Michela Ricci

Oral clindamycin and rifampicin in the treatment of hidradenitis suppurativa‐acne inversa: a prospective study on 23 patients

Editor Hidradenitis Suppurativa-Acne Inversa (HS-AI) is a relapsing and chronic inflammatory skin disease affecting the big folds. HS-AI is currently thought of as being an inflammatory and not an infectious disease, but sometimes various bacteria combined in polymicrobial infections can be present. Coagulasenegative staphylococcus and anaerobic bacteria are the most frequently isolated. The bacteria are suspected of playing a role in the disease process, probably through immune-mediated mechanisms of inflammation. Therapy of HS-AI is often difficult. Medical, surgical and physical therapeutical options are available. Although antibiotics are widely used to treat HS-AI limited data on their efficacy are available. To assess the efficacy and the tolerability of a 10-week combination of oral clindamycin (600 mg daily) and rifampicin (600 mg daily) in the treatment of HS-AI, 23 patients affected by severe and actively inflammatory HS-AI were enrolled in a prospective non comparative study. The ethical committee considered as not needed its official consensus to precede. No restrictions about previous treatments were established. The parameters used to evaluate the efficacy of the treatment were as follows: (i) severity of the disease, assessed with the Sartorius score before (T0) and after (T1) treatment and (ii) the number of exacerbations during the treatment period compared with those occurring in the previous three months. The authors considered as exacerbation the acute development of at least one wide inflammatory lesion. Finally, patients were asked about side-effects during treatment. Statistical analysis was performed using parametric test (t-test). Significance was accepted at P < 0.05. The main clinical-demographic data, collected in a standardized form, are summarized in Table 1. Three patients did not complete the treatment: one for personal reasons, one because of gastro-intestinal side-effects not related to Clostridium difficile colitis, and one, affected by amyotrophic lateral sclerosis, complained of a worsening of the neurological disease, probably not related to antibiotic assumption. The 20 patients who completed the 10-week therapy showed a mean Sartorius score of 132.05 (range 28.00–298.05) at T0 and 71.50 (range 19.50–183.00) at T1 corresponding to a mean reduction of 45.85% (range 5.41–81.95%). The authors considered as responders the 17 patients who achieved a Sartorius score improvement higher than 25%, corresponding to the 85% of the patients who completed the treatment. The mean number of exacerbations was 6.00 (range 1.00–20.00) at T0 and 2.40 (range 0–10.00) at T1 corresponding to a mean reduction of 60% (range 0–100%). Both Sartorius score and the number of exacerbations showed a significant reduction after treatment: P = 0.00098 for Sartorius score and P = 0.0091 for the number of exacerbations, respectively. Three out of 23 patients (13.04%) complained of side-effects, mostly nausea and vomiting: one patient stopped the therapy before the scheduled end, whereas the two remaining completed the 10-week treatment. The efficacy and tolerability of this combination treatment in HS-AI has previously been assessed in three retrospective studies. The present one is the first prospective study and the results are in agreement with those reported in literature (Table 2). The reason why this antibiotic combination is effective is not fully understood yet. This study has some limitations. The patients were not randomized vs. placebo or other treatments. This decision was made for ethical reasons and because, in the authors’ experience, this treatment is the best option in severe HS-AI in terms of efficacy, tolerability, quick onset of action and cost. No data about long-term follow-up and recurrences are given because a maintenance treatment with oral zinc was prescribed, according to the desire of the patients to do as much as possible to maintain the results they had obtained.

Maintenance Therapy for Acne Vulgaris: Efficacy of a 12-Month Treatment with Adapalene-Benzoyl Peroxide after Oral Isotretinoin and a Review of the Literature

Background: The correct therapeutic management of acne should include a maintenance therapy with topical retinoids to prevent recurrences after discontinuing a successful treatment. Objective: To investigate the efficacy of a 12-month maintenance treatment with adapalene 0.1% and benzoyl peroxide (BPO) 2.5% fixed combination gel to control acne relapse after treatment with oral isotretinoin (OI). Methods: The study consisted of 2 phases, namely an active treatment phase (AP) and a maintenance phase (MP). In the AP, 70 consecutive patients with moderate to severe acne were treated with OI until acne remission. Then, patients entered the MP and were treated with adapalene-BPO fixed combination once daily for 12 months. The primary efficacy parameter was the relapse rate during MP. Results: Sixty-eight patients completed the study. Relapse occurred in 2 patients (2.94%). Conclusions: Comparing our findings with published data, the association of a topical retinoid and BPO seems to provide favorable evidence for this combination as maintenance therapy.

Which factors influence quality of life in acne patients

Background  The factors that impact quality of life in acne patient are not fully understood.

