Nicoletta Cassano

Survival rate of antitumour necrosis factor‐α treatments for psoriasis in routine dermatological practice: a multicentre observational study

Adherence is an overall marker of treatment success, and it depends on multiple factors including efficacy and safety. Despite the wide use of tumour necrosis factor (TNF)‐α blockers in the treatment of plaque‐type psoriasis, few data regarding treatment adherence in routine clinical practice are available.

Psoriasis and cardiovascular disease.

Current epidemiological data support the association between psoriasis and cardiovascular (CV) risk, in apparent correlation with psoriasis severity. Although less unanimously, evidence of an increased prevalence of CV diseases among psoriasis patients has been reported, including ischemic heart disease, cerebrovascular, peripheral vascular and heart structural disorders. In particular, various studies showed a correlation between psoriasis and major CV events (i.e., myocardial infarction, stroke), while others investigated subclinical changes of blood vessels, such as intima‐media thickness increase, arterial stiffness and coronary artery calcification. A series of different mechanisms, like traditional CV risk or iatrogenic risk factors, inflammation, hemostasis dysregulation, hyperhomocysteinemia, and shared genetic susceptibility, are thought to underlie this epidemiological association. Among these elements, inflammation and its related cytokine milieu, including Th1‐mediated response and Th17/Treg imbalance, C reactive protein and the newly implicated osteopontin are considered to play a primary role, even if yet to be fully understood.

Low-dose dapsone in chronic idiopathic urticaria: preliminary results of an open study.

Sir, Chronic idiopathic urticaria (CIU) is defined as the occurrence of wheals on most days for more than 6 weeks in the absence of any known causative or triggering agents (1). Most cases of chronic urticaria are classified as ‘idiopathic’, despite intense efforts to determine any aetiological factor, and require long-term treatment with H1-receptor antagonists, which are the first-line approach to uncomplicated forms (2). Here we present our cumulative experience with dapsone in some cases of severe refractory CIU.

Narrow‐band UVB phototherapy combined with tacrolimus ointment in vitiligo: a review of 110 patients

Background  Narrow‐band ultraviolet B (NB‐UVB) phototherapy and topical tacrolimus are included among the most innovative approaches to vitiligo.

Incidence of psoriasis and association with comorbidities in Italy: a 5-year observational study from a national primary care database.

An observational study was conducted to estimate the incidence of psoriasis in Italy, as well as the utilization of healthcare resources and the association with selected comorbidities in psoriasis patients. The data source was the Health Search/Thales Database, containing computer-based patient records from over 900 primary care physicians (PCPs) throughout Italy. The study cohort comprised all adults receiving a first-ever diagnosis of psoriasis during the years 2001-2005. From a total sample of 511,532 individuals, the incidence of psoriasis was 2.30-3.21 cases per 1,000 person-years. Psoriatic arthritis was present in 8% of psoriasis patients. The comparison with matched controls showed that psoriasis patients were more likely to have comorbidities (e.g., chronic bronchitis, chronic ischemic heart disease, obesity and diabetes mellitus) and to undergo PCP visits and hospitalizations, and to refer for specialist visits. The use of non-steroidal anti-inflammatory drugs appeared to be significantly more prevalent in patients as compared to controls. Topical therapy with corticosteroids and non-steroidal preparations accounted for 45.3% and 47.2% of all cases, respectively. Only a minority of cases used systemic immunosuppressive drugs or acitretin. The incidence rate of psoriasis in our study was particularly high and might reflect an overestimation by PCPs. Our results show the association between psoriasis and multiple comorbidities.

Infliximab in recalcitrant severe atopic eczema associated with contact allergy.

Infliximab is an anti-tumour necrosis factor (TNF)-alpha chimeric monoclonal antibody which is effective in diseases associated with a T-helper (Th) 1 response, such as rheumatoid arthritis, Crohns disease and psoriasis. There are sporadic case reports of atopic dermatitis (AD) induced or precipitated by anti-TNF-alpha therapy, which have been attributed to the switch towards Th2-mediated reactions. We report the case of a 30-year-old man with long-standing severe AD associated with contact allergy and poorly responding to conventional treatments. The use of infliximab resulted in a dramatic amelioration of AD lesions and pruritus, persisting at follow-up examinations over a 3-year period. Probably, the unexpected response to infliximab therapy in this case might be due to some peculiar features of AD in our patient (i.e. chronic-continuous course and concomitant contact allergy) which could have been responsible for a more preponderant recruitment of Th1 cells as compared to common forms of AD.

Remission of delayed pressure urticaria after eradication of Blastocystis hominis.

