Anna Lis-Święty

Atopic dermatitis exacerbated with ustekinumab in a psoriatic patient with childhood history of atopy

Ustekinumab is a biological agent that is currently approved for the treatment of moderate to severe plaque psoriasis. It is a monoclonal antibody that binds the p40 subunit of IL-12 and IL-23 to limit the progression of the Th1 and Th17 inflammatory immune responses. Recently, it has been suggested that ustekinumab could represent a potential treatment for atopic dermatitis (AD).1e3 However, inadequate response to ustekinumab in AD patients has also been reported.4 We present a case of paradoxically exacerbated AD during the ustekinumab treatment for psoriasis. A 21-year-old man with a 7 year history of severe psoriasis refractory to conventional systemic treatments and childhood history of atopy (atopic dermatitis-AD, asthma, seasonal rhinitis) was treated with ustekinumab. The patient was without major symptoms from respiratory system and AD lesions within a period of 5 years before the date of starting the treatment. He was taking montelukast, antihistamines, inhaled corticosterois and formoterol for asthma. Psoriatic lesions and no clinical sings of AD were found on baseline examination (Fig. 1). Ustekinumab 45 mg (1 injection at week 0 and week 4, then every 12 weeks) was introduced (according to body weight: 76 kg). After 18 months and following excellent results, the patient decided to discontinue therapy. But 8 months later recurrence of psoriasis was observed and ustekinumab was restarted. The baseline PASI fell from 11,4 to 3,0 after 4 weeks of treatment with ustekinumab, complete remission of psoriasis was achieved after 8 weeks of therapy. However, intense generalized itching occurred since the first dose was administered. Severe AD appeared on the neck and lower limbs about 6 weeks after the reintroduction of ustekinumab (Fig. 2). Eczematous drug eruption and AD exacerbation due to stress, infection, or other external factors (i.e. topical treatments of psoriasis) was excluded in the differential diagnosis. Apart from dermatologic findings, physical examination revealed no abnormalities. Laboratory tests showed peripheral blood eosinophilia (1,48 109/L, compared to the baseline of 0,46 109/L, to the 16 weeks of 0,58 109/L, to the 28 weeks of ustekinumab therapy of 0,67 109/L, and to the recurrence of psoriasis of 0,66 109/L), as well as abnormal increase in serum allergen-specific immunoglobulin E (sIgE) level including dog-, cat-, hamster-, and grass pollen-specific IgE. Total IgE level was 12576 IU/ml (0e100,0 IU/l reference range). Other laboratory data (erythrocyte sedimentation rate, C-reactive protein level, complete blood count, biochemical parameters of liver and kidney, urinalysis) were normal at several time points. Spirometry

New aspects of the treatment of alopecia areata.

Alopecia areata (AA) is a disease involving non-scarring hair loss determined by autoimmune disorders and inflammation. The disease affects hair on the scalp and/or other parts of the body. The AA occurs in people of all ages and affects 1–2% of humans. The purpose of this paper is to present the latest knowledge on the treatment of AA. The decision on the type of treatment depends on the type of hair loss, extent of changes, general health status, the patients age, and his/her motivation. Treatment methods should be chosen individually for each patient.

A systematic review of tools for determining activity of localized scleroderma in paediatric and adult patients

Localized scleroderma (LoS) is a rare inflammatory skin disorder that affects the dermis and sometimes subcutaneous tissues. LoS can have very long periods of quiescence followed by reactivation, but the progression or activity of the disease is difficult to measure. To review the measuring tools used for the evaluation of LoS activity, to choose the most appropriate technique to facilitate progress towards properly assessing the disease, a systematic review of the literature was carried out using the PubMed MEDLINE. Sixty‐three studies describing groups of children, adults or both were reviewed and included in the analysis. Case reports were excluded. The analysed papers were published between June 1986 and February 2016. Data were extracted with a focus on instruments measuring the clinical signs of LoS, health‐related quality of life (HRQoL), laboratory tests and imaging techniques. Perusal of the literature confirmed that clinical characteristics of the lesions were used to identify activity and scoring systems that focused on a series of signs, and were initially validated in cases of childhood‐onset disease; however, there were no data concerning the adult‐onset form of the disease. Adult patients with LoS scored lower on HDLQI than those with paediatric‐onset LoS. No validated biological markers were available as correlative laboratory parameters of LoS activity. For infrared thermography, ultrasound and other imaging techniques, the features of active lesions were described, but were only useful with appropriate clinical correlation. Measuring tools have not been prospectively validated yet. Summarizing, scoring methods seem to provide the most adequate assessment of LoS and deserve to be further investigated. Combined imaging techniques create optimal conditions for the proper interpretation of the temperature at the skin surface, as well as the structure and vascularity of LoS lesions. Additional scores, musculoskeletal or neuroimaging techniques and laboratory parameters are needed for the specific disease subtypes to monitor extracutaneous manifestations.

Localized scleroderma: clinical and epidemiological features with emphasis on adulthood- versus childhood-onset disease differences

Localized scleroderma is a rare inflammatory skin disorder that affects the skin and sometimes underlying subcutaneous tissue, muscles or bones. The disease has two modes of onset: juvenile‐ (JLS) and adult‐onset (aLoS). Clinical features have impact on diagnostic and treatment recommendations, but no consensus on the disease management depending on the age at diagnosis was given.

Subacute cutaneous lupus erythematosus in the course of rheumatoid arthritis: a relationship with TNF-α antagonists and rituximab therapy?

