Lara Tripo

Psoriasis and body mass index

Recently, it has emerged a strong association between increased adiposity, obesity, and psoriasis. Body Mass Index (BMI) is a simple index of weight‐for‐height that is commonly used to classify underweight, overweight and obesity in adults. Psoriasis has also been associated with systemic obesity‐related disorders including type 2 diabetes, hypertension, ischemic heart disease, and combined hyperlipidemia, as a part of metabolic syndrome. Not only the obesity may be associated with higher psoriasis incidence and activity, and prevalence of obesity‐related syndromes, but it may also influence the therapeutic approach to disease and the clinical response to systemic treatment. Consequently, the approach of the experienced dermatologist will take into account all the aspects of the patient clinical conditions including the analysis of BMI for the choice of the best suitable therapy.

Deficiency of serum concentration of 25-hydroxyvitamin D correlates with severity of disease in chronic plaque psoriasis

To the Editor: We read with interest the article by Orgaz-Molina et al regarding the vitamin D status in patients with chronic plaque psoriasis. The authors report a high prevalence (25.6%) of vitamin D deficiency [25(OH)D levels\20 ng mL ] in a cohort of 43 psoriatic patients, independently of age, sex and Psoriasis Area and Severity Index (PASI) score. Low 25(OH)D levels were negatively associated with markers of inflammatory activation (C-reactive protein) and body mass index (BMI). We conducted a case-control study over 4months ( fromSeptember to December) including 68 patients affected by chronic plaque psoriasis and 60 healthy controls. 25(OH)D serum levels were measured in a centralized laboratory using the LIAISON 25OH Vitamin D TOTAL Assay. Logistic regression analysis of the relationship of 25(OH)D levels to demographic data (age, sex and body mass index), alcohol consumption and smoking habit data, exposure time to sunlight, dairy intake, disease duration and severity was performed. Psoriatic patients had significantly lower serum levels of 25(OH)D than healthy controls (P \ .05) with 68% and 97% being vitamin D deficient (\20 ng/mL) and insufficient (\30 ng/mL), respectively (Fig 1). In the logistic regression analysis, vitamin D deficiency was associated with psoriasis independently of age, sex, BMI, alcohol consumption, and smoking habit. Interestingly, serum 25(OH)D had significant negative correlations with PASI score (P\ .001), which signifies a possible link between the extent of vitamin D deficiency and the degree of the severity of psoriasis (Fig 2). Recently, vitamin D deficiency has been implicated as a potential environmental factor triggering some immune-mediated disorders. Our study confirms that vitamin D deficiency may be common in patients with psoriasis and adds some important information concerning a possible link between this deficit and the severity of disease. We conclude that psoriatic patients could be screened for vitamin D insufficiency for a more comprehensive management. Future studies looking at a potential role of oral supplementation of vitamin D in the treatment of psoriasis are warranted.

Treatment of severe nail psoriasis with acitretin: an impressive therapeutic result

Nail psoriasis is common in adult psoriatic patients. Although several new drugs have recently been introduced for the treatment of skin psoriasis, treatment of nail psoriasis still remains a challenge. Topical treatments (e.g., corticosteroids, tazarotene, 5‐fluorouracil, calcipotriol) are the first line in the management of skin psoriasis. The efficacy of these drugs in nail disease, however, is limited, mainly due to the difficulty in penetrating the nail bed and nail matrix. In cases of nail disease resistant to topical treatment, methotrexate, ciclosporin, acitretin, or biological agents can be used. The present authors introduce a 73‐year‐old patient affected by impressive psoriatic nail disease involving all her fingernails and toenails treated by acitretin, a traditional systemic treatment. After 2 months of treatment there was a marked improvement. The clinical improvement of the nails was progressive and 6 months later it was stable and satisfactory. The remarkable response to treatment in this case suggests that oral acitretin, in association to urea nail lacquer, might be useful in the management of disabling severe nail psoriasis even in absence of severe cutaneous involvement.

Tumor necrosis factor-alpha and interleukin-17 differently affects Langerhans cell distribution and activation in an innovative three-dimensional model of normal human skin.