Shiitake dermatitis: toxic or allergic reaction?

contactable and reported clinically significant improvement in itch scores. We further performed a sensitivity analysis assuming that all the subjects who stopped treatment or defaulted had no improvement in their outcome measures at 6 weeks and repeated the comparisons above (n = 40). The overall improvements in all the outcomes remained statistically significant (P ≤ 0.001). Treatment of scrotal LSC is challenging. Limited evidence suggests that topical calcineurin inhibitors may be useful in women with vulvar LSC. In this study, 0.1% tacrolimus ointment was found to be effective in reducing itch intensity in scrotal LSC, with concurrent improvements in itch frequency, sleep, quality of life and physical extent and severity of the lesions. In addition to its immunosuppressive and anti-inflammatory effects, tacrolimus ointment has been shown to have a separate antipruritic effect. Tacrolimus favours the phosphorylation of transient receptor potential vanilloid 1 (TRPV1) ion channels on neurons, resulting in an initial release of substance P, and this likely explains the side effect of initial burning sensation. Subsequently, the desensitization of sensory neurons inhibits transmission of itch signals. This disrupts the itch-scratch cycle which is a cornerstone in the pathogenesis of LSC. The safety profile of topical calcineurin inhibitors has been well established, with the most common adverse effect being a temporary burning sensation at the application site. In our study, a warm or burning sensation was reported in 12 (30.0%) of 40 subjects, which was mild and transient in six subjects. This was intolerable or was accompanied by a significant increase in itch in the other six subjects, who discontinued treatment themselves. No other adverse effects were observed. In conclusion, topical 0.1% tacrolimus ointment, when tolerated, was an effective and safe treatment for scrotal LSC in our study population.

[What's new in acne? New therapeutic approaches].

Summary Well-known topical and systemic treatments for acne have advanced little over the last 10 years. However, many therapeutic approaches are being evaluated both in terms of topical and systemic treatments. The purpose of this paper is to show the progress of innovative drug projects in treating acne. The topical use of new formulations using lipid nanoparticles and microspheres could help for new products based on anti-androgens or retinoids more concentrated and better tolerated. New active agents such as topical antimicrobial peptides, inhibitors of ectopeptidase, omiganan pentahydrochloryde, antisense oligonucleotides, lauric acid are many original ways to explore for the treatment of acne. New treatment regimens for doxycycline and isotretinoin would increase tolerance. Dapsone has been evaluated for isotretinoin-resistant forms. Phototherapy narrowband light (blue or red) can find its place in the strategy for the management of acne. Finally, acne vaccines could be developped too

Contact Sensitization to Emulsifying Agents: An Underrated Issue?

BackgroundThe evidence on the safety of topical preparations containing emulsifiers is limited. ObjectivesThe aims of the study were to assess (1) the prevalence of sensitization to some emulsifiers commonly found in topical products, (2) the sensitization to emulsifiers in relation to sex, age, and predisposing factors, and (3) the frequency of concomitant sensitization to other common allergens. MethodsAll consecutive patients presenting to the Allergy Unit of our Dermatological Department for allergological investigation were enrolled. All patients were patch tested with the Italian Società Italiana di Dermatologia Allergologica Professionale ed Ambientale baseline series and an additional emulsifiers series. Doubtful patch test reactions were not considered. ResultsOf 310 patients, 50 (16%) were sensitized to emulsifiers with 72 positive reactions. Lauryl polyethylene glycol/polypropylene glycol-18/18 methicone gave 26 positive reactions, glyceryl oleate 19, myristyl alcohol, and Amerchol L101 11. Concomitant sensitization to emulsifiers was found in 16 patients. Patients allergic to emulsifiers showed concomitant allergic reactions to allergens commonly found in cosmetics. No significant differences by sex, age, atopic diathesis, and clinical pattern at presentation were noticed. ConclusionsContact allergy to emulsifiers is more frequent than reported. Patients allergic to emulsifiers show frequent positive patch tests to other constituents of cosmetics and topical products.

Hidradenitis suppurativa–acne inversa: a relevant dermatosis in paediatric patients

have shown that the increased vascular risk in patients with psoriasis is due to the increased incidence of CVD risk factors compared with age-matched controls. Thus, using such risk calculators for psoriasis may not underestimate risk, as can occur for other conditions where a multiplication factor is required. Moreover, as chronic, severe psoriasis has been shown to have a similar level of inflammation to rheumatoid arthritis, it may be warranted, in some cases, to use the rheumatoid arthritis multiplication factor. It is also worth noting that NICE now recommends starting with atorvastatin 20 mg for primary prevention, with no role for simvastatin, and aiming for a 40% reduction in non-HDL cholesterol by dose titration. Statins have been shown to have anti-inflammatory properties, which may affect psoriasis severity. More patients with psoriasis will fall under the new lipid recommendations for statin treatment, and this will therefore open up opportunities to investigate whether the possible anti-inflammatory properties of statins will affect the severity or course of psoriasis. Ideally these changes will improve morbidity and mortality not only from the underlying psoriatic pathology but also from its sequelae. In summary, the new lipid modification recommendations from NICE are likely to improve the CVD risk assessment and management of patients with psoriasis. Unintended skin benefits may also ensue from the use of statins in these patients, which should be audited. Although it is not fully clear whether psoriasis is an independent risk factor for CVD in milder cases, patients with psoriasis seem to have an overall increased risk of CVD, making it important for general practitioners to be reminded to be attentive in monitoring this patient group for CVD risk factors.

