Carlo Carrera

Epiluminescence microscopy in cutaneous larva migrans.

Sir, Elsner et al. (1) diagnosed cutaneous larva migrans (CLM) in a patient by means of epiluminescence microscopy (EM). We have evaluated the usefulness of this method in a group of Caucasian patients with clinically suspected CLM who had returned from trips to tropical and sub-tropical countries. We examined 18 patients (10 men and 8 women, aged 20 ± 68 years) in whom the diagnosis of CLM was based on history and clinical picture. EM (610 magni®cation) was carried out in all lesions of the patients. Skin biopsies were not performed. In 14 patients, at least 1 foot was involved. Other localizations were breast, abdomen, thighs, lumbar region, buttocks and calf. CLM was characterized by multiple tracks in 9 patients; in total, we counted approximately 60 tracks in 18 patients. One larva was observed in 1 lesion of 1 patient (5.5%). In total, EM was positive in 1 out of 60 tracks (1.6%). In the last few years, EM has been demonstrated to be a simple, non-invasive, rapid and effective method to con®rm the clinical diagnosis of parasitic diseases of the skin, in particular scabies (2). However, on the basis of our results, EM appears not to be useful to con®rm the clinical diagnosis of CLM. At least 4 hypotheses may be advanced to explain these observations: (a) larvae were already dead when EM was performed; (b) living larvae were localized in deeper layers of the skin, beyond the resolution power of EM; (c) 610 magni®cation is not suf®cient to detect the larvae (this is the most likely hypothesis); and (d) we are unable to use EM properly! We believe that careful clinical history and dermatological examination remain today the most important ®ndings to make a diagnosis of CLM.

A mysterious abdominal pain during active psoriasis

and subsequently treated, and viral gastroenteritis. In each reactivation, hepatitis viruses A, B, C, EBV and HIV were excluded because of blood cultures and negative serology. Urine cultures were negative too. She displayed some comorbidities, namely, anxious-depressive syndrome, bulimia, and arterial hypertension. She was also vaccinated with Calmette Guérin bacillus. The current treatment for psoriasis was acitretin 30 mg daily; however, she failed several therapies, namely, methotrexate for lack of efficacy, cyclosporin for renal toxicity, adalimumab for recurrent fever, and ustekinumab for toxiallergic exantema. The actual presentation was dominated by several erythematous and hyperkeratotic plaques with a severe infiltration, mainly located to the trunk, scalp and in the palmo-plantar area. In the context of these plaques, numerous sterile and confluent pustular elements enriched the medical findings (Fig. 1). Psoriasis Area Severity Index (PASI) was 60 and body surface area (BSA) was 93%, delineating a very severe disease. Vital signs, namely, blood pressure 146/94 mmHg, heart rate of 96 beats/min, and 99% oxygen saturation in room air, were collected and depicted a stable patient. Physical examination revealed distended, not swelled, symmetric abdomen, with generalized pain and tenderness to palpation. There was no palpable liver or spleen. Murphy, Blumberg and Rovsig signs were all negatives. Charcot’s triad was not present. Auscultation revealed sparse obtunded bowel sounds, no tinkles, and no umbilical bruits. Percussion produced tympanic sounds.

PACE study: real-life Psoriasis Area and Severity Index (PASI) 100 response with biological agents in moderate-severe psoriasis

Abstract Background: Few studies have compared the use of different biologics in a real-life setting in plaque psoriasis patients. Objective: To compare the efficacy of biologics in psoriasis/psoriatic arthritis patients. Methods: Patients treated with adalimumab, etanercept and ustekinumab for at least 16 weeks were included. Achievement of Psoriasis Area Severity Index (PASI), PASI 90/100 response and time taken to achieve PASI 90/100 response were measured. Logistic regression was used to evaluate the effect of psoriasis localization on achievement of PASI 100 response. Results: Two hundred and fifty five patients were included. No difference was observed in PASI 90 response between etanercept and ustekinumab (65.5 vs. 55.4%), while adalimumab-treated patients had a higher response versusustekinumab (71.6 vs. 55.4%, p = .02). More patients achieved complete remission (PASI 100 response) with adalimumab versus etanercept (65.7 vs. 23%, p < .001) or ustekinumab (65.7 vs. 44.6%, p = .003). Adalimumab-treated patients achieving PASI 90 responded more quickly (by three and six months) versus ustekinumab or etanercept. PASI100 response was achieved in ∼43% of adalimumab and ustekinumab treated-patients by three months versus etanercept (14.3%), increasing to 92.5, 85.4 and 35.7%, respectively by six months. PASI100 response was associated with psoriasis nail involvement or genital psoriasis. Conclusion: In the real-life setting, adalimumab was the most effective biological agent for the treatment of plaque psoriasis.

