Antonio Vélez

Treatment of severe refractory adult atopic dermatitis with ustekinumab

with ustekinumab Editor, A 21-year-old Caucasian woman presented in March 2003 with a longstanding history of atopic dermatitis (AD) in addition to allergic contact dermatitis that emerged in response to paraphenylenediamine and had been diagnosed one year earlier (Fig. 1). She had undergone topical treatment with corticosteroids and calcineurin inhibitors with little improvement in her condition. Over the next six years, the patient underwent various treatments such as intermittent cycles of oral cyclosporine (4 mg/kg/day), ultraviolet B narrowband therapy (three times weekly), oral prednisone (1 mg/kg/day), and subcutaneous efalizumab (0.7 mg/kg initially followed by 1 mg/kg). In December 2009, the patient began treatment with ustekinumab administered in a single dose of 45 mg. Two weeks later, the patient reported a substantial clinical improvement in her condition, especially in the pruritus. This improvement was rated on a 10-point visual analog scale (VAS). The VAS value before treatment was 9. One month later, the lesions had cleared and only hyperpigmented residual lesions presented on physical examination. The VAS value of pruritus was 0. A second 45-mg dose was administered at that point, according to the recommended dosage in psoriasis (at weeks 0 and 4, followed by every 12 weeks). The patient has currently completed month 12 of treatment. Her condition remains improved and pruritus is absent (Fig. 2). Patients with AD often require systemic immunomodulatory and immunosuppressive agents (cyclosporine, azathioprine, methotrexate, and mycofenolate mofetil), but the use of these agents is limited by their potential toxicity and inadequate patient responses. Ustekinumab is a fully human immunoglobulin G1 (IgG1) monoclonal antibody that binds with high specificity to the p40

Sustained clinical effectiveness and favorable safety profile of topical sirolimus for tuberous sclerosis – associated facial angiofibroma

Background  Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disorder characterized by the development of multisystem hamartomatous tumours. Facial angiofibroma appears in up to 80% of patients and has a considerable psychological impact. Various invasive procedures have been used, although they show limited effectiveness and potential adverse effects.

Bullous scleroderma‐like changes in chronic graft‐versus‐host disease

Cutaneous graft‐versus‐host disease (GVHD) is the most common clinical setting for GVHD after bone marrow transplantation. Chronic cutaneous GVHD is categorized according to the type of skin lesions into lichenoid and sclerodermoid variants, but bullous scleroderma‐like changes are exceptional. Recently, we studied a patient with these alterations. This is the second case described in the literature.

Febrile perianal streptococcal dermatitis.

We describe a child with an unusual presentation of perianal streptococcal dermatitis which included fever, acral scarletiniform desquamation, and extension of erythema to involve the genitalia and proximal thighs, as well as the commonly seen well‐defined erythema of the perianal area. We suggest that isolated group A β‐hemolytic streptococci (GAS) in our patient produced a pyrogenic exotoxin similar to that which appears in scarlet fever.

Reticulohistiocitosis cutánea difusa

The reticulohistiocytoses make up a heterogeneous group of diseases whose origin lies in an accumulation of cells of histiocytic lineage in different tissues and primarily in the skin. Three main clinical forms have been described (multicentric, solitary, diffuse cutaneous), which present with identical histological, ultrastructural and immunohistochemical characteristics. We present a case of diffuse cutaneous reticulohistiocytosis, which is the least common clinical pattern in the spectrum of this disease.

Psoriasis, vasculitis and methotrexate

Report on the association of the psoriasis and vasculitis are a very infrequent in the literature. Such an association as been described in extensive psoriasis and arthropathy psoriasis. In this paper we described two cases in which psoriasis, vasculitis and nephropathy are present together. In both cases the association might be produced by methotrexate. In both cases methotrexate is possible uleashing.

Hidradenitis ecrina neutrofílica secundaria a tioguanina en paciente neutropénico

Neutrophilic eccrine hidradenitis (NEH) is an infrequent, self-limited inflammatory dermatosis characterized by a neutrophilic infiltrate around the eccrine glands. Clinically, it presents with different types of lesions. NEH occurs most frequently in patients who have undergone chemotherapy for hematologic neoplasms. We present a case of NEH in a 70-year-old neutropenic male who received thioguanine for acute myeloid leukemia. The erythematous plaques disappeared in 3-4 weeks. The histological findings were compatible with NEH. Skin cultures ruled out infectious causes.

Factors influencing seasonal patterns of relapse in anti-TNF psoriatic responders after temporary drug discontinuation.

Editor The intraand inter-variability observed with regard to the extent, duration and severity of psoriasis is the result of the interaction of genetic and environmental factors. In clinical practice, once efficacy has been achieved with anti-Tumor Necrosis Factor (TNF) drugs, temporary suspension of such treatment is followed by a disease-free period. To date, the factors that condition the differences in the duration of remission obtained in clinical setting are not well understood. One of the environmental factors that might modulate the clinical expression of psoriasis is seasonal changes. Seasonal variations in solar radiation, degree of humidity or temperature may have a biological effect on the skin and immune system. The aim of the study was to analyse retrospectively in a single-centre cohort of moderate-to-severe plaque psoriasis patients (both sexes, aged 18–75) without associated arthritis and responders to etanercept (n = 174) or adalimumab (n = 36) as the first biologic, the possible importance of the time of year when anti-TNF drugs was withdrawn on timeto-relapse over the 2005–2010 period. The dose, dosing interval and duration of the treatment pattern for each drug until its temporary discontinuation were recorded. Patients were considered responders if a reduction of at least 75% in Psoriasis Area and Severity Index (PASI) was achieved at week 12 for etanercept and week 16 for adalimumab with respect to baseline. Duration of treatment effect was defined as the period of time between the time PASI 75 was reached and relapse. Relapse was defined as loss of at least 50% in PASI improvement from baseline in patients who achieved a clinical response at week 12 or 16 of treatment. Time-to-relapse was defined as the period of time between anti-TNF drug discontinuation and relapse. To explore potential circannual patterns of relapse, we used the Circos software (Canada’s Michael Smith Genome Sciences Centre, URL: http://circos.ca) to visualize 1-year window data for every single patient in the entire cohort in a circular layout (Fig. 1). Markov Chain Montecarlo Methods for generalized linear mixed model were used to obtain a probabilistic model of relapse, and for each relapse, season with year of withdrawal and dermatologist who attended the patient considered random effects, and age, gender, evolution of psoriasis, duration of anti-TNF effect and antiTNF drug as fixed effects. Figure 2 represents the best probabilistic model of relapse (DIC = 4.109) obtained, which includes the season of the year in which the relapse occurred (P = 0.016), patient gender (P = 0.017) and the days elapsed since treatment discontinuation (P = 0.026). In the resulting model, while the risk of relapse was the highest in autumn and the lowest in summer, the probability of relapse occurring early was greater in summer. In winter and spring, the risk increases progressively during the period elapsed since treatment discontinuation, with differences in terms of gender. Few studies to date have analysed the degree of influence of seasonal periods on the activity or response to treatment of psoriasis, mainly with contradictory results. We consider that this influence, if indeed it exists, might not be of sufficient magnitude to avoid the potent effect of anti-TNF drugs on the disease’s natural history. Our results suggest that it could be important to choose the most appropriate time of year to temporarily suspend treatment with anti-TNF drugs. Nevertheless, we believe that by performing a retrospective cross-sectional analysis, it is difficult to analyse the possible influence of seasonal changes on disease activity, as there are many factors that are not taken into account in this approach. However, we consider that this is a new interesting issue in psoriasis research and future multicenter prospective studies on the subject are required.