Bullous pemphigoid occurring under anti-tumor necrosis factor-α therapy

Dear Editor: Anti-tumor necrosis factor-α (TNFα) agents are widely used to treat different kinds of autoimmune diseases, bullous skin diseases included. On the other hand, cases of autoimmune disease secondary to TNFα-targeted therapies have been reported. These include mainly cutaneous vasculitis, lupus-like syndrome, systemic lupus erythematosus, and interstitial lung disease. Only a few cases of bullous skin diseases have also been described [1–3]. The authors report a further case of bullous pemphigoid (BP) occurring in a patient undergoing Infliximab for ulcerative colitis (UC). A 54-year-old woman affected by distal ulcerative colitis since 2000 was treated with azathioprine (150 mg/day– 2.1 mg/Kg) after developing a corticosteroid resistance. After 3 years with good compliance, she presented a flare-up associated with more than 10 bowel movements daily. A complete ileo-colonoscopy with several mucosa biopsies was performed. Endoscopy revealed a diffuse friable mucosa and deep ulcers with blood clots in the left colon (Mayo score 3). Histological examination showed an ulcerated mucosa and marked inflammatory cell infiltration in the lamina propria with cryptitis. Initially, a treatment based on systemic corticosteroids (prednisone 1 mg/Kg/daily at tapering dosage) was performed, obtaining a mild clinical improvement of the disease. Considering the loss of efficacy of azathioprine, to achieve complete remission and to reach mucosal healing, anti-TNFα agent was taken into consideration. As laboratory findings resulted within normal limits, after corticosteroid tapering and discontinuation, Infliximab (5mg/kg) was started. Twenty days after the second infusion (during the induction phase), she developed an itching urticarial eruption located on her trunk and limbs. Over several days, this eruption developed into blisters on erythematous skin. Nikolsky’s sign was negative. The mucosae were not involved. Histological examination of skin biopsy revealed a superficial dermal inflammation consisting of lymphocytes. Deposition of IgG and C3 along the basement membrane was detected by direct immunofluorescence, confirming the clinical suspect of bullous pemphigoid. In the absence of any other known cause, the authors considered the chimeric anti-TNFα drug as a possible inducing factor. For this reason, Infliximab was stopped while systemic corticosteroids were restarted to keep both dermatologic and gastrointestinal diseases under control. After the resolution of the skin eruption, the patient started another human anti-TNFα (Adalimumab, 40 mg s.c. every other week after the induction phase) obtaining clinical improvement of UC in 1 month. After 5 months, the patient still maintains complete clinical remission. Vesicular-bullous lesions did not appear during the treatment with this human anti-TNFα. Pemphigus and the pemphigoid group are autoimmune conditions in which autoantibodies cause skin blistering secondary to loss of connections between skin cells. Pemphigus is characterized by intraepidermal blister due to antibodies that recognize cell adhesion molecules, the desmogleins. A small This manuscript has not previously been published and it is not otherwise submitted for publication. M. Ricci : S. Zauli :A. Virgili :V. Bettoli Department of Medical Sciences, Section of Dermatology, University of Ferrara, Ferrara, Italy

Does Anti-Tumour Necrosis Factor-Alpha Increase Oral Candida Colonization? A Case-control Study in Psoriatic Patients

© 2013 The Authors. doi: 10.2340/00015555-1469 Journal Compilation

Efficacy of new barrier socks in the treatment of foot allergic contact dermatitis.

The prevalence of allergic shoe dermatitis in patch-tested patients for foot dermatitis is reported in the literature to be in the range 3-24.2% (1, 2). It affects both sexes and any age group, including children. The most common shoe allergens reported are potassium dichromate, p-tertiary butylphenol formaldehyde resin, rubber chemicals and dyes present in leather tanning, rubber processing and adhesives. As nickel sulphate may be present in shoe buckles and studs, this may be considered a further shoe allergen (1-8). The warm and humid environment within the shoe provides an ideal situation for the development of allergic contact dermatitis (ACD), favouring both allergen dissemination and skin absorption. The first step in treating ACD is the removal of exposure to the causative allergens, but, for social, environmental or professional reasons (e.g. safety footwear or uniform), this may be difficult in the case of foot ACD. Textile engineering has recently developed socks made of a technological fabric Microair ® barrier (Al-pretec, Venice, Italy), a three-layer fabric designed to provide a physical barrier to allergens and irritants as well as high perspirability (9). The two external layers are made of a polyester microfibre with pique construction (fabric with a raised woven design) and the internal layer is made of a microporous membrane. This membrane is reported by the manufacturer to provide the fabric with total impermeability to liquids, ions and gas, and high wicking due to very high water vapour transmission rate (1062 g/m 2 /24 h). We studied the efficiency of these devices in a selected group of patients affected by ACD to footwear allergens.