Giulia Toni

Oral clindamycin and rifampicin in the treatment of hidradenitis suppurativa‐acne inversa: a prospective study on 23 patients

Editor Hidradenitis Suppurativa-Acne Inversa (HS-AI) is a relapsing and chronic inflammatory skin disease affecting the big folds. HS-AI is currently thought of as being an inflammatory and not an infectious disease, but sometimes various bacteria combined in polymicrobial infections can be present. Coagulasenegative staphylococcus and anaerobic bacteria are the most frequently isolated. The bacteria are suspected of playing a role in the disease process, probably through immune-mediated mechanisms of inflammation. Therapy of HS-AI is often difficult. Medical, surgical and physical therapeutical options are available. Although antibiotics are widely used to treat HS-AI limited data on their efficacy are available. To assess the efficacy and the tolerability of a 10-week combination of oral clindamycin (600 mg daily) and rifampicin (600 mg daily) in the treatment of HS-AI, 23 patients affected by severe and actively inflammatory HS-AI were enrolled in a prospective non comparative study. The ethical committee considered as not needed its official consensus to precede. No restrictions about previous treatments were established. The parameters used to evaluate the efficacy of the treatment were as follows: (i) severity of the disease, assessed with the Sartorius score before (T0) and after (T1) treatment and (ii) the number of exacerbations during the treatment period compared with those occurring in the previous three months. The authors considered as exacerbation the acute development of at least one wide inflammatory lesion. Finally, patients were asked about side-effects during treatment. Statistical analysis was performed using parametric test (t-test). Significance was accepted at P < 0.05. The main clinical-demographic data, collected in a standardized form, are summarized in Table 1. Three patients did not complete the treatment: one for personal reasons, one because of gastro-intestinal side-effects not related to Clostridium difficile colitis, and one, affected by amyotrophic lateral sclerosis, complained of a worsening of the neurological disease, probably not related to antibiotic assumption. The 20 patients who completed the 10-week therapy showed a mean Sartorius score of 132.05 (range 28.00–298.05) at T0 and 71.50 (range 19.50–183.00) at T1 corresponding to a mean reduction of 45.85% (range 5.41–81.95%). The authors considered as responders the 17 patients who achieved a Sartorius score improvement higher than 25%, corresponding to the 85% of the patients who completed the treatment. The mean number of exacerbations was 6.00 (range 1.00–20.00) at T0 and 2.40 (range 0–10.00) at T1 corresponding to a mean reduction of 60% (range 0–100%). Both Sartorius score and the number of exacerbations showed a significant reduction after treatment: P = 0.00098 for Sartorius score and P = 0.0091 for the number of exacerbations, respectively. Three out of 23 patients (13.04%) complained of side-effects, mostly nausea and vomiting: one patient stopped the therapy before the scheduled end, whereas the two remaining completed the 10-week treatment. The efficacy and tolerability of this combination treatment in HS-AI has previously been assessed in three retrospective studies. The present one is the first prospective study and the results are in agreement with those reported in literature (Table 2). The reason why this antibiotic combination is effective is not fully understood yet. This study has some limitations. The patients were not randomized vs. placebo or other treatments. This decision was made for ethical reasons and because, in the authors’ experience, this treatment is the best option in severe HS-AI in terms of efficacy, tolerability, quick onset of action and cost. No data about long-term follow-up and recurrences are given because a maintenance treatment with oral zinc was prescribed, according to the desire of the patients to do as much as possible to maintain the results they had obtained.

First randomized trial on clobetasol propionate and mometasone furoate in the treatment of vulvar lichen sclerosus: results of efficacy and tolerability

A 3‐month topical application of clobetasol propionate (CP) represents the recommended and accepted first‐line treatment for vulvar lichen sclerosus (VLS); however, to date, no randomized controlled trials have compared the efficacy and safety of CP with other topical corticosteroids.

Prospective Clinical and Epidemiologic Study of Vulvar Lichen Sclerosus: Analysis of Prevalence and Severity of Clinical Features, together with Historical and Demographic Associations

Background: Few reports have addressed the associations between clinical, demographic and historical variables of vulvar lichen sclerosus (VLS). Objective: To elaborate the prevalence and severity of signs and symptoms and to identify potential factors predicting the severity and course of VLS. Methods: A prospective cohort of 225 patients affected by VLS was included. Data were collected by direct interview and clinical examination. Results: 98% of patients complained of symptoms, principally itching. Pallor and scarring-sclerosis-atrophy were the most frequent and severe signs. The severity of VLS signs was not associated with age at onset and duration of the disease. About 70% of the patients had previously undergone treatment. Conclusions: VLS-related symptoms were not associated with the clinical features which resulted less severe. Personal history of autoimmune diseases and familial history of VLS did not influence the age at onset and the severity of VLS. A considerable part of patients had previously received inappropriate treatment.

Onychomadesis following hand, foot, and mouth disease: a case report from Italy and review of the literature.

Hand, foot, and mouth disease (HFMD) is a relatively common and highly contagious enteroviral infection that occurs in small epidemics, usually in autumn or spring. The illness primarily affects young children and is clinically characterized by vesicular and erosive stomatitis in combination with vesicular eruption of the palms and soles, and, sometimes, a maculopapular rash. Outbreaks of HFMD have been caused mainly by coxsackie virus (CV) A16 and enterovirus 71, but CV strains A5, A7, A9, A10, B1, B2, B3 and B5 have also been associated with the illness. We report two cases of HFMD-related onychomadesis in Italy and review the published data concerning this emergent condition.

