on at least 2 different areas, shoulders and thighs for example, with readings from 30 minutes to 24 hours);
– heat-contact urticaria. This is reproduced by the application on the forearm of a glass tube containing hot water (38 °C and 50 °C for 1 to 5 minutes). The reaction is immediate except in familiar forms;
– sun-induced urticaria. The lesions are reproduced by sunlight or by solar lamps;
– water-induced urticaria. The provocation test consists in the application of a damp compress at 37 °C to the back for 20 to 30 minutes;
– vibratory angio-œdema. The lesions are reproduced by a vibrating machine.
Certain of these tests are not without risk and should be carried out in conditions of maximum security for the patient.

Question 2

Faced with chronic urticaria, what are the minimum paraclinical investigations necessary?
For which patients is a more complete check-up required, and which one?

The etiology of chronic urticaria can be looked at from three points of view:
– the frequence of pathologies which are said to be associated with chronic urticaria, studying the standards of methodological proof in published series;
– associated illnesses where the diagnosis may have a bearing on the treatment of the urticaria (cf. question 4);
– underlying illnesses detected during the tests for chronic urticaria.
An analysis of the literature concerning bacterial infections shows no association between "sources of local infection" and chronic urticaria. There is no need for a systematic investigation for dental or sinusal infection.
Testing for Helicobacter pylori does not seem justified except in the presence of evocative digestive symptoms (grade B).
Among the parasitoses, only Toxocara canis seems, according to a single study in the literature, to be associated with the existence of chronic urticaria.
No significant association has been shown between viral infection and the appearance of chronic urticaria.
The implication of a genuine food allergy seems to be exceptional in chronic urticaria, in contrast to acute urticaria, and therefore no specific complementary examination is indicated (grade B).
Among the auto-immune diseases, the only significant association concerns the presence of auto-antibodies (Ab) and auto-immune thyroiditis (antithyroperoxydase and/or antithyroglobulin Abs).
The results of a biopsy of an ‘ordinary’ isolated urticaria with no other associated cutaneous or extracutaneous lesions are of no value in the search for a systemic illness.
Overall, the value of the different batteries of complementary examinations proposed in the literature for the etiological diagnosis of chronic urticaria is poor.
Faced with a patient suffering from chronic urticaria, the panel proposes that the paraclinical tests should be directed towards the information obtained during questioning and in the clinical examination, distinguishing between two situations (Fig. 1):

Patients presenting isolated ordinary chronic urticaria without clinical indication of the origins

The panel proposes that, at first, no systematic complementary examinations should be carried out (grade B).
To begin with, an antihistaminic anti-HI treatment should be proposed for 4 to 8 weeks.
After this period of initial treatment and only in those patients considered to be resistant to this treatment, a minimal test series, consisting of: full blood count (FBC), sedimentation rate (SR), level of C reactive protein, search for antithyroperoxydase Abs (and if positive, TSH level) is proposed (grade B).
The panel did not propose including toxocarosis serology, nor the complement level, nor investigation of antinuclear factors in this minimal paraclinical series of tests, and proposed that they should only be undertaken in the event of an inflammatory syndrome, in anomalies detected in FBC, or where secondary clinical signs indicating the causes appear.

Patients presenting clinical signs suggesting the etiology

Certain examinations will be requested immediately in accordance with the diagnosis suggested by the information given by the patient and by clinical examination:

– cold urticaria: cryoglobulinemia, cryofibrinogenemia, monoclonal immunoglobulin, cold agglutinines;
– sun-induced urticaria: standardised phototests;
– chronic or recurring isolated angio-œdemas, without superficial lesions: search for a deficiency in the C1 esterase inhibitor. Unexplained, chronic angio-œdema localised on the face (in the absence of IEC, sartans, aspirin or NSAIDs): panoramic dental X ray, sinus scan;
– “atypical” urticaria (fixed, not very pruritic urticaria) where there is association with other cutaneous signs (livedo, nodules, purpura, etc.): cutaneous biopsy;
– clinical dysthyroiditis: TSH level, antithyroglobulin Abs, antithyroperoxydase Abs, even anti-TSH receptor Abs;
– in the event of extracutaneous signs suggesting a systemic illness, the paraclinical examinations necessary are those indicated by the history and the clinical examination.