The EPIPSOFIRE project: A Preliminary Report

Postmarketing Phase IV

AB0806 Skeletal Dimorphisms are Independently Related to Musculo-Skeletal Discomfort in a Cohort of Psoriatic Subjects

Background Musculo-skeletal discomfort stands as the main clinical clue whenever psoriatic subjects are sent for rheumatological referral. Although skeletal dimorphisms (such as scoliosis, varus deformity of the knees, flat feet and so on) may play a role in the occurrence of painful symptoms, such issue is still poorly investigated. Objectives Our aim was to investigate the influence of skeletal dimorphisms on musculo-skeletal discomfort in a series of patients with mild psoriasis subjects, in comparison to other factors. Methods Among the psoriatic patients routinely followed-up in a dermatological clinic dedicated to psoriasis care, a cohort of 307 consecutively enrolled subjects was established for an epidemiological study. Patients on biological treatment and those unable to give informed consent were not eligible. All candidates underwent a thorough rheumatological evaluation. Details about history of pain and skeletal dimorphisms were collected as well. Imaging and laboratory investigations were performed as needed. Diagnosis was established through expert opinion. Results The 307 studied patients had mean age of 53.8 years (SD 16.3); 188 (61.2%) were males. Median psoriasis duration was 11 years (IQR 4.5-20), median PASI score was 3.1 (IQR 1.6-6.5). Systemic therapies were prescribed to 91 (29.6%) subjects. Pain on examination was observed in 105 patients (34.2%). In this series, female gender, obesity and the presence of skeletal dimorphisms were all significantly related to pain on examination, while current smoking and age at the time of enrolment were not. In particular, the comparison between the several age classes composing this series (bounded by decades) did not highlight any statistically significant differences. At univariate analysis, gender seemed to be more frequently related to the presence of musculo-skeletal pain, even among obese psoriatic subjects (P<0.05). A significantly higher proportion of skeletal dimorphisms was found in females as well (P<0.05). The multivariable analysis, performed through unconditional logistic regression showed that skeletal dimorphisms remained an independent factor related to pain on examination as well as gender and obesity. Conclusions In this study, skeletal dimorphisms were unexpectedly found to be related to musculo-skeletal discomfort, independently from obesity and gender. The influence of that kind of disorders on psoriatic disease needs to be further investigated, in order to establish its significance on the natural history of this condition. Disclosure of Interest None declared

SAT0393 Distinguishing Spinal Diseases from Spondylitis among Psoriatic Subjects: the Performance of ASAS Inflammatory Back Pain Definition in A Mono-Centric CASE Series

Background Inflammatory back pain (IBP) is a symptom related to axial spondyloarthritis. Applying the ASAS IBP definition in a large validation cohort yielded sensitivity and specificity of 79.6% and 72.4%, respectively. Objectives Since ASAS IBP definition was never tested in psoriatic subjects, we report here the performance of those criteria in such peculiar setting. Methods All the subjects followed up at our dermatological clinic were consecutively referred to rheumatologist whether: a) spontaneously reporting musculo-skeletal complaints; b) the dermatologists noticed limping or articular/digital swelling. Dermatological features (PASI score, age of onset, previous/current therapies) were recorded. All referred subjects underwent a thorough rheumatological evaluation encompassing joint counts (tender, swollen, damaged), entheses counts and others as suggested in the international consensus. Patients also underwent radiographic evaluation of painful areas, laboratory test were performed if needed. PsA diagnosis was established through expert opinion. Subjects with incomplete data were excluded from this report. Results Subjects referred were 277, data were available for 257 (92.8%). At enrolment females were 135 (52.5%), the mean age was 56.2 years (SD 12.8), median psoriasis duration was 10.5 years (IQR 4-19). Plaque psoriasis was prevalent (78.9%), the median PASI score was 3.2 (IQR 1.2-6), 34 subjects (13.4%) scoring ≥10. TNF-inhibitors, methotrexate, cyclosporine A or systemic steroids were given to 73 subjects (28.4%). Spinal pain was reported by 77 subjects (30%), IBP by 25 subjects (9.7%). Psoriatic arthritis (PsA) cases were 109 (42%), of whom 64 were diagnosed as consequence of enrolment. Psoriatic spondylitis was detected in 17 cases (15.6% of PsA), 100 subjects (41.7% of the sample) had spinal diseases other than spondylitis. The performance of ASAS IBP definition in our sample was as follows: sensitivity 70.6%, specificity 94.6%; positive predictive value 48%, negative predictive value 97.8%; positive likelihood ratio 13.03, negative likelihood ratio 0.31. When psoriatic spondylitidies were compared to other spinal diseases, positive and negative likelihood ratios were 6.4 and 0.95, respectively (the other parameters changed slightly). Conclusions ASAS IBP definition showed a good performance when applied to psoriatic subjects. Although tested in a small series, the performance was more specific than the original validation. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1325

Tomesa balneophototherapy in mild to severe psoriasis: a retrospective clinical trial in 174 patients

Psoriasis is a chronic inflammatory skin disease with a high social and psychological impact on the quality of life of patients. Tomesa balneophototherapy is based on bathing in a magnesium‐rich salt solution combined with exposure to narrowband ultraviolet B phototherapy. We conducted a retrospective clinical trial on 174 patients affected by mild to severe psoriasis undergoing Tomesa balneophototherapy. The basal course consisted of three to five sessions per week for a total of 30 sessions. Subsequently, patients could continue with a maintenance course of one session per week for a total of 30 sessions. We recorded a significant reduction of the mean Psoriasis Area and Severity Index (PASI) index with an achievement of at least PASI 75 in 52.1% of the 119 patients who completed the basal course and an improvement of the ‘quality of life’ of patients. The good efficacy obtained by this treatment, and the psychological impact on the quality of life of patients, demonstrated that Tomesa balneophototherapy could be a good option for the treatment of a chronic disease associated with psychological distress, like psoriasis.