Sir, Blastocystis hominis is one of the most common human intestinal protozoans in the world, especially in developing countries. Nevertheless, current knowledge about this parasite is incomplete and, despite recent progresses, several issues are still controversial and much debated, such as the clinical relevance and pathogenicity (1–4). B. hominis has been found in patients with gastrointestinal symptoms as well in asymptomatic individuals. It has long been considered a harmless commensal but growing evidence seems to support its role as a pathogenic parasite. In the absence of conclusive data, it could be hypothesized that the pathogenic potential and virulence of Blastocystis are conditioned by other concomitant factors, such as the host response, and depend on the number of organisms or the type of strains, considering that a remarkable antigenic and genetic heterogeneity among isolates has been demonstrated (4). Extra-intestinal manifestations of B. hominis infection have rarely been reported and include infectious or reactive arthritis (5–7) and skin disorders (8–11), such as palmoplantar or diffuse pruritus and chronic urticaria. A 32-year old woman with a history of allergic rhinitis had since October 1998 suffered from chronic recurrent urticaria which was almost controlled by treatment with H1-receptor antagonists. Whealing subsided after 4 years, when cutaneous manifestations were replaced by painful swellings in pressure sites. For this reason, she was examined in November 2002, where a delayed pressure urticaria (DPU) was diagnosed. Treatment with systemic corticosteroids gave only partial benefit. Subsequently, dapsone was introduced at a dose of 25 mg/day. Symptoms gradually ameliorated over a 3-month period without disappearing. After dapsone discontinuation, her symptoms became severe and disabling within 1 month, despite regular treatment with H1-receptor antagonists. Skin lesions on the feet were sometimes associated with marked pain, which was so intense that it induced the patient to wear larger shoes than usual. Whealing of common urticaria or angioedema never occurred. The only concomitant symptoms reported by the patient were mild ponderal loss and persistent asthenia. Pressure challenge tests confirmed the diagnosis of DPU. Laboratory investigations failed to disclose any systemic diseases, including malabsorption, endocrinological, autoimmune and rheumatological disorders. Full blood count, including eosinophil count, erythrocyte sedimentation rate, C-reactive protein, cryoglobulins, circulating immune complexes, C3, C4, C1-INH, IgE and other immunoglobulins were all within the normal range. Chest radiography, radiographic examination and laser Doppler flowmetry of the limbs revealed unremarkable findings, as well as serological investigations, oropharyngeal swabs and faecal antigen test with Helicobacter pylori. Stool examinations on three consecutive samples were positive for B. hominis. The patient was then treated with metronidazole 1.5 g/ day for 10 days. DPU began to improve 2 weeks after

Efficacy and Safety of Systemic Treatments for Psoriasis in Elderly Patients

Management of psoriasis in elderly patients can be challenging, because of the impairment of immune system efficiency and the presence of comorbidities that contra-indicate systemic therapies. We studied the safety and efficacy of systemic traditional and biological treatments in 187 consecutive psoriatic patients aged > 65 years. At week 12 of therapy, Psoriasis Area and Severity Index 75 was achieved by 49%, 27%, 46% and 31% of patients who received methotrexate, acitretin, cyclosporine or PUVA, and 64.1%, 64.7%, 93.3%, 57.1% and 100% of patients who received etanercept, adalimumab, infliximab, efalizumab and ustekinumab. The rate of adverse events was 0.12, 0.32, 1.4 and 0.5 per patient-year in the methotrexate, acitretin, cyclosporine and PUVA groups and 0.11, 0.35, 0.19, 0.3 and 0.26 in the etanercept, adalimumab, infliximab, efalizumab and ustekinumab groups. Traditional drugs were less effective than biologics in our elderly population. Etanercept was associated with a lower rate of adverse events compared with other treatments.

Chronic Pruritus in the Absence of Specific Skin Disease An Update on Pathophysiology, Diagnosis, and Therapy

Chronic pruritus is a major and distressing symptom of many cutaneous and systemic diseases and can significantly impair the patient’s quality of life. Pruritus perception is the final result of a complex network involving dedicated nerve pathways and brain areas, and an increasing number of peripheral and central mediators are thought to be involved. Itch is associated with most cutaneous disorders and, in these circumstances, its management overlaps with that of the skin disease. Itch can also occur without associated skin diseases or primary skin lesions, but only with nonspecific lesions secondary to rubbing or scratching. Chronic itch with no or minimal skin changes can be secondary to important diseases, such as neurologic disorders, chronic renal failure, cholestasis, systemic infections, malignancies, and endocrine disorders, and may also result from exposure to some drugs. The search for the cause of pruritus usually requires a meticulous step-by-step assessment involving careful history taking as well as clinical examination and laboratory investigations.Few evidence-based treatments for pruritus are available. Topical therapy, oral histamine H1 receptor antagonists, and phototherapy with UV radiation can target pruritus elicitation in the skin, whereas antiepileptic drugs, opioid receptor antagonists, and antidepressants can block signal processing in the CNS.

Regressing cutaneous malignant melanoma and vitiligo-like depigmentation.

Association of malignant melanoma (MM) with various clinical forms of skin depigmentation is well‐known. We report a case highlighting the importance of careful examination of patients with skin hypomelanoses, including vitiligo and halo nevi, in order to exclude the presence of MM.