Gino A. Vena

Psychological distress and coping strategies in patients with psoriasis: the PSYCHAE Study.

Objective  Our objectives were to determine the prevalence of psychological distress in a large sample of Italian patients with psoriasis; to establish whether disease severity and psychological distress are associated; to identify the strategies employed to cope with psoriasis; to evaluate the coping strategies employed by dermatologists; and to identify potential predictors of psychological distress.

3-Dimethylaminopropylamine: a key substance in contact allergy to cocamidopropylbetaine?

In the past year, 1200 consecutive eczematous patients were tested with cocamidopropylbetaine 1% aq. Contact allergy was evinced in 46 subjects (3.8%), while irritant reactions (slight erythema only) were observed in 15 cases (1.25%). 30 out of 46 patients with allergic reactions were subsequently tested with the substances used in the synthesis of cocamidopropylbetaine, together with a sample of cocamidopropylbetaine declared by the supplier to possess a greater purity. In all 30 subjects, positive reactions were obtained to 3‐dimethylaminopropylamine (DMPA) 1% aq., while the cocamidopropylbetaine denned of purer grade, at 0.5% and 1% aq., gave positive reactions in 10% and 53% of cases, respectively. These results suggest that the DMPA present at various levels as an impurity in the commercial product is responsible for cocamidopropylbetaine allergy. Owing to the inconsistency of positive reactions to cocamidopropylbetaine of variable purity, and to the consistency of positive reactions to DMPA, it seems likely that these reactions may also be connected with the presence in the product, defined of purer grade, of unknown amounts of DMPA as impurity. Structural similarities between the 2 molecules cannot be considered in this case, because the DMPA structure is radically changed in its transformation to the betaine structure, Further experiments with other molecules related to the above structures are in hand.

Sulfite contact allergy

In the last 2 years, 2,894 consecutive eczematous patients were patch tested with sodium metabisulfite 1% pet. Positive reactions were elicited in 50 subjects (1.7%). All 50 patients were also positive to potassium metabisulfite 1% pet. and sodium bisulfite 1% and 5% pet., while only 2 of them were positive to sodium sulfite 1% pet. Prick tests and intradermal tests with a sodium metabisulfite solution (10 mg/ml) were negative. No flare‐ups of dermatitis or patch test were provoked by oral challenge with 30 mg and 50 mg of sodium metabisulfite. The dermatitis was taken to be occupational in 7 cases. In only 5 out of 43 non‐occupational cases was the positive reaction considered relevant.

Psoriasis and cardiovascular disease.

Current epidemiological data support the association between psoriasis and cardiovascular (CV) risk, in apparent correlation with psoriasis severity. Although less unanimously, evidence of an increased prevalence of CV diseases among psoriasis patients has been reported, including ischemic heart disease, cerebrovascular, peripheral vascular and heart structural disorders. In particular, various studies showed a correlation between psoriasis and major CV events (i.e., myocardial infarction, stroke), while others investigated subclinical changes of blood vessels, such as intima‐media thickness increase, arterial stiffness and coronary artery calcification. A series of different mechanisms, like traditional CV risk or iatrogenic risk factors, inflammation, hemostasis dysregulation, hyperhomocysteinemia, and shared genetic susceptibility, are thought to underlie this epidemiological association. Among these elements, inflammation and its related cytokine milieu, including Th1‐mediated response and Th17/Treg imbalance, C reactive protein and the newly implicated osteopontin are considered to play a primary role, even if yet to be fully understood.

Low-dose dapsone in chronic idiopathic urticaria: preliminary results of an open study.

Sir, Chronic idiopathic urticaria (CIU) is defined as the occurrence of wheals on most days for more than 6 weeks in the absence of any known causative or triggering agents (1). Most cases of chronic urticaria are classified as ‘idiopathic’, despite intense efforts to determine any aetiological factor, and require long-term treatment with H1-receptor antagonists, which are the first-line approach to uncomplicated forms (2). Here we present our cumulative experience with dapsone in some cases of severe refractory CIU.

