L. Leal

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 granulomatous panniculitis and sarcoidal granulomatous papular eruption in a patient with metastatic melanoma treated with a BRAF inhibitor

Dear Editor, Metastatic malignant melanoma is associated with poor outcomes. The fact that up to 80% of cases of primary melanoma harbor mutations in the BRAF gene has led to the development and recent approval of novel BRAF inhibitor drugs that, in comparison with dacarbazine, significantly improve progression-free survival. Because of limited experience with these drugs, a number of unusual side-effects have not yet been described. A 41-year-old Caucasian woman was included in a clinical trial of dabrafenib therapy (150 mg twice daily) because she had a stage IV melanoma, harboring a BRAF mutation, that failed to respond to radiotherapy and ipilimumab (CTLA-4 inhibitor). Eight months after inclusion, she presented with high fever, arthralgia, joint swelling and tender, painful, erythematous subcutaneous nodules located mainly in the upper and lower limbs (Fig. 1a). A punch biopsy revealed a lobular pattern of panniculitis with a predominantly lymphohistiocytic infiltrate forming non-necrotizing granulomas, a scarcity of neutrophils and no evidence of vasculitis (Fig. 1b). The lesions resolved completely in response to a tapered regime of corticosteroids. Five months later, the patient presented with multiple 1–1.5mm non-painful erythematous and violaceous papules and nodules, scattered bilaterally and symmetrically over the antecubital skinfolds and dorsal aspect of the hands (Fig. 1c). The patient had no systemic symptoms. Anatomopathological findings for a second punch biopsy revealed a full-thickness dermal infiltrate of numerous epithelioid histiocytes and giant multinucleated cells forming non-necrotizing granulomas. A surrounding crown of lymphocytes was present in all the granulomas, prominent in approximately half and less noticeable otherwise (Fig. 1d). No Melan-A-positive cells were found in relation to the inflammatory infiltrate in either of the biopsies, indicating an absence of cancer cells. The rash responded well to treatment with a topical steroid ointment. The main causes of non-necrotizing granulomas, namely, sarcoidosis and infections, were excluded and both the 8and 13-month reactions were attributed to treatment with dabrafenib. After 18 months, pulmonary progression of malignant melanoma was detected and dabrafenib therapy was suspended. The remaining granulomatous papules resolved completely within 2 weeks of dabrafenib suspension. Although the pathogenic mechanisms of granuloma formation have not yet been unraveled, our case reflects a previously unreported association between two infrequent granulomatous toxicities in the same patient, mild in nature and requiring no treatment discontinuation. Isolated noncaseating granulomas as reported by us were found in one of two cases of panniculitis described by Zimmer et al. for patients receiving BRAF inhibitor therapy. As for the diagnosis of granulomatous dermatitis, only two cases have been described to date, referring to three patients treated with BRAF inhibitors. In these cases, the rash consisted of multiple asymptomatic erythematous non-scaly and violaceous papules scattered bilaterally over the upper and lower (a)

Dermatomyofibroma on the nape of the neck: a report of 2 pediatric cases.

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Sinus piloso plantar. Utilidad de la dermatoscopia

Dermoscopy has been incorporated as a useful dermatologic diagnostic tool in recent years. Its original indication----the differential diagnosis of pigmented lesions----has been broadened to include other noncancerous skin diseases, such as diseases of the hair, psoriasis, scabies, and connective tissue diseases. We report a case in which dermoscopy was used to rule out a pigmented plantar lesion. A 67-year-old woman was referred to our department for the diagnosis of a presumed pigmented lesion on the sole of her right foot. The primary care physician suspected melanoma. The patient did not relate it to any injury and explained that the lesion had appeared over the previous month. She denied any preexisting pigmented lesion at this site. On inspection, there was a macule of uneven pale brown color, with a diameter of 3 mm. The type of lesion was not readily diagnosed with the naked eye (Fig. 1). We examined the lesion with a digital dermatoscope (MoleMax III, Derma Medical Systems, Vienna, Austria) (Fig. 2). A coiled hair shaft was observed below a normal stratum corneum, simulating an accumulation of pigment. This finding led to a diagnosis of pilonidal sinus. Scraping of the stratum corneum with a #11 scalpel blade allowed the hair to be removed. We explained the harmless, benign nature of the plantar lesion to the patient. When asked about her habits, she denied working as a hair stylist. Hence, it was assumed that the hair had become embedded in the stratum corneum accidentally. Pilonidal sinus or ‘‘barber’s sinus’’ is a well-known occupational skin disease that tends to affect hairdressers or barbers. These professionals can experience penetration of hairs under their skin. An inflammatory response and a foreign body granuloma often develop. The most common site for this disorder is the interdigital spaces of the hands, although cases on the soles of the feet have also been described. No inflammatory response was observed in our patient. Hence, the condition resembled coiling hairs that grow below the stratum corneum on the legs of some women after waxing or shaving. Confusion of pilonidal sinus with other processes is not uncommon, and there has even been a report of a case of a coiled hair below the stratum corneum of the pubic skin simulating a larva migrans. Dermoscopy was useful in this case and prevented unnecessary surgical removal of the lesion.