Evelin Jasmine Paternò

Bilateral Thoracoscopic T2 to T3 Sympathectomy Versus Botulinum Injection in Palmar Hyperhidrosis

BACKGROUND Bilateral T2 to T3 thoracoscopic sympathectomy and injection of botulinum toxin-A are presently the most effective modalities in the treatment of primary palmar hyperhidrosis. In this study we evaluated comparative merits of the two therapies. METHODS Patients suffering primary palmar hyperhidrosis were treated by either bilateral T2 to T3 thoracoscopic sympathectomy (n = 68) or by injection of botulinum toxin-A (n = 86). The groups were homogeneous for relevant demographic, physiologic, and clinical data. Quantification of sweat production was performed by Minors iodine starch and glove tests. Subjective changes were assessed by quality of life questionnaires (Hyperhidrosis, Dermatology Life Quality Index, Short Form-36, Nottinghams Health Profile) and patients satisfaction self-assessment. A cost comparison between groups was also carried out. RESULTS No operative mortality or major morbidity was recorded in either group. Minors test showed a more significant reduction in the surgical group: +94% versus +63% at 6 months and +94% versus +30% at 12 months. Compensatory sweating was significantly greater and long-lasting in the surgical group. All subjective tests improved rapidly and significantly in both groups. After 6 months, results mildly worsened in the surgical group and more significantly in the botulinum group. Patients satisfaction was initially greater in the botulinum group (p = 0.03), but after 6 months it significantly reversed (p = 0.04). Surgical treatment cost approximately as much as four botulinum treatments. CONCLUSIONS Thoracoscopic sympathectomy is superior to botulinum toxin-A injection. The greater initial costs and discomfort are offset by a greater reduction in compensatory sweating.

Localized morphea treated with imiquimod 5% and dermoscopic assessment of effectiveness

The cases are reported of two women patients presenting asymptomatic solitary lesions: one in the anterior tibial region of the right leg, the other on the right arm. The first patients lesion was 3 cm in diameter and had appeared 2 years earlier as a translucent oval atrophic patch with a definite border. The second patient presented a whitish area with a lilac ring, 2.5 cm in diameter, which had appeared nearly a year earlier. Both patients had no other similar cutaneous lesions, and their family histories for cutaneous disease were negative. The lesions underwent punch biopsy, and the histopathological findings confirmed the diagnosis of morphea. Laboratory investigations showed no abnormalities. Imiquimod 5% cream was prescribed for 5 consecutive days a week for 16 weeks. Clinical and dermoscopic assessment of the lesions was performed before treatment, during follow-up and at treatment end point. No local or systemic side effects were observed during treatment. Following treatment, both patients achieved complete clinical remission of the lesions, with a definitive improvement in the lesions’ initial disfiguring features.

Topical treatment of actinic keratoses with piroxicam 1% gel: a preliminary open-label study utilizing a new clinical score.

AbstractBackground: The cyclo-oxygenase enzymes 1 and 2 (COX-1 and COX-2) are both involved in skin tumorigenesis, causing inhibition of apoptosis, angiogenesis, invasiveness, recruitment of growth factors, immunosuppression, and production of carcinogens. Piroxicam is a nonselective nonsteroidal anti-inflammatory drug that blocks the activity of COX-1 and COX-2. Objective: To evaluate the efficacy and tolerability of piroxicam 1% gel in the treatment of actinic keratoses. Methods: Piroxicam 1% gel was applied twice daily for 12 weeks to 31 actinic keratoses. The lesions were evaluated clinically and by means of dermoscopy at an initial baseline visit, at intermediate visits, and after 90 days. Changes were evaluated using a new scoring system (AKESA), based on the clinical presence of erythema, scale, and atrophy on a target lesion. Results: In our experience, the use of piroxicam 1% gel for 90 days induced complete regression in 48% of evaluated actinic keratoses, corresponding to keratotic and verrucous clinical variants. In these lesions, the AKESA score was markedly reduced after treatment. Adverse effects were pruritus, mild erythema, dry skin, and, rarely, rash. Conclusions: Our preliminary trial shows that piroxicam exerts anti-tumorigenic effects and may play a useful role in the chemoprevention of skin cancers.

Effect of calcipotriol on etanercept partial responder psoriasis vulgaris and psoriatic arthritis patients.

Patients who respond only partially to etanercept may require additional treatments that act synergistically to improve their therapeutic response while at the same time reducing the dose required and the risk of side-effects. The aim of this study was to evaluate the effecti veness of topical calcipotriol in etanercept partial responder patients. We enrolled 120 patients affected by psoriasis vulgaris and psoriatic arthritis. A 50 mg dose of etanercept was administered twice weekly for the first 12 weeks, followed by a 25 mg dose twice weekly for an additional 12 weeks. At week 12, for 45 patients who had not achieved PASI 50, calcipotriol cream was also prescribed twice daily for 4 weeks and then once daily for a further 8 weeks. At week 24, of the 45 patients in the group treated with etanercept plus calcipotriol, 14 (31.1%) had achieved PASI 75, and 23 PASI 50, while 8 (17.7%) had dropped out of therapy; of the 75 patients who continued etanercept in monotherapy with a 25 mg dose twice weekly for another 12 weeks, 71 (94.6%) had achieved PASI 50 and 57 (76.0%) PASI 75. The application of calcipotriol in etanercept partial responder patients had therefore helped 37 out of 120 patients (31%) achieve at least PASI 50. This is the first report about the controlled combination of topical calcipotriol and etanercept in a large group of psoriatic patients. The efficacy and cost-effectiveness of the combined treatment is evidenced by the good response shown at week 24 by a group of etanercept low-responder patients using drugs sparingly and limiting likely toxicity.