Occupational sensitization to epoxy resin and reactive diluents in marble workers

10 out of 22 marble workers handling a bicomponent resin, based on epoxy resin and ortho‐cresyl glycidyl ether (CGE), developed Contact dermatitis and airborne contact dermatitis within 20 days to 2 months of exposure. All 22 subjects were patch tested with epoxy resin, bisphenol A, epichlorohydrin and a series of reactive diluents. The 10 symptomatic subjects were all positive to the reactive diluent CGE, and 4 of them also to epoxy resin. The other reactive diluents that gave positive reactions were phenyl glycidyl ether (7 cases), cyclohexanedimethanol glycidyl ether (2 cases), 1,6‐hexanediol diglycidyl ether (2 cases) and allyl glycidyl ether (1 case). The findings of our Study suggest that allergic potential is directly proportional to the electronic charge available, for all electron‐rich molecules (solvents, high and low polymers, reagents) that interact with the glycidyl ether group. Lesser, but still noticeable, effects are detected when activation of the glycidyl group is related to the possible formation of intramolecular hydrogen bonds. In practice, the occupational problem was partly solved by changing the type of glycidyl ether.

Incidence of psoriasis and association with comorbidities in Italy: a 5-year observational study from a national primary care database.

An observational study was conducted to estimate the incidence of psoriasis in Italy, as well as the utilization of healthcare resources and the association with selected comorbidities in psoriasis patients. The data source was the Health Search/Thales Database, containing computer-based patient records from over 900 primary care physicians (PCPs) throughout Italy. The study cohort comprised all adults receiving a first-ever diagnosis of psoriasis during the years 2001-2005. From a total sample of 511,532 individuals, the incidence of psoriasis was 2.30-3.21 cases per 1,000 person-years. Psoriatic arthritis was present in 8% of psoriasis patients. The comparison with matched controls showed that psoriasis patients were more likely to have comorbidities (e.g., chronic bronchitis, chronic ischemic heart disease, obesity and diabetes mellitus) and to undergo PCP visits and hospitalizations, and to refer for specialist visits. The use of non-steroidal anti-inflammatory drugs appeared to be significantly more prevalent in patients as compared to controls. Topical therapy with corticosteroids and non-steroidal preparations accounted for 45.3% and 47.2% of all cases, respectively. Only a minority of cases used systemic immunosuppressive drugs or acitretin. The incidence rate of psoriasis in our study was particularly high and might reflect an overestimation by PCPs. Our results show the association between psoriasis and multiple comorbidities.

Risk factors of hypertension, diabetes and obesity in Italian psoriasis patients: a survey on socio-demographic characteristics, smoking habits and alcohol consumption

We evaluated risk factors such as socio-demographic characteristics, smoking habits and alcohol consumption, associated with hypertension, diabetes and obesity in psoriasis patients, in order to plan health education programs that could prevent the onset or progression of co-morbidities. The study population consisted of 1376 patients with psoriasis who were consecutively recruited at 21 Italian Departments of Dermatology. Information concerning socio-demographic variables, smoking and alcohol consumption, and the presence of chronic disorders such as hypertension, type 2 diabetes and obesity was collected. The risk of co-morbidities according to the various exposure variables was calculated using logistic regression models. Psoriasis patients living in extremely urban areas showed the highest risk of diabetes (OR = 1.99, 95% CI 1.06-5.23) and obesity (OR = 2.60, 95% CI 1.10-16.12), as compared to patients living in rural areas. The OR for hypertension was higher for smokers (> 15 cigarettes per day, OR = 1.37, 95% CI 1.01-2.03) and drinkers (> 2 glasses/day of wine, OR = 2.11, 95% CI 1.31-3.40). The OR for diabetes or obesity was higher for drinkers: 1 drink/day (OR = 1.93, 95% CI 1.01-3.67) and > 1 drink/day of spirits (OR = 2.90, 95% CI 1.43-5.82), respectively. The results of our survey highlight the need to detect psoriasis patients with different susceptibilities to co-morbidities in order to plan specific health campaigns aimed at changing peoples lifestyles with respect to smoking, drinking and diet.

Remission of delayed pressure urticaria after eradication of Blastocystis hominis.