Abstract Introduction: Drug-induced subacute cutaneous lupus erythematosus (DI-SCLE) is caused by different medicines, first of all: calcium channel blockers, angiotensin converting enzyme inhibitors, thiazides, terbinafine, statins and antagonists of tumor necrosis factor-α (TNF-α). DI-SCLE does not distinguish from idiopathic form of the disease, clinically, histopathologically and immunologically. However, receding of symptoms is observed after recapture of the provoking drug. Aim: To present a patient with rheumatoid arthritis (RA), who developed SCLE after treatment with TNF-α antagonists and rituximab. Case report: In a 31-year-old woman with RA leucopenia due to treatment with etanercept and adalimumab was observed. Therefore, the treatment was changed to rituximab, but after starting the therapy, erythematous and oedematous skin lesions of an oval or annular shape appeared on the cheeks, auricles, lips and the decolette. Histopathological evaluation of the skin lesions revealed SCLE. Ro/SS-A and La/SS-B antibodies were detected in serum. Regression of skin lesions and hematologic disturbances was achieved after starting corticosteroid therapy. Conclusions: Co-existence of SCLE with RA should be considered in some patients. The role of TNF-α antagonists and rituximab therapy in induction of idiopathic form of SCLE requires further investigations.

Erythema nodosum caused by ascariasis and Chlamydophila pneumoniae pulmonary infection - a case report.

Erythema nodosum belongs to a group of relatively common hypodermal inflammations. It occurs mainly among women, particularly young women. The etiology of the disease is not clear. Most frequently, changes appear on the surface of the frontal part of the shins. Initially, red nodules change in color to dark brown and then to yellow and green. There is neither dissolution nor cicatrization of the exanthema. Regression is frequent. We present a case of erythema nodosum caused by Ascaris lumbricoides infection as well as by an early Chlamydophila pneumoniae infection, whose etiology has rarely been described in the literature. We were not able to confirm which factor was responsible for the occurrence of the skin changes as treatment of both infections was effective and all skin changes later disappeared completely. Particular attention should be paid to the fact that precise diagnosis of a patient and the search for etiologic factors, even rare ones, are crucial to obtain good results with treatment of erythema nodosum.

Neurological abnormalities in localized scleroderma of the face and head: a case series study for evaluation of imaging findings and clinical course.

Abstract Introduction: Localized scleroderma (LoS) of the face and head is often associated with neurological manifestations and/or imaging abnormalities in the central nervous system (CNS). Case series: We present an analysis of 20 cases of LoS affecting the face and head. The CNS symptoms and/or abnormalities in high-resolution computed tomography (HRCT) and/or magnetic resonance imaging (MRI) were observed in 12 patients (60%). In addition to the mild and unspecific disorders (e.g. headaches), serious neurological complications probably in the course of vasculitis were revealed: epilepsy (in two patients), epilepsy and pyramidal sings (in one patient). Neurological disorders and LoS occurred at the same time (in three patients) or at the course of the disease (nine patients) and no later than 29 years since the onset of the disease. No link between neurological disorders and the LoS clinical morphology, immunological and other laboratory parameters has been established. Conclusions: CNS involvement is not correlated with the clinical course of the facial and head LoS and may occur years after the disease initial symptomatology. Imaging follow-up is not required if there is not any emerging neurological symptom. In some cases, however, both HRCT and MRI are useful for monitoring disease evolution and addressing therapeutic choices.

Antiphospholipid antibodies in localized scleroderma: the potential role of screening tests for the detection of antiphospholipid syndrome

Introduction The presence of antiphospholipid antibodies (aPL) is associated with infections, drugs and autoimmune disorders. Those antibodies are also detected in approximately 5–20% of the healthy population. The presence of aPL can lead to the occurrence of thrombotic events or abortion, which define the antiphospholipid syndrome (APS). Aim To evaluate the potential role of aPL in diagnosing APS in patients with localized scleroderma (LoS). Material and methods Serum samples from 45 patients with various forms of LoS were examined. They were screened with the commercially-available immunodot assay Anti-Phospholipid 10 Dot (GA Generic Assays GmbH, Dahlewitz, Germany). A number of clinical and laboratory parameters, especially APS symptoms, were assessed in patients with positive aPL: arterial and venous thrombotic events, obstetric complications, thrombocytopenia and neurological symptoms. Results The following profile of aPL IgG or IgM was obtained from patients with LoS: cardiolipin 15/45, phosphatidic acid 41/45, phosphatidyl-choline 0/45, -ethanolamine 6/45, -glycerole 1/45 (patient with Lyme disease), -inositol 7/45, -serine 14/45, annexin V 34/45, β2GPI 21/45, prothrombin 30/45. Antiphospholipid antibodies profile screening in these individuals revealed two cases of suspected secondary laboratory APS. However, no such clinical and laboratory parameters were found in other LoS patients with positive aPL. Similarly, no association was found between the presence of aPL and either thrombotic events or other APS symptoms. Conclusions Antiphospholipid antibodies are commonly found in patients with LoS but the exact role of these antibodies remains unclear. Clinical manifestations of APS are not frequently seen during LoS.

Successful therapy of cyclosporin A in pityriasis lichenoides et varioliformis acuta preceded by hand, foot and mouth disease.

To our knowledge, there are no previously published cases of enteroviral infection complicated by pityriasis lichenoides et varioliformis acuta (PLEVA). A 30-year-old woman is reported with a severe form of PLEVA, preceded by hand, foot and mouth disease. Immunosuppressive treatment with cyclosporin A resulted in rapid clinical improvement.

Serum androgens and prostate‐specific antigen levels in androgenetic alopecia: is there a difference between frontal and vertex baldness?

Androgenetic alopecia (AGA) seems to be a marker of increased risk of prostate cancer (PCa).