Question 3

When are allergological examinations necessary, and which ones?

In chronic urticaria, allergic causes are greatly overestimated. The panel considers that allergological investigations have a small role. They should be undertaken within a strict framework.
It is essential to differentiate between “food allergy”, which is an immunological mechanism and very rare, and “food intolerance”, which is more common and most often linked to an overconsumption of biogene amines (cf. question 1). This food intolerance is also known as “false food allergy”.

When ?

Detailed questioning indicates the necessity for allergological investigations. Certain manifestations are suggestive, such as postprandial dyspeptic problems, which suggest a false food allergy, localised contact urticaria or episodes of recurrent angio-œdema on the face in a child, which suggests a true food allergy.
The allergological investigations are limited to the search for an allergy or food intolerance and contact urticaria.

Which tests ?

• Pointless investigations:
– pneumallergens: there is no need to look for sensitisation to pneumallergens during the course of isolated chronic urticaria (grade B);
– additives, preservatives, contaminants: the role of preservatives, of additives and of contaminants (nickel in particular) in the genesis of chronic urticaria is currently limited to specific situations (excessive consumption of a single product, additive or preservative, which is, in practice, very rare);
– flavourings: flavourings (natural and artificial) are more and more present in foodstuffs but lack of knowledge of the chemical formulas of the majority of them renders investigation impossible;
– drugs: the pharmacological mechanism of chronic or recurrent urticaria and of drug-induced angio-œdema is not immunological. Allergological investigations are therefore not indicated (grade B).
• Useful investigations:
– false food allergy and true food allergy: false food allergy is the most frequent cause of chronic urticaria related to food consumption. It is often considered to be a non-specific aggravating factor in chronic urticaria. The biogene amines (histamine, tyramine), or overconsumption of a foodstuff (milk, wheat) which lead to a fermentation colopathy, are responsible (cf. question 1). Certain drugs (aspirin and NSAIDs) and alcohol increase intestinal permeability, which indirectly favors a histaminoliberation source of chronic urticaria.
The preliminary investigation essential to all food allergy exploration is the analysis of a food diary kept over 7 days, which includes a review of all labels and simple assessible data such as the extension of the lesions, the severity of the pruritis and the use of antihistaminic anti-H1.
Excessive consumption leads to an avoidance of these foodstuffs for a period of at least 3 weeks. The diagnosis of false food allergy is confirmed by the marked improvement of the urticaria, even its resolution, after an avoidance diet has been established. The other allergological investigations are of no use in the case of a false food allergy (grade B).
Suspicion of a true food allergy (for example to hidden allergens like peanuts and sesame seeds) relies on a search for IgE-dependent sensitisation to foodstuffs using cutaneous tests which are more reliable than biological ones. This stage requires specialised medical skills. Suspicion of sensitisation requires avoidance of the foodstuff for 3 weeks. However, the improvement which may be observed after an avoidance diet is not sufficient for a firm diagnosis. Only the oral provocation test can confirm a true food allergy. This must only be undertaken in a highly specialised unit which is capable of dealing with an anaphylactic shock.
– contact urticaria: investigation of contact urticaria, suggested by the history, consists of prick tests or open tests (direct application on the skin without use of a cupula) with immediate reading. In the event of a negative result, a repeated open test may be tried.

Question 4

In which circumstances does etiological evidence have an effect on the treatment and evolution of chronic utricaria?

One of the main interests in etiological testing is to highlight diseases in cause which will involve treatments having an effect on the therapy for the chronic urticaria.

Chronic physical urticaria

The diagnosis of chronic physical urticaria affects the treatment because certain triggering situations can sometimes be avoided (cf. question 1). Second generation antihistaminic anti-H1s, however, are the generally accepted treatment for this condition.

Chronic contact urticaria

Avoiding the allergens involved is justified in chronic contact urticaria.

