Linda Lazzeri

Evaluation of an oral supplement containing Phyllanthus emblica fruit extracts, vitamin E, and carotenoids in vitiligo treatment.

Phyllanthus emblica, vitamin E, and caroteinods are compounds showing antioxidative, anti‐inflammatory, and repigmenting effects, whose role in vitiligo treatment has not been evaluated so far. Sixty‐five subjects (group A) were treated with one tablet of an oral supplement containing P. emblica (100 mg), vitamin E (10 mg), and carotenoids (4.7 mg) three times/day for 6 months and compared with a control group (group B, 65 patients), which instead was not treated with antioxidants. Both groups were simultaneously treated with a comparable topical therapy and/or phototherapy. After a 6 months follow‐up, a significantly higher number of patients in group A had a mild repigmentation on the head/neck regions (p = 0.019) and on the trunk (trend, p = 0.051). The number of patients who presented no repigmentation in head/neck, trunk, upper, and lower limbs was significantly higher in group B (respectively, p = 0.009, p = 0.001, p = 0.001, p = 0.025). Moreover, group B patients showed higher signs of inflammation (p = 0.002), a more rapid growth of the lesions (p = 0.039), a higher percentage of worsening disease (p = 0.003), and more erythema (p = 0.059), whereas group A patients showed a higher percentage of steady disease (p = 0.065). Our results suggest that the supplement with antioxidants in patients with vitiligo might represent a valuable instrument to increase the effectiveness of other vitiligo treatments. [Correction added after online publication 06‐Oct‐2014: the dosages of vitamin E and carotenoids have been updated.]

Dermatosis Papulosa Nigra and 10,600-nm CO2 laser, a good choice

Abstract Dermatosis Papulosa Nigra (DPN) is a common skin condition observed in black people and considered a benign epithelial tumor, and more specifically, a particular topographic form of seborrheic keratosis. We treated five female patients affected by DPN with 10,600-nm CO2 laser. We propose the 10,600-nm CO2 laser as a valid therapeutic option in patients affected by DPN, since the treatment is well tolerated, causes no major side effects, and is effective and long lasting.

Adult Onset Vitiligo: Multivariate Analysis Suggests the Need for a Thyroid Screening

Background. There are limited epidemiological studies evaluating the effect of age at onset on disease features in vitiligo. Objectives. To identify factors associated with adult onset vitiligo in comparison with childhood onset vitiligo. Patients and Methods. We retrospectively collected medical records of 191 patients. Such records included clinical examination, personal and familial medical history, laboratory evaluations, concomitant vitiligo treatment and drug assumption. Results. 123 patients with a disease onset after the age of 40 (adult onset vitiligo) were compared with 68 patients who developed vitiligo before the age of 12 (childhood onset vitiligo). Multivariate analysis revealed that personal history of thyroid diseases (P = 0.04; OR 0.4), stress at onset (P = 0.002; OR = 0.34), personal history of autoimmune thyroid disease (ATD) (P = 0.003; OR = 0.23), and thyroid nodules (P = 0.001; OR 0.90) were independently associated with adult onset vitiligo, whereas family history of dermatological diseases (P = 0.003; OR = 2.87) and Koebner phenomenon (P < 0.001; OR = 4.73) with childhood onset vitiligo. Moreover, in the adult onset group, concomitant thyroid disease preceded vitiligo in a statistically significant number of patients (P = 0.014). Conclusions. Childhood onset and adult onset vitiligo have different clinical features. In particular, ATD and thyroid nodules were significantly associated with adult onset vitiligo, suggesting that a thyroid screening should be recommended in this group of patients.

Efficacy and safety of Adalimumab after failure of other anti-TNFα agents for plaque-type psoriasis: clinician behaviour in real life clinical practice

Abstract Introduction: During treatment with biologic agents for psoriasis (Pso) in a number of patients a failure may occur and discontinuation with transitioning to another drug or an optimization strategy, consisting in a dose-adjustment or a co-medication with a traditional systemic agent, represent two possible alternatives. Objective: The SAFARI study objective was a retrospective observation of adalimumab efficacy and safety profile after switching from other anti-TNFα agents related to clinician behavior after the failure of the first-line agent. Results: The retrospective multicenter observation demonstrated that after a first-line anti-TNFα failure adalimumab efficacy was consistent at week-12 and 24 with a further significant improvement at week-48 with a proportion of patients achieving PASI75/PASI90/PASI100 of 83.3, 71.6, and 56.9.%, respectively. Clinician strategies to extend drug-survival after first-line anti-TNFα failure, such as co-medication or dose-adjustment, were irrelevant to future drug effectiveness. Conclusions: Adalimumab profile was excellent in this 5-year retrospective observation, showing the clinical validity of interclass transitioning among anti-TNFα options.

