Angela Patrì

Managing Moderate-to-Severe Psoriasis in the Elderly

Managing psoriasis in the elderly can be difficult for physicians, who must consider comorbidities, the resulting polypharmacy, and progressive functional impairment of several organs. Indeed, topical agents are the first-line treatment for limited disease. Phototherapy is recommended if topical drugs are not sufficient and the patient has multiple comorbidities and risk factors that make them a poor candidate for an oral or injectable systemic agent. The most important pharmacokinetic alteration in the elderly population is the decreased excretory capacity of the kidney; thus, cyclosporine should be considered a last resort treatment, and the administered dose of methotrexate should be lowered according to the reduction in estimated creatinine clearance. Acitretin can be used in the absence of severe renal insufficiency, paying attention to lipid profile, treating eventual hyperlipidemia, and closely monitoring liver enzymes. Available data on biological drugs in the elderly are limited. Biologics are associated with a small but significant overall risk of infections. However, there is no convincing evidence that the relative risk of infection with anti-tumor necrosis factor (TNF)-α therapy increases with age. Nevertheless, the package inserts for biologics recommend caution when administering these medications to the geriatric population, due to the high baseline risk of infection in such patients. Etanercept seems to be well tolerated, possibly because of its lower immunosuppressive characteristics compared with other biologics. However, studies with larger sample sizes are needed to confirm its safety.

Effect of weather and environmental factors on the clinical course of psoriasis

Dear Editor, Psoriasis is a chronic disease, the prevalence of which shows geographic variations,1 suggesting that it might be influenced by climatic factors such as sun exposure and humidity.2 ,3 In order to assess the effect of weather and both outdoor and indoor environmental factors on the clinical course of psoriasis, we analysed the answers given to a specific questionnaire administered to 300 consecutive patients attending the psoriasis outpatient clinic of our department. The role of exposure to rainy, windy, muggy, hot, cold and sunny climates, as well as of seasonality in relation to the outdoor environment and the effect of domestic heating and ventilation systems …

The risk of herpes zoster in the anti-TNF-α era: a case report and review of the literature

BACKGROUND Tumor necrosis factor-α (TNF-α) inhibitors represent efficacious therapeutic agents in many chronic inflammatory diseases such as psoriasis and rheumatoid arthritis. However they have been connected with increased risk of infection and reactivation of a variety of infectious agents, such as viruses. The reactivation of varicella zoster virus infection causes herpes zoster (HZ), a self-limiting, dermatomally localized, vesicular rash that can be accompanied by postherpetic neuralgia and severe neurological complications. MAIN OBSERVATIONS Limited information has been published regarding HZ during therapy with TNF-α inhibitors especially for the occurrence of HZ during adalimumab treatment. We report the case of a 58-year-old immunocompetent man with a 18-year history of plaque psoriasis who develops ophthalmic HZ during treatment with adalimumab. CONCLUSION We report this case to enrich the literature and to highlight the increased risk of HZ infections in patient on anti-TNF-α therapy (incidence of HZ is about 3-fold increased respect to general population). Clinically, these infections often have atypical presentations that may hamper prompt diagnosis. Therefore, it is very important to identify early signs and symptoms of herpes zoster in patients on biologic therapy in order to start prompt efficient antiviral treatment to prevent the development of severe complications.

Psoriasis in children with type 1 diabetes: A new comorbidity to be considered?

Type 1 diabetes mellitus (T1DM) is the most common endocrine disease of childhood, due to an immune-mediated destruction of insulin-producing pancreatic b-cells. Comorbidities are frequent in T1DM and can severely affect clinical management [1]. To date, vitiligo and alopecia areata are the only described cutaneous comorbidities associated with T1DM, while psoriasis is usually associated with type 2 diabetes mellitus [2]. Psoriasis is an inflammatory skin disease affecting up to 2% of children in Europe and, in particular, 2.1% in Italy [3, 4]. To date, psoriasis prevalence in T1DM is not well known. Aim of our study was to investigate prevalence of psoriasis in T1DM patients in pediatric age.

