Manuela Selores

The Protective Role of HLA-DRB1∗13 in Autoimmune Diseases

Autoimmune diseases (AIDs) are characterized by a multifactorial aetiology and a complex genetic background, with the MHC region playing a major role. We genotyped for HLA-DRB1 locus 1228 patients with AIDs-213 with Systemic Lupus Erythematosus (SLE), 166 with Psoriasis or Psoriatic Arthritis (Ps + PsA), 153 with Rheumatoid Arthritis (RA), 67 with Systemic Sclerosis (SSc), 536 with Multiple Sclerosis (MS), and 93 with Myasthenia Gravis (MG) and 282 unrelated controls. We confirmed previously established associations of HLA-DRB1∗15 (OR = 2.17) and HLA-DRB1∗03 (OR = 1.81) alleles with MS, HLA-DRB1∗03 with SLE (OR = 2.49), HLA-DRB1∗01 (OR = 1.79) and HLA-DRB1∗04 (OR = 2.81) with RA, HLA-DRB1∗07 with Ps + PsA (OR = 1.79), HLA-DRB1∗01 (OR = 2.28) and HLA-DRB1∗08 (OR = 3.01) with SSc, and HLA-DRB1∗03 with MG (OR = 2.98). We further observed a consistent negative association of HLA-DRB1∗13 allele with SLE, Ps + PsA, RA, and SSc (18.3%, 19.3%, 16.3%, and 11.9%, resp., versus 29.8% in controls). HLA-DRB1∗13 frequency in the AIDs group was 20.0% (OR = 0.58). Although different alleles were associated with particular AIDs, the same allele, HLA-DRB1∗13, was underrepresented in all of the six diseases analysed. This observation suggests that this allele may confer protection for AIDs, particularly for systemic and rheumatic disease. The protective effect of HLA-DRB1∗13 could be explained by a more proficient antigen presentation by these molecules, favouring efficient clonal deletion during thymic selection.

Allergic contact dermatitis to Aloe vera

We present the case of a 72‐year‐old woman observed for dermatitis on the legs followed by apperance of erythema on the eyelids. She had a past history of peripheral venous insufficiency and had been using self home‐made Aloe vera juice over the legs for relief from pain. Patch tests showed positive reactions to the leaf of Aloe, the macerated Aloe jelly, and nickel sulfate. Although most manufacturers process Aloe products avoiding its irritant extracts, and probably as a consequence reports of allergic reactions are rare, one must remember that the growing popularity on the use of Aloe products may stimulate its use ‘as is’ by the patients. Furthermore, it is important to specifically ask patients about the use of these products, because they consider it as innocuous and thus would not spontaneously provide such information.

Epicardial adipose tissue and coronary artery calcification in psoriasis patients.

Psoriasis is a chronic, immune‐mediated disease associated with several cardio‐metabolic comorbidities, accelerated atherosclerosis and cardiovascular disease (CVD). Other causes beyond systemic inflammation and traditional cardiovascular risk factors (CVRF) may be implicated in the increased risk of CVD observed in these patients. Epicardial adipose tissue (EAT), a type of visceral adipose tissue surrounding the heart and coronary vessels has been implicated in the development of coronary artery disease, by endocrine mechanisms, but particularly by local inflammation.

Cardiovascular comorbidities in childhood psoriasis

BackgroundPsoriasis is a common, chronic, systemic inflammatory skin disease associated with numerous cardiovascular comorbidities. Much evidence of this association exists in the adult population, data available in childhood psoriasis is more limited.ObjectivesTo analyze the prevalence of excess adiposity, cardiovascular risk factors, metabolic syndrome and lipid profile in children with psoriasis comparing to control group with similar age and sex distribution.Materials & methodsA case-control study was conducted with children, 5–15 year-sold, with moderate-to-severe plaque-type psoriasis and a control group comprising children with other skin diseases without systemic inflammatory diseases.ResultsPsoriatic children had a significantly higher prevalence and greater odds of excess adiposity compared to controls: BMI (≥85th percentile; OR 4.4; 95%CI 1.2–15.6), waist circumference (>75th percentile; OR 7.4; 95%CI 2.0–27.7) and waist-to-height ratio (>0.490; OR 4.6; 95%CI 1.3–17.0). A higher prevalence of metabolic syndrome was observed in children with psoriasis compared to controls (25% vs 3.7%;P=0.07), and two components of the metabolic syndrome were significantly higher in the psoriasis group: waist circumference (75% vs 29.6%; P = 0.002) and the high blood pressure component (30% vs 3.7%P=0.032). Finally, an altered and more atherogenic lipid profile was observed among psoriatic patients without excess adiposity.ConclusionThis study demonstrates that comorbidities known to be associated with adult psoriasis are also observed in childhood psoriasis, reinforcing the need for screening cardiovascular comorbidities in children with psoriasis and promoting healthy lifestyle choices in these patients. Moreover, it also suggests that its association with psoriasis may be in part genetically determined rather than uniquely acquired.

Framingham Risk Score underestimates cardiovascular disease risk in severe psoriatic patients: implications in cardiovascular risk factors management and primary prevention of cardiovascular disease.

