Section 1 – Chapter 2 Evidence-Based Dermatology
Fitzpatrick’s Dermatology in General Medicine 8 th ed.
Evidence-Based Dermatology
Evidence-based Medicine
• Evidence-based medicine (EBM) is the use
of the best current evidence in making
decisions about the care of individual
patients.
• Recommendations about treatment,
diagnosis, and avoidance of harm should
take into account the validity, magnitude of
effect, precision, and applicability of the
evidence on which they are based
• An important principle of EBM is that the
quality (strength) of evidence is based on a
hierarchy.
• A systematic review is an overview that
answers a specific clinical question; contains
a thorough, unbiased search of the relevant
literature; uses explicit criteria for assessing
studies; and provides a structured
presentation of the results.
• A systematic review that uses quantitative
methods to summarize results is a meta-
analysis. Meta-analysis is credited with
allowing the recognition of important
treatment effects by combining the results
of small trials that individually lacked the
power to demonstrate differences among
treatments.
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Section 1 – Chapter 2 Evidence-Based Dermatology
Fitzpatrick’s Dermatology in General Medicine 8 th ed.
• Not all systematic reviews and meta-
analyses are equal. A systematic review can
be only as good as the clinical trials that it
encompasses
The type of clinical study that constitutes best
evidence is determined by the category of
question being asked.
• Questions about therapy and prevention
are best addressed by RCT (GOLD
STANDARD)
• Questions about diagnosis are best
addressed by cohort studies
• Cohort studies, case-control studies, and
postmarketing surveillance studies best
address questions about harm
Finding The Best Evidence
The ability to find the best evidence to answer
clinical questions is crucial for the practice of
EBM.
The most useful sources for locating the best
evidence about treatment include the
following:
• The Cochrane Library
• The MEDLINE (Medical Literature Analysis
and Retrieval System OnLine) and EMBASE
(ExerptaMedica Database) databases
• Primary journals
• Secondary journals
• Evidence-based dermatology and EBM
books
• The National Guideline Clearing-house
(http://www.guideline.gov/)
• The National Institute for Health and
Clinical Excellence (http://www.nice.org.uk)
Critically Appraising The Evidence
The criteria for critically appraising papers
about treatment, diagnostic tests, and harmful
effects of exposures are shown in tables below.
Papers that meet these criteria are more likely
to provide information that is accurate and
useful in the care of patients
Critically appraising evidence consists in
determining whether the results are: valid (i.e.,
they are as unbiased as possible); clinically
important; and applicable to the specific
patient being seen.
1. Evidence about Therapy and prevention
 Random;
 Complete follow-up of all patients
entered into the study;
 Intention-to-treat analysis of results;
 Masking of investigators, patients, and
statisticians where possible;
 Equal treatment of groups;
 Similarity between treatment groups
with regard to the distributions of
prognostic variables.
 Clinical outcome measures that are
clear-cut and clinically meaningful
(clearly defined, must be as objective as
possible, and must have clinical and
biologic significance) to the physician
and his or her patients
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Section 1 – Chapter 2 Evidence-Based Dermatology
Fitzpatrick’s Dermatology in General Medicine 8 th ed.

 a lack of clearly defined and useful  Useful measures of the magnitude of

outcome variables remains a major the treatment effect are the difference
problem in interpreting dermatologic in response rate and its reciprocal, the
clinical trials. NNT.
 To strengthen clinical trials and help  The NNT represents the number of
validate their conclusions, investigators patients one would need to treat to
should select only a few outcome achieve one additional cure or clinically
variables and should choose them relevant improvement.
before initiation of the study.  The confidence interval provides a
 Special precautions are recommended useful measure of the precision of the
to recognize and remain skeptical of treatment effect.
substitute or surrogate endpoints,
especially when no differences are
detected in clinically important
outcomes
 Once sound, clinically relevant outcome
measures are chosen, the magnitude of
the difference between the treatment

groups in achieving these meaningful 2. Evidence about Diagnostic Test

outcomes should be determined.

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Section 1 – Chapter 2 Evidence-Based Dermatology
Fitzpatrick’s Dermatology in General Medicine 8 th ed.

3. Evidence about Harmfull Effect

Applying Evidence to Specific Patients

Applying the evidence to treatment of specific
patients involves determining whether the
evidence from studies is applicable to a given
patient. This decision is based on the patient’s
condition and values. It involves asking a series
of questions that are specific to the type of
evidence being considered

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