Jesús Luelmo

Circulating levels of lipocalin-2 and retinol-binding protein-4 are increased in psoriatic patients and correlated with baseline PASI

Psoriasis has been related to metabolic syndrome (MS). Adipocytokines produced by white adipose tissue may be involved in the pathogenesis of psoriasis and its association with MS. Our objectives were to characterize the profile of a number of different inflammatory and atherogenic markers, vitamins, adipokines and cytokines and their potential involvement in MS in patients with moderate-to-severe psoriasis without joint involvement compared to anthropometrically matched controls, and to evaluate correlation with severity of the skin disease and changes after narrow-band UVB (NB-UVB) phototherapy. We designed a prospective cross-sectional study. Baseline waist circumference, body fat composition, lipid, carbohydrate and calcium metabolism profile, inflammation markers, homocysteine and vitamins D, B6, B12 and folic acid, leptin, resistin, omentin, lipocalin-2, adipocyte fatty acid-binding protein, retinol-binding protein-4 (RBP-4), interleukin-6, soluble tumour necrosis factor receptor 1 (sTNFR1) and interleukin-17 of 50 psoriasis patients and 50 gender, age and body mass index-matched controls were recorded, then evaluated after NB-UVB in the patients. The patients had higher baseline serum concentrations of leptin, RBP-4, lipocalin-2 and sTNFR1. Baseline psoriasis area and severity index correlated with serum concentrations of RBP-4 and lipocalin-2 only. Principal components analysis disclosed a component including vitamins B12, B6, folic acid, calcidiol and HDL-cholesterol that was only present in healthy controls and opposed to a cluster of variables which promote MS. This component was absent in the patients. Our results point to lipocalin-2 and RBP-4 as relevant mediators of the trend towards MS in psoriatic patients.

Effect of narrowband ultraviolet B therapy on inflammatory markers and body fat composition in moderate to severe psoriasis

Background  Previous studies have shown increased prevalence of metabolic syndrome in patients with psoriasis.

Multicentric Reticulohistiocytosis-Mimicking Dermatomyositis

Multicentric reticulohistiocytosis is a rare disorder of unknown etiology, characterized by skin and mucosal papulonodular eruptions and destructive polyarthritis. Histopathological study of these lesions shows a nodular infiltrate composed of histiocytes and multinucleated giant cells, with an eosinophilic, granular, ‘ground-glass’ cytoplasm. We report a case of multicentric reticulohistiocytosis with skin lesions mimicking dermatomyositis and we also review previously reported cases describing such a clinical situation. Our case further emphasizes that multicentric reticulohistiocytosis can mimic clinical features of dermatomyositis. A macular or patch-like erythema in a photodistributed fashion, in addition to other clinical manifestations, can be mistaken for dermatomyositis. However, skin biopsies from these areas may early differentiate both conditions with different treatment options and morbidity.

Lipopolysaccharide-binding protein is increased in patients with psoriasis with metabolic syndrome, and correlates with C-reactive protein.

Lipopolysaccharide‐binding protein (LBP) is a reliable indicator of serum lipopolysaccharide (LPS) concentration. Raised levels of circulating LPS can trigger an increase in chronic pro‐inflammatory cytokines, which may mediate the development of insulin resistance and obesity. Psoriasis is a chronic inflammatory skin disease that has been associated with metabolic syndrome. We aimed to study the expression of LBP in patients with psoriasis treated with narrowband ultraviolet B phototherapy, and controls matched by age, gender and body mass index (BMI). We did not find any differences in serum LBP concentration between patients and controls, and serum LBP did not correlate with the Psoriasis Area and Severity Index. However, patients with psoriasis and metabolic syndrome had higher serum concentration of LBP than controls. Furthermore, correlation with BMI and apolipoprotein B was present in controls, but not in patients with psoriasis. Serum LBP level did not change significantly after treatment with phototherapy.

Wells' syndrome related to tetanus vaccine

A 69‐year‐old woman was admitted to the Surgery Department of our hospital in November 1993 because of persistent erythematous skin lesions suspected clinically to be infectious cellulitis‐ Two months before admission she had noticed a red itchy pruriginous plaque, neasuring 10 × 5 cm, on her left buttock that had become larger in spite of treatment with oral antimicrobials. One month before entry, two more lesions flared up on her right buttock and left groin that soon became infiltrated. She did not notice any systemic symptoms. Past history of urticaria, atopy, tinea infection, or insect bites was not recalled. Two months before the first skin lesion erupted, the second dose of a tetanus vaccine had been given to the patient.

Experiencia de 4 años de funcionamiento de una unidad multidisciplinar de psoriasis y artritis psoriásica

INTRODUCTION AND OBJECTIVES Up to 30% of patients with psoriasis develop joint disease, the course of which can be improved by early diagnosis and treatment. The aim of this study was to describe our experience with a new multidisciplinary psoriasis and psoriatic arthritis unit over a period of 4 years (2009-2012). MATERIAL AND METHODS Implementation of a PSOriasis Rheumatology and Dermatology unit (PSORD) to provide patient care and physician training. In the first phase of the project, referral criteria for the unit were defined and several meetings were organized to train and prepare the specialists involved in the program. In the second phase, a schedule was drawn up for monthly patient visits with the PSORD team. Starting in 2011, training was offered to dermatologists and rheumatologists from other hospitals interested in implementing a similar model. RESULTS A total of 259 visits (71% first visits, 8% no-shows) were scheduled during the period analyzed, with a median of 8 visits (range, 2-14 visits) per session. Sixty-three percent of the patients were referred from the rheumatology department. Diagnosis and treatment were modified in 32% and 47% of cases, respectively. Three training courses were held with 15 physicians from 6 hospitals, 3 of which created similar units. CONCLUSIONS The PSORD model improved the management of difficult-to-diagnose and/or uncontrolled disease, the early diagnosis and treatment of psoriatic arthritis, and collaboration between dermatologists and rheumatologists. Finally, the model lends itself to being exported to other settings.