Cutaneous hyperpigmentation induced by apremilast

Apremilast is an oral inhibitor of phosphodiesterase-4 (PDE4) recently approved for the treatment of psoriasis and psoriatic arthritis (PsA). We report the case of a 70-year-old female patient affected with severe psoriasis and PsA for more than 30 years, who developed cutaneous skin hyperpigmentation while treated with oral apremilast 30 mg/bid (Fig. 1). Over decades, she had been variously treated with PUVA, acitretin, cyclosporine-A, and methotrexate. She was also treated with infliximab first and then adalimumab with optimal response of cutaneous and articular symptoms; however, during both biologics she developed ANA-positivity with levels up to 1:1280 that were completely reversible after treatment suspension. Eight weeks after adalimumab discontinuation, the patient presented with a psoriasis area and severity index (PASI) score of 5, severe morning stiffness, visual analog scale (VAS) pain 6, important functional limitation with tender, swollen, and painful II, III, IV-distal interphalangeal (DIP) and metacarpophalangeal (MCP) joints of both hands, and ultrasonographic active tenosynovitis of all the involved articulations. In addition, she developed new PsA symptoms at the right ankle and metatarsal sites of the right foot. The patient had a BMI > 30, arterial hypertension, atrial fibrillation, osteoporosis, hypovitamin D levels, and depressive syndrome, respectively treated with atenolol, cardioaspirin, propafenone, cholecalciferol, and escitalopram. Of note, the patient had seriously photo damaged skin with multiple solar lentigines at photo-exposed sites (upper and lower arms, dorsa of hands, face, and back-trunk). Typically, she had no photodamaged skin where she performed UV-protection with clothes. Treatment with apremilast was started and as soon as week 4 of treatment, the patient experienced almost complete clearance of cutaneous plaques with a little benefit on pain (VAS 4) and morning stiffness. At week 8 of treatment, PASI response was maintained with further improvement of PsA symptoms (morning stiffness, VAS pain 3, reduction of swollen and tender DIP-MCP joint count, and amelioration of metatarsal and ankle limitation of function). The patient did not report side effects other than weight loss (almost 5 kg), however we noticed a general cutaneous dark hyper pigmentation of the whole body, especially of the severe photo damaged areas, of the solar lentigines and seborrheic keratoses of the trunk as for intense UV exposure. We could not check hair color since the patient usually dyed her hair. Notably, the patient denied use of sun beds or sun exposure. PDE4 is a key regulator of intracellular signaling by degrading of the second messenger cyclic adenosine-30,50-monophosphate (cAMP), which in turn activates transcription of pro-inflammatory mediators and inhibits anti-inflammatory cytokines including IL-10. Apremilast inhibits PDE4 thus increasing the intracellular cAMP levels and reducing all the major players in the

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.

First case of secukinumab successful therapy in a very elderly psoriatic patient

Dear Editor, Elderly psoriasis patients are a growing population (Phan et al., 2016) but frequently excluded from biological clinical trials, suggesting that advanced age is a risk factor for adverse events during these therapies. The present study reports the first case of a very elderly patient (>75 years old) with severe psoriasis who was successfully treated with anti-IL-17 secukinumab. An 85-year-old Italian female (body mass index of 26) presented with a 20-year history of plaque-type psoriasis. In addition to that, the patient also had a medical history of hypertension, hypercholesterolemia, and gastroesophageal reflux disease. On physical examination, the Psoriasis Area and Severity Index (PASI) score was 18.5 (Figure 1). No articular involvement was reported. The skin lesions responded poorly to previous conventional treatments including methotrexate (10 mg/week), narrowband ultraviolet B phototherapy, and topical agents (i.e., steroids and calcipotriol). Because of the severity of the clinical features and the intolerance and inefficacy to conventional systemic therapies and