Chronic urticaria and drugs

Drugs usually act as aggravating factors in chronic urticaria.
Certain histaminoliberating substances (opiates, codeine, curares, beta-lactamines, vancomycin, iodine contrast products, atropine, pentamidine, polymyxine B, Dextran-type macromolecules) are liable to aggravate chronic urticaria, most often triggering attacks of acute urticaria or angio-œdema. Certain of these products (betalactamines, curares) are, moreover, responsible for acute urticaria by means of a true, IgE-mediated allergy.
According to the literature, 25 to 55% of cases of chronic urticaria are aggravated or even triggered by aspirin or the NSAIDs, by a non allergic mechanism.
The IEC result in angio-œdemas essentially located on the face, generally arising during the first 3 weeks of their use, but sometimes also after several months or years of treatment. In patients, the use of sartans (inhibitors of the angiotensine II receptors) risks the recurrence of angioœdema in 30% of cases. Aspirin and the NSAIDs can also be responsible for recurrent angio-œdemas.
In practice, the identification and avoidance of drugs which aggravate chronic urticaria is always justified. An angio-œdema antecedent is a contre-indication to IEC. The occurrence of angio-œdema under IEC requires the withdrawal of the drug, and the use of a different class of drugs, if possible not one of the sartans. On the other hand, the presence (or history) of chronic urticaria (apart from angio-œdemas) is not a contra-indication to the use of IEC.

Chronic urticaria and food

The false food allergy caused by overconsumption of foodstuffs rich in histamines or histaminoliberators constitutes the most frequent cause of chronic urticaria linked to food intake (cf. question 3). It is considered as a non-specific aggravating factor in chronic urticaria. When a false food allergy is suspected, avoidance of foodstuffs rich in biogene amines is recommended (cf. question 3).

Proving a food allergy to additives, preservatives and flavourings is very difficult in practice. An avoidance diet for these substances is only rarely indicated.

Establishing the existence of a true food allergy (for example to masked antigens) is exceptional and requires an avoidance diet after confirmation of the diagnosis by an oral provocation test.

Urticaria and infections

To date there is no infection associated with chronic urticaria for which the treatment has a clearly demonstrated effect on the evolution of the chronic urticaria.

Urticaria and general illnesses

• Auto-immune thyroiditis: the frequence of auto-immune thyroiditis is significantly increased in patients who present with chronic urticaria. L-thyroxine treatment has not been shown to have an effect on the progression of chronic urticaria associated with this condition. When the TSH is normal, the panel does not recommend opotherapy with L-thyroxine when the only aim is to treat the associated chronic urticaria (grade C).
• Other general illnesses: Evidence of a systemic illness (systemic vasculitis, auto-immune illness, cancer, etc.) is rare, exceptional even, during the course of chronic urticaria, and the progression of the lesions is not always related to the treatment of the associated illness.

Special cases concerning children

The syndromes of chronic urticaria in children (CINCA syndrome, hyper-IgD syndrome, Mckle-Wells syndrome, Still’s disease etc) require a specialist’s opinion.

Question 5

What treatment modalities are proposed for patients presenting an idiopathic chronic urticaria which is resistant to antihistaminic mono-therapy?

Definition of the resistance

The second generation anti-H1 antihistamines are the preferred treatment for chronic urticaria (grade A) and enable the disease to be controlled in the majority of cases. The literature does not provide any information indicating a preferred drug.
The panel considers that a well-run treatment has the following characteristics:
– a dosage which must correspond to the approved label;
– continuous treatment;
– good compliance;
– regular evaluation of the treatment (every three months, for example);
– end to the treatment, tapering if necessary, after lasting and complete remission of the lesions.
Resistance to anti-H1 antihistamines can only be assessed after 4 to 8 weeks of well-run treatment, bearing in mind the natural history of urticaria, in which spontaneous remission is possible.
The panel considers that, in the absence of complete remission, the only criteria which should lead to a change of treatment are:
– adverse effects on the quality of life;
– important pruritis;
– extension of the lesions, outbreaks of angio-œdema.
At this stage the panel proposes that the history and clinical examination should be repeated, looking for:
– poor compliance;
– triggering or aggravating factors which can be dealt with: drugs, foodstuffs, psychological factors;
– associated signs which suggest a symptomatic urticaria and lead to the appropriate tests (cf. question 3).
The panel also advises that, even if the urticaria remains clincially ‘isolated’, the following biological examinations should be carried out: FBC, SR, CRP level and antithyroperoxydase Abs.