Etanercept e infecciones

Resumen Los tratamientos biologicos para la psoriasis, principalmente los inhibidores del factor de necrosis tumoral alfa (TNF-α), han demostrado su eficacia y seguridad desde los ensayos clinicos hasta su posterior comercializacion. Sin embargo, los estudios de farmacovigilancia han detectado un ligero incremento de las infecciones. El manejo del riesgo infeccioso en los pacientes con psoriasis en tratamiento con etanercept u otros medicamentos anti-TNF pasa por valorar la idoneidad de su uso en aquellos pacientes con infecciones por los virus de la hepatitis C, B y de la inmunodeficiencia humana, con infecciones activas localizadas o generalizadas, con riesgo de sepsis (portadores de cateteres endovenosos y sondas urinarias permanentes) o con trastornos subyacentes que pudieran predisponer a sufrir infecciones (diabetes, hemodialisis). En caso de que un paciente en tratamiento con etanercept presente una infeccion, si esta es grave debe suspenderse el tratamiento y si es leve debera seguirse estrechamente al paciente, y la interrupcion del tratamiento se decidira en funcion de su evolucion. La larga experiencia de uso de etanercept en diferentes enfermedades permite afirmar que tiene un buen perfil de seguridad en lo que se refiere a las infecciones, si se toman las precauciones referentes a la tuberculosis y a la concomitancia de otras infecciones activas durante el tratamiento.

Cutaneous Desmoid Tumor: Resolution of the Surgical Defect with a Dermal Regeneration Template and an Epidermal Autograft

Desmoid tumors (DTs) belong to the group of fibromatoses. They are slow-growing tumors that can be subdivided into fascial superficial fibromatoses and extra-abdominal fibromatoses. The most widely accepted classification of fibromatosis is that introduced by Enzinger and Weiss (Table 1). The first group comprises Dupuytren’s contracture (palmar fibromatosis), Ledderhose disease (plantar fibromatosis), Peyronie’s disease (penile fibromatosis), holoderma (knuckle pads), and deep muscle– aponeurotic fibromatosis. DT, also known as aggressive fibromatosis, has been described in abdominal and extra-abdominal locations. It can arise on the abdominal wall after pregnancy or after surgical manipulation. A form has been associated with Gardner’s syndrome and familial adenomatous polyposis. Its biological behavior is locally aggressive, with progressive growth and a high rate of recurrence after surgery. Local or distant metastases are exceptional. Primary cutaneous DT is exceedingly rare and has seldom been reported in the medical literature. Its clinical and histologic appearance can be similar to dermatofibrosarcoma protuberans and fibrosarcoma, and differential diagnosis from these tumors is mandatory to establish correct treatment and prognosis.

Identification and management of comorbidity in psoriatic arthritis: evidence- and expert-based recommendations from a multidisciplinary panel from Spain

The objective is to establish recommendations, based on evidence and expert opinion, for the identification and management of comorbidities in patients with psoriatic arthritis (PsA). The following techniques were applied: discussion group, systematic review, and Delphi survey for agreement. A panel of professionals from four specialties defined the users, the sections of the document, possible recommendations, and what systematic reviews should be performed. A second discussion was held with the results of the systematic reviews. Recommendations were formulated in the second meeting and voted online from 1 (total disagreement) to 10 (total agreement). Agreement was considered if at least 70% voted ≥7. The level of evidence and grade of recommendation were assigned using the Oxford Centre for Evidence-Based Medicine guidance. The full document was critically appraised by the experts, and the project was supervised at all times by a methodologist. In a final step, the document was reviewed and commented by a patient and a health management specialist. Fourteen recommendations were produced, together with a checklist to facilitate the implementation. The items with the largest support from evidence were those related to cardiovascular disease and risk factors. The panel recommends paying special attention to obesity, smoking, and alcohol consumption, as they are all modifiable factors with an impact on treatment response or complications of PsA. Psychological and organizational aspects were also deemed important. We herein suggest practical recommendations for the management of comorbidities in PsA based on evidence and expert opinion.

Modelos de atención multidisciplinar en pacientes con artritis psoriásica en España

OBJETIVE To describe (structure, processes) of the multidisciplinary care models in psoriatic arthritis (PsA) in Spain, as well as barriers and facilitators of their implementation. METHODS A qualitative study was performed following structured interviews with 24 professionals (12 rheumatologists, 12 dermatologists who provide multidisciplinary care for patients with PsA). We collected data related to the hospital, department, population and multidisciplinary care model (type, physical and human resources, professional requirements, objectives, referral criteria, agendas, protocols, responsibilities, decision- making, research and education, clinical sessions, development and planning of the model, advantages and disadvantages of the model, barriers and facilitators in the implementation of the model. The models characteristics are described. RESULTS We analyzed 12 multidisciplinary care models in PsA, with at least 1-2 years of experience, and 3 subtypes of models, face-to-face, parallel, and preferential circuit. All are adapted to the hospital and professionals characteristics. A proper implementation planning is essential. The involvement and empathy between professionals and an access and well-defined referral criteria are important facilitators in the implementation of a model. The management of agendas and data collection to measure the multidisciplinary care models health outcomes are the main barriers. CONCLUSIONS There are different multidisciplinary care models in PsA that can improve patient outcomes, system efficiency and collaboration between specialists.