Crack abuse‐induced recalcitrant ulcers

Figure 1 Ulcerative lesion on the palmar aspect of the right thumb. Figure 2 Close-up of some of the patient’s tattoos. up to 2.5 cm in diameter. Partially covered with crusts, the ulcers had fi rst appeared two months earlier, and – despite topical antibiotic therapy – had gradually grown in size. Physical examination revealed a number of ear expanders, nose and eyebrow piercings, a transdermal implant below the right eye, as well as multiple tattoos (Figure 2 ). The patient’s medical history was remarkable for alcohol abuse and addiction to various drugs, including ketamine, ecstasy, MDMA (3,4-methylenedioxy-methamphetamine), cocaine, THC, and crack.

Surprise from skin nodules after travel to South America

Editor A 33-year-old Italian woman presented to our outpatient clinic on October 2013, showing four umbilicated nodules surrounded by erythematous, oedematous areas, on the right shoulder and buttock (Fig. 1). Itching, moving sensation, pain and serosanguinous discharge were reported. Interestingly, anamnesis revealed that, 1 month earlier, the patient had returned from an humanitarian mission in Brazil. The patient described a particularly painful insect bite, occurred during a visit in a rural area, followed by small erythematous papules evolving, during 2 weeks, into furuncular-like nodules. Local and systemic antibiotics, but also topical corticosteroids, were administered during 2 months, without improvement. At the first observation, the crateriform nodules appeared as pyogenic lesions of the shoulder and we decided to take a swab from the yellow drop mimicking purulent discharge. However, the ‘drop’ disappeared and no fluid emerged after palpation. Conversely, exerting an energic centripetal pressure around the nodules, we obtained the slow leakage of a larva. Thus, four larvae, one from each nodule, were extruded and fixed in 10% formaldehyde for entomologist consultation; prophylactic ciprofloxacin for 7 days was prescribed. Successively Dermatobia (D.) hominis larvae were identified (Fig. 2) and the diagnosis of myiasis by D. hominis was made. The patient recovered with hyperchromic scars in 2 weeks. Myiasis is a tropical disease due to Diptera larvae, contracted via mosquitoes bite. It comprises cutaneous myiases (furuncular and creeping eruptions), wound myiases and myiases of cavities and viscera. D. hominis is the most common agent of cutaneous myiasis in travellers. It lives in Central and South America, as parasite of cattle and other domestic stocks. Closer to Europe, furuncular myiasis can also be caused by Cordylobia rhodaini (Lund fly) typically found in the African rainforest, and by Cordylobia anthropophaga (African tumbu fly, also known as mango fly and putzi fly) responsible for the majority of furuncular lesions in Sub-Saharan, West and Central Africa. Cutaneous myiasis lesions are not usually multiple, each of them harbouring one larva, whose removal constitutes the treatment of choice. In addition, topical and/or systemic antibiotics are recommended, to avoid secondary infection. In Europe, diagnosis is easily overlooked due to its rarity and unspecific clinical appearance. Indeed, as initially in our case, furuncularlike nodules are often mistaken as common pyoderma, sebaceous cyst, or folliculitis. To date, very few cases about infestation by D. hominis are reported in Italy, thus contributing to physicians scarce awareness and under-diagnosis. Several reasons explain why reporting cases of myiasis in non-endemic countries is important. Modern lifestyle implies intense intercontinental mobility: travelling to and from tropical or sub-tropical regions, such as South America or West and Central Africa, has led to an increased incidence of myiasis, which, in fact, some years ago, resulted to be the fourth most common travel-associated skin disease. An incorrect diagnosis may lead, consequently, to inappropriate and/or damaging treatment and, possibly, to disease progression. In fact, severe clinical manifestations after D. hominis infestation are rare but possible: systemic inflammation, leucocytosis, eosinophilia and increased IgE have been reported. However, its most severe complication is represented by fatal cerebral myiasis, resulting from infestation of the skin covering infants fontanelles. Therefore, physicians from non-endemic countries should not underestimate myiasis, being ready to feel suspicion towards apparently banal, common