Among the several cytokines involved in the psoriasis pathogenesis, tumor necrosis factor (TNF)-alpha and interleukin (IL)-17 play a central role. Many biomolecular steps remain unknown due to difficulty to obtain psoriatic models. To investigate the effect of TNF-alpha and IL-17 on the ultrastructure, immunophenotype, and number of epidermal Langerhans cells (LCs), human skin explants (n=7) were cultured air-liquid interface in a Transwell system. Four different conditions were used: medium alone (control), medium added with 100 ng/ml TNF-alpha or 50 ng/ml IL-17 or a combination of both cytokines. Samples were harvested 24 and 48 h after cytokine addition and were frozen. Samples harvested at 24h were also processed for transmission electron microscopy (TEM). By immunofluorescence analysis with anti-human Langerin antibody (three experiments/sample) we calculated the percentage of LCs/mm(2) of living epidermis after 24 and 48 h of incubation (considering control as 100%). At 24h LC number was significantly higher in samples treated with both cytokines (216.71+15.10%; p<0.001) and in TNF-alpha (125.74+26.24%; p<0.05). No differences were observed in IL-17-treated samples (100.14+38.42%). After 48 h, the number of epidermal Langerin-positive cells in IL-17- and TNF-alpha treated samples slightly decreased (94.99+36.79% and 101.37+23% vs. their controls, respectively). With the combination of both cytokines epidermal LCs strongly decreased (120+13.36%). By TEM, upon TNF-alpha stimulus LCs appeared with few organelles, mostly mitochondria, lysosomes, and scattered peripherical BGs. Upon IL-17 stimulus, LCs showed a cytoplasm with many mitochondria and numerous BGs close to the perinuclear space and Golgi apparatus, but also at the periphery, at the beginning of the dendrites. The addition of both cytokines did not affect LC ultrastructure. Our study showed that IL-17 induced significant changes in LC ultrastructure, while the combination of both cytokines seems to have a strong chemo-attractant effect on epidermal LCs, supporting the relevance of investigating the interplay between LCs and pro-inflammatory cytokines in the ongoing of the disease.

Focused UV-B narrowband microphototherapy (Biopsorin). A new treatment for plaque psoriasis.

Skin irradiation with ultraviolet light B (UV‐B) and in particular the emission peak at 311 nm represents an effective therapeutic regimen for psoriasis.

Paradoxical effect of infliximab in a patient with hidradenitis suppurativa

We report a case of infliximab-induced acne, described only in few reports previously (1,2), in a 19-year-old patient with hidradenitis suppurativa (HS) (3,4). The onset occurred 5 years before baseline visit during puberty. At the moment of our clinical examination, the patient showed inflammatory nodules and cysts with no central necrosis, along with spontaneous lesion rupture and discharge of purulent fluid. Extensive fibrotic scars and deep abscesses with sinus tract and fistula formation developed adjacent to primitive inflammatory lesions. Secretory components were drained via long straight excretory ducts into pilosebaceous follicle reducing hair growth. These manifestations involved, primarily, the intertriginous areas, such as the axilla, groin and gluteal cleft (FIG. 1a,c,e). The patient referred pain, swelling, pruritus, purulent discharge and discontinuos bleeding, difficulties in defecation, and constipation. The baseline Dermatology Life Quality Index (DLQI) was 21 demonstrating that the disease had an extremely large effect on his life. Previously the patient had been long treated with systemic antibiotics and corticosteroids with no beneficial effects. He was initially treated with a combination of amoxicillin and clavulanic acid (825 + 175 mg), administered twice a day for 6 days/month for 6 months. A few months after this first treatment, doxycycline hyclate (100 mg) was administered once a day for 10 days/month; he repeated the treatment four times. Simultaneously, he performed pulse steroid therapy. Prednisone was given in a dose of 25 mg a day reducing the dosage every week for 1 month. On December 2009, the patient was treated for the first time with oral retinoids (acitretin 10 mg/die) for 2 months. The patient improved greatly, but he had to stop the therapy because of xerosis and dry fauces. Moreover, he showed increased blood levels of triglycerids (280 mg/dL), erythrocyte sedimentation rate (ESR = 80 mm/h) and C-reactive protein (CRP = 80 mg/L). On March 2010, he started Infliximab therapy at the dosage of 5 mg/Kg/die at weeks 0, 2, 6, and then every 8 weeks, according to standard protocol. At the fourth infusion, we took a picture demonstrating the treatment efficacy. Particularly, active inflammatory abscesses and granulomatous tissue were wholly healed and evolved into ropelike scars. There was neither purulent secretion or pain, and the patient was able to carry out normal daily activities and relationship with his peers. The DLQI, calculated after the third session, was extremely improved achieving score 9. Most of all, we appreciated a significant change of two fistular and granulomatous lesions localized on the left gluteus and inguinal cleft (FIG. 1d,f). Suppurative and granulomatous lesions of the axilla were repaired, evolving in scarring tracts with renewed growth of hair (FIG. 1b) Markers of systemic inflammation were decreased (ESR = 25 mm/h; CRP = 10 mg/L), reflecting the improvement of skin manifestations. The only drawback, despite no previous medical history of acne (FIG. 2a), has been the outbreak of comedones and papulopustules on the chin, cheeks, and forehead. An erythematous suppurative nodule was located near the eyebrow region (FIG. 2b,c). This case report confirms the efficacy of Infliximab in HS, also reported in other case series (5–7). As aforementioned, the only drawback was the outbreak of acne lesions on the Address correspondence and reprint requests to: Nicola Bruscino, Resident in Dermatology, Department of Dermatology II, University of Florence, P.zza Indipendenza 11, Florence 50129, Italy, or email: bruscio@alice.it. Conflict of interest: None declared.