Severe psoriasis has been associated with increase cardiovascular mortality, due to a higher prevalence of traditional cardiovascular risk factors and premature atherosclerosis, as a consequence of its systemic inflammation. Recently, it has been estimated that severe psoriasis may confer an increased 6.2% on long‐term risk of cardiovascular disease based on Framingham Risk Score, which can have practical implications in the treatment of cardiovascular risk factors and primary prevention of cardiovascular disease, as treatment guidelines account for the risk of cardiovascular disease in treatment goals. The aim of this study was to analyze the influence of the attributable risk of severe psoriasis on long‐term risk of cardiovascular disease and its implication on the correct treatment of cardiovascular risk factors and primary prevention of cardiovascular disease on a real‐world cohort of patients. One hundred severe psoriasis patients without psoriatic arthritis or previous cardiovascular disease were evaluated and it was found that more than half of the patients were reclassified to a higher cardiovascular risk category with important clinical implications on the correct management of their cardiovascular risk factors and primary prevention of cardiovascular disease, as a considerable proportion of patients with hypertension, hypercholesterolemia and coronary heart disease equivalent risk were not being correctly managed.

Immediate and Delayed Hypersensitivity to Mite Antigens in Atopic Dermatitis

Atopic dermatitis (AD) is a common disorder and appears to be on the increase, especially among children. It was thought at first to be a manifestation of immediate hypersensitivity, but it is now known that delayed hypersensitivity also plays an important role. Sensitivity to mite antigens is found in 20% to 60% of patients when immediate hypersensitivity is evaluated by the detection of specific IgE antibodies and prick tests, and in 30% to 50% of patients when delayed hypersensitivity is studied by patch testing. A prospective randomized study was carried out in the pediatric dermatology clinic on a sample of 51 children under 15 years of age. A prevalence of immediate and delayed hypersensitivity to mites, like that described for other populations, was found. It was further found that there was a positive association, not described in the literature, between the younger age groups and delayed hypersensitivity to mite antigens, while the opposite was true for immediate hypersensitivity. We believe that patch tests with airborne allergens, specifically mites, should be part of the protocol for assessing children with AD, particularly in the younger age groups.

Maintenance treatment of psoriasis with cyclosporine A: Comparison between continuous and weekend therapy

coding, chart reviews to ensure proper documentation, problem-based learning sessions, conferences with the billing department, and active daily feedback on resident coding and documentation by attendings during clinics. Although teaching and learning these topics requires time and effort, improper coding and billing can lead to the downfall of a practice. Brief and repeated didactic sessions early in residency will likely leave a long-term impact by creating a foundation to build upon postresidency. More importantly, making sure residents understand documentation, coding, and billing will ensure that academic dermatology practices can be sustained.

Pemphigus vegetans in a patient with colonic cancer

Pemphigus vegetans is a rare variant of pemphigus vulgaris characterized by vegetating plaques in the flexural regions. The coexistence of pemphigus vegetans and internal neoplasm is rare, being described only in four cases in the literature. We report the case of a patient with a typical skin eruption of pemphigus vegetans, who was detected with colonic cancer.

Generalized morphea and lichen sclerosus et atrophicus successfully treated with sulphasalazine.

To the Editor: A 75-year-old white woman was first seen with erythematous, infiltrated plaques with violaceous border initially on the breast (Fig. 1) and lumbar region. Thes’e plaques later became necrotic white and involved most of the tegument, giving the subject the feeling of pulling and hardening of the skin, which made movement difficult. There was no relevant past history with respect to pathology, and no history of previous pharmacological administration. Skin biopsy showed hyperkeratosis, decreased epidermal thickness, and destruction of the normal papillary structure. In the papillary dermis there was a strip of hyalinization, edema, with prominent capillary vessel ectasy, beneath which there was multifocal lymphocyte and histiocyte infiltration. The reticular dermis was markedly thickened, projecting into the connective tissue septa made up mainly of thickened collagen bundles. There was also a moderate infiltration of lymphocytes and histiocytes around the vessel and nerve bundles involving the dermal subcutaneous junction. Direct immunofluorescence was negative. There was no evidence of Raynaud’s phenomenon, dysphagia or dyspnea. Full blood count, ESR, liver and ludney function tests, chest X-ray and ECG were all normal. The rheumatoid factor test was negative, as were those for anti-nuclear antibodies and proteins in the acute phase of inflammation.

Erectile dysfunction in psoriasis patients

BackgroundAn association between psoriasis and sexual dysfunction has been explored. However, not much is known about the factors behind erectile dysfunction in these patients.ObjectivesTo compare the prevalence and the severity of erectile dysfunction in patients with and without psoriasis and to determine potential associations between erectile dysfunction and psoriasis patients’ characteristics.Materials & MethodsAn observational cross-sectional study was conducted at two tertiary hospital-based Dermatology departments. Consecutive adult men with psoriasis or other skin conditions were recruited. Data were collected using an anonymous, self-completed, designed questionnaire, which included the Dermatology Life Quality Index and the 5-item version of the International Index of Erectile Function.ResultsA total of 135 psoriasis patients and 201 controls were included. Psoriasis patients had a higher prevalence of erectile dysfunction than controls (61.5% vs 43.8%, p = 0.001), and an increased risk of more severe forms of erectile dysfunction. Dermatology Life Quality Index, genital psoriasis and psoriasis duration were not associated with the presence of erectile dysfunction. In multivariate logistic regression, psoriasis and diabetes were found to be independent risk factors for erectile dysfunction with estimated odds ratios of 2.28 (CI 95%, 1.40–3.27) and 3.49 (CI 95%, 1.40–8.66), respectively.ConclusionThis study suggests psoriasis as a risk factor for erectile dysfunction. Atherosclerosis is a plausible connecting link, adding up to the already acknowledged effect of psychological factors in these patients. From a clinical standpoint, because erectile dysfunction may precede overt cardiovascular disease, it can be used as a precocious marker of cardiovascular risk in psoriatic men.