Therapeutic strategy for chronic urticaria resistant to second generation anti-H1 antihistamine monotherapy

• Initial strategy: the panel considers that anti-H1 antihistamines remain the only treatment. The two recommendations which follow are proposed by the panel and reflect professional practice and the opinions of experts. No information in the literature suggests that one strategy is preferable to the other:
– monotherapy: replacement of the second generation anti-H1 antihistamine with another molecule of the same class;
– bitherapy: the most frequently used association is that of a second generation anti-H1 antihistamine in the morning, with a first generation anti-H1 antihistamine with a sedative effect taken in the evening, mainly in cases of pruritis and problems with sleeping.
Evaluation of the efficacy of the chosen strategy should be made after 4 to 8 weeks of treatment. The criteria for evaluation are those already stated and it is necessary that particular attention should be paid to the patient’s own opinion.
In the event of the failure of one of these two strategies, the panel considers that the treatment of choice should be another anti-H1 antihistamine, trying different molecules successively, separately or in combination, before considering the use of alternative treatments.
• Failure of the preceding strategies: in view of the rarity of such situations, the panel considers that these patients should be discussed in a specialised unit by a multidisciplinary team, case by case.
The different studies found in the literature are low-weight or contradictory:
– doxepine: its use has been proposed in two non-recent studies at level 2;
– anti-H2 antihistamines: the association of an anti-H1 antihistamine with an anti-H2 anti-histamine has been proposed in the past when the choice of anti-H1 antihistamines was limited. The panel considers that the choice of such an association is not justified nowadays;
– antileucotrienes: there is no argument for proposing this therapeutic class in current clinical practice.
Furthermore, knowledge of the risks of certain other therapies counterindicates their use outside the framework of clinical trials:
– systemic corticotherapy: the panel considers that there is no place for this treament in chronic idiopathic urticaria;
– immunosuppressors, notably cyclosporine;
– ultraviolet treatments.
In the current state of knowledge, the other therapies which have been proposed have no place in the treatment of chonic idiopathic urticaria.

Question 6

When should psychological factors be taken into account and how should they be dealt with?

When considering the treatment of psychological factors in chronic urticaria, the following points must be born in mind:
– this is a chronic pathology which requires long term and specific treatment;
– urticaria is a dermatological disease, affecting a highly visible part of the body which is important for quality of life and personal relationships;
– there are clincial particularities like pruritis or the potential risk of angio-œdema;
– there are very few controlled studies published concerning the psychological factors in chronic urticaria and their treatment. However, as for other chronic dermatoses, an association between stress, anxio-depressive symptoms and chronic urticaria has been reported with no study able to establish if it is the cause or the consequence. No relationship between the severity of the chronic urticaria and that of the anxio-depressive state has been shown. The intensity of the pruritis may always be increased by a depressive syndrome. Among the personality problems, only the prevalence of alexithymia (difficulties in verbalising emotions) has been studied and it is equally important in chronic urticaria as in psoriasis (study level 3). A reduction in the quality of life has been demonstrated. For all these reasons, the panel considers that it is legitimate to treat the psychological factors involved in chronic urticaria. This attitude seems all the more reasonable in that it relies essentially on clinical facts. The panel emphasises that further studies are necessary to detail the real importance of psychological factors in chronic urticaria.

When is it necessary to treat the psychological factors?

There is no study which has appeared to date in the literature dealing with the ideal timing for starting psychological treatment in chronic urticaria.
At the first consultation the panel proposes that particular attention should be paid to giving the patient a detailed explanation of the condition, of its chronic evolution and the treatment programme and the removal of his fears. In certain situations, a more extensive investigation would seem more appropriate:
– when there is physical evidence of suffering or a request for psychological help from the patient;
– in the case of chronic urticarias resistant to anti-H1 antihistamine treatment;
– in the presence of certain physical urticarias, in particular delayed urticaria to pression.
A few simple questions can act as guidelines:
• To what extent do the symptoms interfer with the quality of life of the patient?
• What are the possible secondary benefits?
• Do stress factors exist? What is their possible relationship with the eruptions?
• Do physical and/or psychological symptoms of anxiety exist?
• Are there isolated depressive symptoms or ones associated with ideas of suicide?