Vitiligo masks malignant acanthosis nigricans in a woman with ovarian cancer

Acanthosis nigricans (AN) is characterized by hyperpigmented, verrucous plaques, sometimes itching and affecting the intertriginous surfaces, neck, and mucocutaneous regions. There are four different types of AN: malignant (MAN), benign, syndromic, and pseudo-AN associated with obesity and insulin resistance. MAN, especially if associated with tripe palms and the sign of Leser–Tr elat, is secondary to several neoplasms, in particular gastrointestinal adenocarcinomas and less frequently gynecological adenocarcinomas. In the presence of AN, an exhaustive malignancy screening is mandatory because cancers associated with AN present poor prognosis being usually very aggressive and in a late stage: the average survival after their discovery is reported to be 8.7–11.9 months. MAN tends to follow the course of the cancer: skin manifestations progress in parallel with the underlying tumor and usually recovers after cancer treatment. Otherwise, the persistence or recurrence of skin lesions can be a significant indicator of unsuccessful treatment or neoplasm recurrence. For what concerns MAN etiology, a peptide with growth factor properties (such as transforming growth factor alpha, or melanocyte stimulating hormone alpha or insulin line growth factor 1) produced by the tumor could be implicated. Vitiligo is a progressive disorder characterized by hypomelanotic macules and patches involving the extremities and areas around body orifices. Three different types of vitiligo have been described: segmental (SV), non-segmental (NSV), and mixed vitiligo (MV). The cause of vitiligo is still debated, and the two major pathogenetic hypotheses are focused on immune-mediated or oxidative stress against melanocytes. Significant associations between NSV and personal history of autoimmune diseases can be detected while SV would be subsequent either by a mosaic mutation or by a neurotoxic damage against melanocytes. Recently Neri et al. found a significant association between MV and halo nevi, concluding that MV could be the consequence of a primary cutaneous defect responsible for SV, which can trigger, in immune predisposed people, a generalized immune response against melanocytes. We report the case of a 60-year-old woman with a previous diagnosis of vitiligo. She came to our attention because, on the background of depigmented patches in the typical areas of vitiligo (as axillary, inguinal, genital, intermammary, and perioral regions) developed velvety and depigmented cutaneous thickening with hypertrophic, depigmented, and symmetric verrucose excrescences (Fig. 1).

Metastatic vulvar carcinoma

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Safety and efficacy of HCV eradication during etanercept treatment for severe psoriasis

Treatment of severe psoriasis in HCV positive patients is challenging, because several psoriasis medications have a toxic effect on the liver, and interferon alpha, used to treat hepatitis, can induce worsening of psoriatic lesions. TNF‐alpha inhibitors seem to be a safe and effective option in HCV positive psoriatic patients, but there are concerns about long‐term safety, impact on liver fibrosis progression and risk of immune‐mediated liver injury. With regard to HCV treatment, new direct‐acting antiviral therapies (DAA) seem to be extremely effective, with minimal side effects, but little is known about possible interactions with other medications, particularly with biologics. We report the case of a psoriatic patient, in treatment with Etanercept, who needed to undergo HCV eradication with Daclastavir and Sofosbuvir because of worsening liver fibrosis due to chronic hepatitis C. The present treatment produced excellent results in terms of HCV eradication and control of psoriatic lesions, without side effects.

Cutaneous sarcoidosis during rituximab treatment for microscopic polyangiitis: an uncommon adverse effect?

1 Department of Dermatology, Maebashi Red Cross Hospital, Maebashi, Gunma, Japan 2 Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan 3 Department of Dermatology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan 4 Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan Naoko MORIMOTO1 Akira SHIMIZU2 Kazunori OHNISHI1 Yutaka SHIMOMURA3,4