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Going paperless: a new era for patient‐reported outcome measures in dermatology

by Sticherling et al. is still of great importance. The authors raised several important issues. Firstly, there is an urgent need to find a safe and effective steroid-sparing agent in BP. Systemic GCS remain the most popular treatment option in severe cases due to their high efficacy in controlling the disease. Nevertheless, long-term use is associated with numerous adverse events, especially in BP, which is a disease of the elderly population with many comorbidities. Moreover, high doses of GCS are associated with increased mortality rates in the first year after hospitalization. Secondly, although many medications are used as steroidsparing agents, including azathioprine, mycophenolate mofetil and a combination of tetracycline with nicotinamide, methotrexate or dapsone, there is a lack of good-quality randomized clinical trials reliably assessing the efficacy and safety of these treatment options. In many countries, the choice of treatment strategy is based on expert opinion, drug availability or current trend. Undoubtedly, the recently published European consensus will help to unify the management of BP. Still, many of the recommendations are based on data not from randomized clinical trials but from case series, retrospective single-centre studies or expert opinion. Finally, although the results from the study by Sticherling et al. failed to reach statistical significance, dapsone still seems to be an effective steroid-sparing agent in BP. Several nonrandomized, mainly retrospective, studies on the efficacy of dapsone in BP have been published. Results from these studies indicate that the efficacy may reach 20–45 5% in monotherapy, 76% in combination with potent topical corticosteroids and 92–100% in combination with systemic GCS. Nevertheless, none of these studies assessed the steroid-sparing potential of dapsone; therefore, the trial designed by Sticherling et al. sets an important direction for future research. The incidence rate of dapsone-related adverse events in BP varied considerably in previous papers, reaching 58% in the study by Bouscarat et al. Sticherling et al. reported one patient treated with a combination of GCS and dapsone who died due to hepatic toxicity and renal failure. The risk of dangerous side-effects, including haemolytic anaemia, methaemoglobinaemia and neutropenia, always needs to be taken into consideration in patients treated with dapsone. Therefore, further research on the safety of dapsone in the elderly population of patients with BP is essential. To conclude, the current study, despite its limitations, is an important step forward, highlighting the urgent need to find a safe and effective steroid-sparing agent for elderly patients with BP.