Treatment methods for psychological factors

In the majority of cases, the initial treatment of psychological factors is assumed by the doctor treating the patient with chronic urticaria:
– the preferential choice of an anti H1-antihistamine sedative in the event of pruritis associated with sleep problems and/or corresponding anxiety;
– psychological support, reassurance of the patient.
Treatment of stress may be necessary (relaxation, behaviour based therapies, etc.).
In the event of anxiety and/or recognisable depressive syndromes, the use of specific treatments is justified as normal good practice. In depressive syndromes the use of new generation antidepressors is preferable (non tricyclic, non IMAO).
A psychiatric opinion can be considered case by case if the illness significantly alters the quality of life or when the psychological support offered by the attendant doctor and the treatments prescribed for the psychological problems are found to be inadequate.

Organising Committee

M.S. DOUTRE, president: immunologist, dermatologist, Bordeaux, D. BUCHON: general practitioner, Bugeat, P. DOSQUET: methodologist ANAES, Paris, N. DUPIN: dermatologist, Paris, P. JOLY: dermatologist, Rouen, F. LEYNADIER: internist, allergologist, Paris
A. NASSIF: dermatologist, Paris, C. PAINDAVOINE: methodologist ANAES, Paris
L. PRIN: immunologist, Lille, M.D. TOUZÉ: methodologist ANAES, Paris

Panel

P. JOLY, president: dermatologist, Rouen, P.A. BUFFET: dermatologist, Paris, O. CHOSIDOW: dermatologist, Paris, B. DECHAMPS: allergologist Dieppe, M. D’INCAN: dermatologist, Clermont-Ferrand, F. DUMEL: general practitioner, Audincourt, C. GUY: pharmacologist, Saint-Étienne, P. JEGOUZO: biologist, Ussel, T. PAPO: internist, Paris, H. PICHERIT: general practitioner, Deville-lès-Rouen, P. PLANTIN: dermatologist, Quimper, F. RANCÉ: pediatrician, allergologist, Toulouse, G. SALIBA: dermatologist, Arles, F. THIBAUT: psychiatrist, Rouen

Experts

E. COLLET: dermatologist, Dijon, JF. NICOLAS: immunologist, dermatologist, Pierre-Bénite, A. BARBAUD: dermatologist, Nancy, D. TENNSTEDT: dermatologist, allergologist, Bruxelles, P. MATHELIER-FUSADE: dermatologist, allergologist, Paris, D.A. MONERET-VAUTRIN: internist, allergologist, Nancy, B. CRIBIER: dermatologist, Strasbourg, É. HACHULLA: internist, Lille, D. HAMEL-TEILLAC: dermatologist, Paris, S. CONSOLI: dermatologist, psycho-analysist, Paris, M.T. GUINNEPAIN: dermatologist, allergologist, Paris

Bibliographical group

C. MATEUS: dermatologist, Paris, M. BUFFET: dermatologist, Paris, D. BARCAT: internist, Bordeaux, P. CARVALHO: dermatologist, Rouen, I. KUPFER: dermatologist, Brest, E. AMSLER: dermatologist, Paris

Acknowledgements. We thank the Agence Nationale d’Accréditation et d’Evaluation en santé for granting us permission to translate this text.
The complete text (in French) is available by written request to:
Agence Nationale d’Accréditation et d’Évaluation en Santé Service communication
159, rue Nationale, 75640 Paris Cedex 13
and can be consulted on the website of the ANAES: www.anaes.fr rubric “Publications”

The organisation of this consensus conference was made possible thanks to grants from:
3 M, Astra-Zeneca, Fujisawa, Galderma, Glaxo, Léo, Novartis, Pierre Fabre, Roche, Schering-Plough

We are indebted to Jenny Messenger for translating this article