Clinical characteristics of psoriasis in inflammatory bowel disease patients

rithm used to estimate an individuals’ 10-year cardiovascular risk, was assessed in 263 patients with hidradenitis suppurativa from Irish and Danish centres. The majority (80%) had scores of 10% or less (low risk), 15% had moderate risk scores (10–20%), and only 10 patients (5%) had high risk scores of >20%. The authors concluded that the high incidence of obesity and metabolic syndrome in patients with hidradenitis suppurativa represent non-conventional cardiovascular risk factors, unassessed by Framingham Risk Score, therefore true cardiovascular risk may be significantly higher. In conclusion, evidence suggests that hidradenitis suppurativa, such as others chronic inflammatory conditions, is associated with an increased prevalence of cardiovascular risk factors and subclinical atherosclerosis. Therefore, we agree with Vinkel et al. that we, as dermatologist, should have an active approach for screening atherosclerotic cardiovascular risk factors in patients with hidradenitis suppurativa, especially in those with elevated age.

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

Reduction in psoriasis related pruritus during biologic therapy

Dear Editor According to a recent multinational population based study, itch is the most common and bothersome symptom in psoriasis (Lebwohl, Kavanaugh, Armstrong, & Van Voorhees, 2015), and it is reported by 64%– 97% of psoriatic patients (Prignano, Ricceri, Pescitelli, & Lotti, 2009; Roblin, Wickramasinghe, & Yosipovitch, 2014). Despite its prevalence and importance, there is paucity of data regarding pruritus associated with plaque psoriasis and effective antipruritic treatment. However a significant reduction in psoriasis related pruritus during therapy with some biological agents has been observed recently (Mrowietz et al., 2015; Revicki et al., 2007; Zhu et al., 2014). The objectives of our study were to characterize the extent of pruritus in patients with moderate-to-severe psoriasis, and to evaluate and compare the effect of four different biological therapies on itch. We enrolled 103 consecutive patients, attending the Florence University Psoriasis Service between June 2014 and September 2015, who were candidate for biological treatment with etanercept (ETN), adalimumab (ADA), infliximab (IFX), or ustekinumab (UST) (dosage schemes recommended by German S3 Guidelines) (Nast et al., 2012). Inclusion criteria required being 18 years old, having a diagnosis of moderate-to-severe plaque psoriasis (body surface area 10% and PASI 10), and either failing, being intolerant to or contra-indicated for at least two conventional systemic psoriasis treatments. Presence of other dermatological or systemic conditions causing pruritus was considered as exclusion criteria. Validated instruments to study pruritus are few. We used a 6-point Likerttype scale (05no itch and 55most severe itch), which has proved to have good test–retest reliability and responsiveness in psoriatic patients (Gottlieb, Feng, Harrison, & Globe, 2010). Pruritus levels were categorized as follows: 05no itch, 1–35mild-to-moderate itch, 45 severe itch. Patients which reported no pruritus at baseline were excluded from further statistical analysis. Pruritus assessment was repeated after 24 weeks of biological treatment. Topical medications were not allowed during this period. Patients’ demographics and clinical characteristics for each treatment group are listed in Table 1. Pruritus was reported by 92 patients (89%) at baseline, 52% of whom reported severe itching (level 4). Mean pruritus score in the total patient population at baseline was 3.53 (6 1.16 STD). Mean BMI and PASI scores were similar between patients belonging to different treatment arms. At the end of the 24th week overall pruritus score was significantly reduced (0.8861.09); 51% of patients reported no itching (score50), and 30.5% showed a decrease in pruritus level of 1. Pruritus intensity was unchanged in 17 patients; among them 6 were treated with ADA, 6 with ETN, 2 with IFX, and 3 with UST. None showed increased pruritus. The efficacy of each treatment on pruritus intensity was assessed by paired t-test, which revealed a significant score reduction in every treatment arm (p< .001, Figure 1). One-way analysis of variance (ANOVA) was performed to compare the change in pruritus during therapy among the four different treatment groups (ADA, IFX, ETN, UST). No significant difference in reducing pruritus was found among all biological agents tested. Analysis of variance was also performed in order to evaluate the relationship between itch improvement and baseline itch category. According to our data, patients who reported greater itch at baseline had greater improvement at week 24 (p< .0001), and this result is congruent with those observed by Mrowietz et al. (2015). A further analysis of variance was performed in order to assess a potential correlation between PASI and pruritus at week 24. However, we did not find any statistically significant association between PASI percentage decrease and pruritus score reduction (Figure 2). In conclusion, all biological agents considered in the study (ADA, IFX, ETN, UST) proved to be effective in reducing pruritus, particularly in patients with severe baseline itch. Moreover, lack of pruritus improvement seems to be independent of PASI reduction.