Clobetasol propionate vs. mometasone furoate in 1-year proactive maintenance therapy of vulvar lichen sclerosus: results from a comparative trial.

Twice‐weekly proactive application of mometasone furoate 0.1% ointment (MMF) over 52 weeks was found to be an effective and safe therapy option in maintaining vulvar lichen sclerosus (VLS) remission and in preventing relapse.

Maintenance Therapy for Acne Vulgaris: Efficacy of a 12-Month Treatment with Adapalene-Benzoyl Peroxide after Oral Isotretinoin and a Review of the Literature

Background: The correct therapeutic management of acne should include a maintenance therapy with topical retinoids to prevent recurrences after discontinuing a successful treatment. Objective: To investigate the efficacy of a 12-month maintenance treatment with adapalene 0.1% and benzoyl peroxide (BPO) 2.5% fixed combination gel to control acne relapse after treatment with oral isotretinoin (OI). Methods: The study consisted of 2 phases, namely an active treatment phase (AP) and a maintenance phase (MP). In the AP, 70 consecutive patients with moderate to severe acne were treated with OI until acne remission. Then, patients entered the MP and were treated with adapalene-BPO fixed combination once daily for 12 months. The primary efficacy parameter was the relapse rate during MP. Results: Sixty-eight patients completed the study. Relapse occurred in 2 patients (2.94%). Conclusions: Comparing our findings with published data, the association of a topical retinoid and BPO seems to provide favorable evidence for this combination as maintenance therapy.

Continuous vs. tapering application of the potent topical corticosteroid mometasone furoate in the treatment of vulvar lichen sclerosus: Results of a randomized trial

Topical corticosteroids are the first‐line treatment for vulvar lichen sclerosus (VLS). However, evidence on the most appropriate treatment regimen is lacking.

Dermoscopy in plasma cell balanitis: its usefulness in diagnosis and follow‐up

intake as well as personal or family history of ichthyosis. Abdominal and pelvis ultrasound, chest X-ray and routine laboratory examinations, including glycaemia and thyroid, hepatic, renal and lipid profiles, showed no alteration. Moreover, the levels of serum angiotensin-converting enzyme, vitamin D, calcium and tumour markers were normal, and anti-nuclear antibodies and serological test for human immunodeficiency virus were negative. A skin biopsy from a scaling area was performed, which confirmed the clinical diagnosis of AI by revealing hyperorthokeratosis, hypogranulosis and a reduced rete-papilla pattern (Fig. 2). Since the ichthyosic manifestations were poor responsive to emollient and topical keratolytic (urea 30% and salicylic acid 10% ointments) therapies, we decided to stop acitretin and any topical treatments for AI and to control the psoriatic plaques only with topical steroids. Two months later we noted a significant regression of AI (Fig. 1c,d). After further 3 months the patient presented another time to our clinic for a worsening of her psoriasis and acitretin therapy was reintroduced. Following 4 weeks the ichthyosic manifestations occurred again on the lower limbs. Thus, we decided to suspend acitretin and to begin cyclosporine to control her psoriatic manifestations; after 4 weeks AI regressed and there was no recurrence after 3 months of follow-up. Although the pathophysiologic mechanism responsible for AI is far from clear, some Authors have suggested that it may be due to impaired skin lipogenesis with consequent disruption of the function of some enzymes which are involved in the process of cornification. This hypothesis could explain the onset of a such condition after the start of acitretin therapy in our case since it is well known that this drug is able to decrease skin lipogenesis. However, it is important to underline that druginduced AI is a very rare condition and, therefore, it is possible that drugs, including acitretin, may act as triggering factors in patients with a clinically silent defect of some enzymes involved in the process of cornification and/or suffering from subclinical acquired disorders (tumours, dysmetabolisms, etc.) that may favour the onset of AI. Further studies are required to elucidate the actual mechanisms underlie AI.

Avocado and soybean extracts as active principles in the treatment of mild-to-moderate vulvar lichen sclerosus: results of efficacy and tolerability.

Limited evidence is available on the effectiveness of treatments alternative to corticosteroids for vulvar lichen sclerosus (VLS). The present study aimed to assess the efficacy and tolerability of avocado and soybean extracts (ASE) as active principles of both a topical product and a nutritional supplement in the treatment of active mild‐to‐moderate VLS.

[What's new in acne? New therapeutic approaches].

Summary Well-known topical and systemic treatments for acne have advanced little over the last 10 years. However, many therapeutic approaches are being evaluated both in terms of topical and systemic treatments. The purpose of this paper is to show the progress of innovative drug projects in treating acne. The topical use of new formulations using lipid nanoparticles and microspheres could help for new products based on anti-androgens or retinoids more concentrated and better tolerated. New active agents such as topical antimicrobial peptides, inhibitors of ectopeptidase, omiganan pentahydrochloryde, antisense oligonucleotides, lauric acid are many original ways to explore for the treatment of acne. New treatment regimens for doxycycline and isotretinoin would increase tolerance. Dapsone has been evaluated for isotretinoin-resistant forms. Phototherapy narrowband light (blue or red) can find its place in the strategy for the management of acne. Finally, acne vaccines could be developped too