Carmela Coviello

Infliximab in recalcitrant severe atopic eczema associated with contact allergy.

Infliximab is an anti-tumour necrosis factor (TNF)-alpha chimeric monoclonal antibody which is effective in diseases associated with a T-helper (Th) 1 response, such as rheumatoid arthritis, Crohns disease and psoriasis. There are sporadic case reports of atopic dermatitis (AD) induced or precipitated by anti-TNF-alpha therapy, which have been attributed to the switch towards Th2-mediated reactions. We report the case of a 30-year-old man with long-standing severe AD associated with contact allergy and poorly responding to conventional treatments. The use of infliximab resulted in a dramatic amelioration of AD lesions and pruritus, persisting at follow-up examinations over a 3-year period. Probably, the unexpected response to infliximab therapy in this case might be due to some peculiar features of AD in our patient (i.e. chronic-continuous course and concomitant contact allergy) which could have been responsible for a more preponderant recruitment of Th1 cells as compared to common forms of AD.

Cyclosporine in the treatment of generalized granuloma annulare.

A 56-year-old man had numerous small papules, some in an annular pattern, on the trunk, upper and lower extremities , and neck that had appeared gradually during the last 6 months. Histologic examination showed a palisading granuloma of the papillary dermis with a predominantly lymphohistiocytic infiltrate; there was no fragmentation of elastic fibersor elastophagocytosis. Direct immunofluorescence testing results were negative. GGA was diagnosed. Blood glucose, cholesterol, uric acid, immunoglobulin, and complement levelswere normal. Treatment with diaminodiphenylsulfone (DDS), 100 mg/day, was started. After 12 weeks the eruption was unchanged and treatment was stopped. With the informed consent of the patient , treatment with cyclosporine, 6 mgjkgjday, was started. Cyclosporine trough levels and serum creatinine levels were monitored twice monthly throughout treatment. After 2 weeks the papules began to flatten, and the erythema was reduced. The lesions had virtually disappeared after 30 days. The dose of cyclosporine was decreased to 3 mg/kg /day, and therapy was continued for another 90 days, at the end of which time complete clearing was obtained (Figs. I and 2). During the following year no recurrence was noted.

Treatment of Psoriasis Vulgaris with the Two-Compound Product Calcipotriol/Betamethasone Dipropionate followed by Different Formulations of Calcipotriol

AbstractBackground: A calcipotriol (calcipotriene)/betamethasone dipropionate two-compound product has been shown to be efficacious for the treatment of psoriasis vulgaris. It is usually administered once daily for up to 4 weeks followed by treatment with corticosteroid-free conventional products (e.g. calcipotriol). The aim of this study was to evaluate the efficacy and tolerability of a 4-week treatment with the two-compound product in psoriasis vulgaris and the effects of sequential 8-week maintenance treatment with different calcipotriol formulations. Methods: After an initial 4-week phase with the once-daily calcipotriol/betamethasone dipropionate two-compound product, adult patients with stable psoriasis vulgaris entered an 8-week maintenance phase and were allocated to one of the following treatments: calcipotriol ointment twice daily, calcipotriol cream twice daily, or calcipotriol cream once daily in the morning and calcipotriol ointment once daily in the evening. Clinical assessment was performed at baseline, after 4 weeks and after 12 weeks, and employed evaluation of the severity of pruritus using a scale from zero to four and the Psoriasis Area and Severity Index (PASI). Results: After 4 weeks’ treatment with the calcipotriol/betamethasone dipropionate two-compound product, a significant improvement in the severity of psoriasis was observed in all groups, with a mean reduction in the PASI of 71.3% (p < 0.001 vs baseline). A significant improvement in pruritus was also obtained after 4 weeks. These results were maintained after 8 weeks of treatment with calcipotriol, regardless of the formulation used. Treatment was very well tolerated and accepted by patients. On a scale ranging from poor to excellent, more patients treated with calcipotriol cream (49%) rated the acceptability of the treatment as excellent when compared with patients treated with the calcipotriol ointment (33%) or both calcipotriol formulations (36%). Conclusion: This study shows that the calcipotriol/betamethasone dipropionate two-compound product causes a rapid and marked improvement in both psoriasis lesions and pruritus. Our preliminary results suggest that the three calcipotriol-based regimens are equally effective in maintaining the therapeutic results obtained with the calcipotriol/betamethasone dipropionate two-compound product and that the use of calcipotriol cream was the best accepted maintenance treatment.

Oral retinoids in the treatment of pityriasis lichenoides

The aetiopathogenesis of pityriasis lichenoides (PL) is still far from clearly understood. However, the involvement of delayed-type immune dysfunctions has recently been hypothesized. On the basis of this premise, and in view of the recognized immunomodulating effects of synthetic derivatives of vitamin A, an open trial was carried out of the efficacy and tolerability of oral etretinate in four men, aged 21 to 49 years, with PL. With a daily dosage of 1 mg/kg, full resolution was achieved in 6-18 weeks. The overall tolerability was good, with mild to moderate mucocutaneous side-effects. The relapse-free period had currently reached 8-12 months. Oral etretinate seems to be a promising therapeutic tool in the management of PL, for which to date no definitive treatment exists.

Topical 5-fluorouracil in the treatment of discoid lupus erythematosus. Preliminary study over two years

To our knowledge, no trial has so far been performed of 5-fluorouracil (5-FU) in the treatment of discoid lupus erythematosus. This open label study was carried out in 12 patients (5 males and 7 females, aged 20 to 47 years) to assess the short-and long-term efficacy and tolerability of a daily application of an ointment containing 5% 5-FU. The study was started in October 1993 when the disease was at a high degree of activity following summer sunlight exposure. After a 4-to 24-week treatment period, full remission was achieved in all patients. Healing resulted in cosmetically acceptable dyschromic and/or atrophic changes. During the summers 1994 and 1995, exacerbation of preexisting lesions and appearance of new lesions were observed in eight and two patients, respectively. However, remission of these lesions was obtained with a short course of therapy. The overall tolerability of the treatment was good or excellent in all patients. On the basis of the results of this preliminary study, topical 5-FU seem...