The relevance of piroxicam for the prevention and treatment of nonmelanoma skin cancer and its precursors

Piroxicam (PXM), a nonsteroidal anti-inflammatory drug, is an enolic benzothiazine and a potent member of the oxicam series. The drug suppresses the synthesis of proinflammatory enzymes, such as cyclo-oxygenases-1 and -2 (COX-1 and 2), downregulates the production of prostaglandins (PGs) and tromboxanes, and inhibits polyamines production by blocking ornithine decarboxylase induction involved in nonmelanoma skin carcinogenesis. In addition, PXM is able to induce tumor cell apoptosis and suppresses metalloproteinase 2 activities. Skin carcinogenesis is a multistep process in which the accumulation of genetic events leads to a gradually dysplastic cellular expression, deregulation of cell growth, and carcinomatous progression. COX-1 upregulation plays a significant role in PG and vascular epidermal growth factor production supporting tumor growth. Increased level of PGs in premalignant and/or malignant cutaneous tumors is also favored by upregulation of COX-2 and downregulation of the tumor suppressor gene 15-hydroxy-prostaglandin dehydrogenase. Chemoprevention can be a hopeful approach to inhibit carcinoma occurrence before an invasive tumor develops. The chemopreventive effect of nonsteroidal anti-inflammatory drugs on nonmelanoma skin cancers has been established. In this study, we highlighted the different modalities of action of PXM on the pathogenesis of nonmelanoma skin cancer, analyzing and evaluating binding modes and energies between COX-1 or COX-2 and PXM by protein–ligand molecular docking. Our clinical experience about the local use of PXM on actinic keratoses and field cancerization is also reported, confirming its efficacy as target therapy.

Dermoscopy as an adjuvant tool for detecting skin leiomyomas in patient with uterine fibroids and cerebral cavernomas

BackgroundHereditary syndromes frequently need the cooperation of different specialties to increase diagnostic competence. Multiple cutaneous and uterine leiomyomatosis syndrome is a rare autosomal dominant disorder caused by the mutations of the fumarate hydratase gene, demonstrated in 80 to 100 percent of affected individuals. This can be linked to an increased risk of renal cancer in both sexes. The skin involvement is described to highlight the diagnostic role of the cutaneous counterpart in identifying this rare syndrome.Case presentationA 37-year-old woman suffering from several uterine fibroids presented multiple, painful, papulo-nodules on her left subscapular side, both forearms and legs. The patient underwent surgery on six lesions: five were leiomyomas, whilst one was a dermatofibroma. Genetic sequencing did not evidence known fumarate hydratase gene mutations. Dermoscopy showed a brown delicate pigmented network and included leiomyomas among the non-melanocytic benign skin tumours featuring a dermatofibroma-like pattern. Abdominal computerized-tomography scan did not reveal renal cancer, but brain magnetic resonance imaging showed one asymptomatic cerebral cavernoma. The patient benefited from the surgical removal of the five larger cutaneous lesions and from gabapentin, which relieved her pain.ConclusionsThis observation highlights the usefulness of dermoscopy in the diagnosis of cutaneous leiomyomas disclosing multiple cutaneous and uterine leiomyomatosis syndrome. Dermoscopy should be performed for non-melanocytic multiple lesions mimicking leiomyomas in a large number of patients, to establish a strict classification and identify false negative cases or evaluate them as dermatofibromas. In this case, the dermatologist recognized the risk of renal cancer and cerebral cavernomas.

Peculiar clinical and dermoscopic remission pattern following imiquimod therapy of basal cell carcinoma in seborrhoeic areas of the face

Imiquimod is a 240.3-Da synthetic imidazoquinolinamine (C14H16N4), developed in 1983 and approved in 1997 by the US Food and Drug Administration for the topical treatment of external genital and perianal warts and, more recently, also for actinic keratosis and superficial basal cell carcinomas. We report five cases of patients affected by basal cell carcinomas localized in seborrhoeic areas of the face, successfully treated with topical imiquimod and characterized by the occurrence of eruptive epidermoid cysts at the end-point of therapy. The dermatoscopic evaluation disclosed the presence in all lesions of a common feature characterized by a hyperkeratotic yellow-withish area, resembling ‘popcorn’, excluding dermoscopic basal cell carcinoma features. Furthermore, histological proof confirmed the diagnosis of epidermoid cysts. As reported in the literature and as observed in our clinical experience, the occurrence of epidermoid cysts, after the topical treatment of basal cell carcinomas with imiquimod, may represent a local immune reaction that is drug-related and is a typical remission pattern in particular anatomical areas. We also emphasized the usefulness of dermoscopy in supporting the clinical diagnosis of epidermoid cysts, excluding the presence of tumoural residue or recurrence. In the future, it will be possible to follow-up the lesions after treatment avoiding the post-control biopsy punch.

