Sara Minghetti

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.

Proactive maintenance therapy with a topical corticosteroid for vulvar lichen sclerosus: preliminary results of a randomized study.

The chronic and relapsing nature of vulvar lichen sclerosus (VLS) represents a challenge for its long‐term management after an effective treatment with topical corticosteroids.

First randomized trial on clobetasol propionate and mometasone furoate in the treatment of vulvar lichen sclerosus: results of efficacy and tolerability

A 3‐month topical application of clobetasol propionate (CP) represents the recommended and accepted first‐line treatment for vulvar lichen sclerosus (VLS); however, to date, no randomized controlled trials have compared the efficacy and safety of CP with other topical corticosteroids.

Prospective Clinical and Epidemiologic Study of Vulvar Lichen Sclerosus: Analysis of Prevalence and Severity of Clinical Features, together with Historical and Demographic Associations

Background: Few reports have addressed the associations between clinical, demographic and historical variables of vulvar lichen sclerosus (VLS). Objective: To elaborate the prevalence and severity of signs and symptoms and to identify potential factors predicting the severity and course of VLS. Methods: A prospective cohort of 225 patients affected by VLS was included. Data were collected by direct interview and clinical examination. Results: 98% of patients complained of symptoms, principally itching. Pallor and scarring-sclerosis-atrophy were the most frequent and severe signs. The severity of VLS signs was not associated with age at onset and duration of the disease. About 70% of the patients had previously undergone treatment. Conclusions: VLS-related symptoms were not associated with the clinical features which resulted less severe. Personal history of autoimmune diseases and familial history of VLS did not influence the age at onset and the severity of VLS. A considerable part of patients had previously received inappropriate treatment.

Low-cumulative dose isotretinoin treatment in mild-to-moderate acne: efficacy in achieving stable remission

Background  Aimed at the reduction of post‐treatment relapse of severe acne, the cumulative dose of oral isotretinoin should be ≥120 mg/kg. However, data on the appropriate oral isotretinoin treatment regimen in mild and moderate acne are lacking.

Acute Acne Flare following Isotretinoin Administration: Potential Protective Role of Low Starting Dose

E-Mail karger@karger.ch www.karger.com flammatory flares may occur during the first 3–5 weeks of treatment [5] . The flares manifest by paradoxical aggravation of acne, notably of the inflammatory component. As a rule, mild forms of flare resolve spontaneously and do not require change or discontinuation of treatment. Sometimes, inflammatory flare-up can be particularly severe and may distress the patient. These severe flares must be distinguished from acne fulminans, which is accompanied by systemic signs, articular symptoms and biochemical signs of inflammation [6] . Severe inflammatory acne deterioration may lead to scar development. In severe cases, systemic steroid therapy and either reduction or discontinuation of isotretinoin are necessary. The actual responsibility of oral isotretinoin in the extent of these flares is not proven. However, improvements usually occur upon discontinuation of isotretinoin, while increases in dosage can aggravate the inflammation. In order to avoid acne flares, many authors suggest to start oral isotretinoin treatment with a dose of no more than 0.5 mg/kg/ day for the first month, and then to increase the daily dosage to 1 mg/kg [7] . With the present observational study, we wanted to assess whether initial daily doses ! 0.5 mg/kg can further reduce the occurrence of flares during the first month of isotretinoin administration. Between October 2002 and October 2007, 132 acne patients (67 males and 65 females, mean age 20.3 years) whose clinical features are reported in table 1 , group 1, were treated with oral isotretinoin at an initial daily dose ̂ 0.2 mg/kg. The dosage was subsequently increased by 5 mg every 2 weeks, until the maximum tolerated dose (between 0.5 and 1 mg/kg of body weight) was reached. All patients were treated until acne clearing, without exceeding a total cumulative dose of 150 mg/kg. With the aim of

Clobetasol propionate vs. mometasone furoate in 1-year proactive maintenance therapy of vulvar lichen sclerosus: results from a comparative trial.

Twice‐weekly proactive application of mometasone furoate 0.1% ointment (MMF) over 52 weeks was found to be an effective and safe therapy option in maintaining vulvar lichen sclerosus (VLS) remission and in preventing relapse.

Mometasone fuoroate 0.1% ointment in the treatment of vulvar lichen sclerosus: a study of efficacy and safety on a large cohort of patients

Guidelines identify a 3‐month topical application of an ultra‐potent corticosteroid ointment as the mainstay of medical treatment for vulvar lichen sclerosus (VLS). However, there are no trials providing evidence that any specific corticosteroid is superior to another.

Long-term maintenance therapy for vulvar lichen sclerosus: the results of a randomized study comparing topical vitamin E with an emollient

BACKGROUND The chronic and relapsing nature of vulvar lichen sclerosus (VLS) represents a challenge for its long-term management after an effective treatment with topical corticosteroids. OBJECTIVE To compare the effect of topical vitamin E with that of an emollient in reducing the risk of VLS relapse over a 52-week maintenance treatment. METHODS 156 patients with VLS were enrolled in a 12-week active treatment phase on topical 0.1% mometasone furoate ointment once daily. Those who achieved disease remission entered a 52-week maintenance phase in which patients were randomized to apply either an emollient or topical vitamin E once daily. RESULTS 80 patients entered the maintenance phase. At 52 weeks, for the vitamin E maintenance group, the cumulative crude relapse rate was 27.8% and the cumulative modified crude relapse rate was 55.6%. For the emollient maintenance group, the cumulative crude relapse rate was 22.7% and the cumulative modified crude relapse rate was 50.0%. The median time to relapse was 20 weeks for the vitamin E group and 18.7 weeks for the emollient group. CONCLUSION Once VLS has been stabilized with topical corticosteroids, long-term treatment with both vitamin E and emollients may be considered in maintain LS remission.

Continuous vs. tapering application of the potent topical corticosteroid mometasone furoate in the treatment of vulvar lichen sclerosus: Results of a randomized trial

Topical corticosteroids are the first‐line treatment for vulvar lichen sclerosus (VLS). However, evidence on the most appropriate treatment regimen is lacking.