Sir, Blastocystis hominis is one of the most common human intestinal protozoans in the world, especially in developing countries. Nevertheless, current knowledge about this parasite is incomplete and, despite recent progresses, several issues are still controversial and much debated, such as the clinical relevance and pathogenicity (1–4). B. hominis has been found in patients with gastrointestinal symptoms as well in asymptomatic individuals. It has long been considered a harmless commensal but growing evidence seems to support its role as a pathogenic parasite. In the absence of conclusive data, it could be hypothesized that the pathogenic potential and virulence of Blastocystis are conditioned by other concomitant factors, such as the host response, and depend on the number of organisms or the type of strains, considering that a remarkable antigenic and genetic heterogeneity among isolates has been demonstrated (4). Extra-intestinal manifestations of B. hominis infection have rarely been reported and include infectious or reactive arthritis (5–7) and skin disorders (8–11), such as palmoplantar or diffuse pruritus and chronic urticaria. A 32-year old woman with a history of allergic rhinitis had since October 1998 suffered from chronic recurrent urticaria which was almost controlled by treatment with H1-receptor antagonists. Whealing subsided after 4 years, when cutaneous manifestations were replaced by painful swellings in pressure sites. For this reason, she was examined in November 2002, where a delayed pressure urticaria (DPU) was diagnosed. Treatment with systemic corticosteroids gave only partial benefit. Subsequently, dapsone was introduced at a dose of 25 mg/day. Symptoms gradually ameliorated over a 3-month period without disappearing. After dapsone discontinuation, her symptoms became severe and disabling within 1 month, despite regular treatment with H1-receptor antagonists. Skin lesions on the feet were sometimes associated with marked pain, which was so intense that it induced the patient to wear larger shoes than usual. Whealing of common urticaria or angioedema never occurred. The only concomitant symptoms reported by the patient were mild ponderal loss and persistent asthenia. Pressure challenge tests confirmed the diagnosis of DPU. Laboratory investigations failed to disclose any systemic diseases, including malabsorption, endocrinological, autoimmune and rheumatological disorders. Full blood count, including eosinophil count, erythrocyte sedimentation rate, C-reactive protein, cryoglobulins, circulating immune complexes, C3, C4, C1-INH, IgE and other immunoglobulins were all within the normal range. Chest radiography, radiographic examination and laser Doppler flowmetry of the limbs revealed unremarkable findings, as well as serological investigations, oropharyngeal swabs and faecal antigen test with Helicobacter pylori. Stool examinations on three consecutive samples were positive for B. hominis. The patient was then treated with metronidazole 1.5 g/ day for 10 days. DPU began to improve 2 weeks after

Safety of anti-TNFα agents in the treatment of psoriasis and psoriatic arthritis

Context: The efficacy and favorable safety profile of anti-tumor necrosis factor (TNF) agents in the treatment of psoriasis and psoriatic arthritis (PsA) are supported by several randomized controlled studies and meta-analyses. However, some concerns on the long-term safety of these drugs still exist, as these studies generally included small patient numbers and were performed in selected patient populations. Objective: This review presents and discusses current evidence on the safety of anti-TNFα agents in patients with psoriasis and PsA, with a focus on European registry studies and case reports of particular importance. Methods: Key studies on the safety of anti-TNFα agents in the treatment of adult patients with psoriasis or PsA were identified by a MEDLINE search (last updated 10 November 2011) based on several interrelated queries, with a focus on European registries. Other studies and case reports were included if deemed relevant. Studies concerning other conditions, such as rheumatoid arthritis (RA), were included as appropriate when data in psoriatic disease were unavailable or insufficient. Results: Available data on the safety of anti-TNFα agents such as etanercept in psoriasis and PsA appear reassuring, even if some concerns still exist. Most notably, data suggest a higher incidence of infection and lymphoma amongst patients treated with the anti-TNFα monoclonal antibodies infliximab and adalimumab compared with etanercept. Conclusion: The overall safety profile of monoclonal antibodies in patients with psoriasis, PsA and RA seems less favorable than that of etanercept, particularly in terms of risk of infection and hepatotoxicity.