Tazarotene as alternative topical treatment for onychomycosis

Background Distal and lateral onychomycoses are the most frequent forms of onychomycosis, causing subungual hyperkeratosis that usually limits local penetration of antimycotic drugs. Tazarotene exerts anti-inflammatory and immune-modulating activities toward both infective agents and damaged keratinocytes. Given the well-documented efficacy of tazarotene on hyperkeratotic nail psoriasis, we investigated its therapeutic use in onychomycosis. Patients and methods We designed a preliminary open clinical trial in patients affected by distal and lateral subungual onychomycosis of the toenails and verified the fungistatic activity of tazarotene in vitro. Fifteen patients were treated with topical tazarotene 0.1% gel once per day for 12 weeks. Mycological cultures and potassium hydroxide stains of nail samples were performed at the beginning and at the end of the study. Treatment was considered effective when clinical healing and negative mycological culture were obtained. Onycholysis, nail bed discoloration, and subungual hyperkeratosis were measured using standardized methodologies and analyzed by means of Mann–Whitney test and analysis of variance. Fungistatic activity of tazarotene was evaluated by disk diffusion assay. Results Six patients (40%) reached a mycological cure on target nail samples already after 4 weeks of treatment. Complete clinical healing and negative cultures were reached in all patients at week 12, with a significant improvement of all clinical parameters of the infected nails. Disk diffusion assay after 48 hours of incubation with tazarotene solution showed a central area of inhibition in all examined fungal cultures. Conclusion Our results documented a good clinical outcome using topical tazarotene 0.1% gel in distal and lateral subungual onychomycosis and its fungistatic activity of tazarotene in vitro. The majority of patients appeared cured at a 6-month follow-up. The efficacy and safety of tazarotene must be confirmed on a larger number of patients, although already documented in nail psoriasis patients often affected by onychomycosis.

Combination of Low-dosage Cyclosporine and Topical Pimecrolimus in Severe Atopic Dermatitis with Chronic Hepatitis B

Sir, Atopic dermatitis (AD) is associated with genetic and environmental factors, defects in the cutaneous barrier, bacterial and viral skin infections and immunological changes (1). AD influences the quality of life of both the patient and his or her family (2). Topical steroids are the gold standard treatment for AD, but their use is limited by potential adverse effects, including impairment of the function Langerhans’ cells, cutaneous atrophy, telangiectasias and acne. Nonsteroidal immunomodulant drugs, such as calcineurin inhibitors, tacrolimus and pimecrolimus, do not have these side-effects. Pimecrolimus is indicated in both the shortand long-term treatment of AD (3) and can be applied to areas such as the face and neck. Cyclosporin A (CsA) is another calcineurin inhibitor that blocks the activation of T lymphocytes with transcriptional block of the interleukin (IL)-2, IL-4, tumour necrosis factor (TNF)-α and interferon (IFN)-γ cytokine genes. CsA is used in adults and in children with severe AD refractory to topical treatments (4). AD may be associated with hepatitis; in fact, atopic patients have presented an inadequate Th-1 response and impaired function of natural killer (NK) cells, promoting chronic liver infections such as hepatitis B (5). Treatment with CsA has a therapeutic effect both on hepatitis B and hepatitis C as it inhibits viral replication (6). We report here a patient with severe AD and chronic hepatitis B who was treated successfully with combined treatment of low-dose of CsA (100 mg/daily) and local pimecrolimus.

Treatment of disfiguring chronic graft versus host disease in a child with topical pimecrolimus

Chronic cutaneous graft-versus-host disease (GVHD) is a severe clinical and pathological manifestation that occurs in patients after allogenic peripheral blood stem cell or bone marrow transplantation. Acute and chronic forms of cutaneous GVHD show various manifestations including exanthema, erythrodermia and toxic epidermal necrolysis as acute reactions, and lichenoid or sclerodermatous changes as chronic reactions. The beginning of the treatment of chronic GVHD is systemic immunosuppression and the efficacy of extracorporeal photopheresis, UVA1 phototherapy, and narrowband UVB phototherapy is currently under investigation for treatment of GVHD. Nevertheless, cutaneous chronic GVHD may also respond to topical therapy such as corticosteroids, azathioprine, tacrolimus and pimecrolimus. Pimecrolimus (SDZ ASM 981) is part of the new class of novel ascomycin immunomodulating macrolactams, and was developed for the treatment of inflammatory skin disease. We report a case of a generalized cutaneous GVHD in a 9-year-old Iranian boy that occurred after bone-marrow transplantation for b-thalassemia major. The patient showed a significant improvement with topical pimecrolimus 1% cream twice daily for 9 weeks.