Sergio Di Nuzzo

Nutrition and Inflammation in Older Individuals: Focus on Vitamin D, n-3 Polyunsaturated Fatty Acids and Whey Proteins

Chronic activation of the inflammatory response, defined as inflammaging, is the key physio-pathological substrate for anabolic resistance, sarcopenia and frailty in older individuals. Nutrients can theoretically modulate this phenomenon. The underlying molecular mechanisms reducing the synthesis of pro-inflammatory mediators have been elucidated, particularly for vitamin D, n-3 polyunsaturated fatty acids (PUFA) and whey proteins. In this paper, we review the current evidence emerging from observational and intervention studies, performed in older individuals, either community-dwelling or hospitalized with acute disease, and evaluating the effects of intake of vitamin D, n-3 PUFA and whey proteins on inflammatory markers, such as C-Reactive Protein (CRP), interleukin-1 (IL-1), interleukin-6 (IL-6) and tumor necrosis factor α (TNF-α). After the analysis, we conclude that there is sufficient evidence for an anti-inflammatory effect in aging only for n-3 PUFA intake, while the few existing intervention studies do not support a similar activity for vitamin D and whey supplements. There is need in the future of large, high-quality studies testing the effects of combined dietary interventions including the above mentioned nutrients on inflammation and health-related outcomes.

Hypertriglyceridaemia with bexarotene in cutaneous T cell lymphoma: the role of omega-3 fatty acids

Bexarotene is approved for the treatment of cutaneous T cell lymphomas in patients refractory to at least one prior systemic therapy. Associated hypertriglyceridaemia requires monitoring, but can readily be managed with concomitant medication, such as fenofibrate. Here we report three cases of hypertriglyceridaemia secondary to bexarotene assumption, which was adequately managed with omega‐3 fatty acids. If fenofibate‐related side effects occur, or a statin is required to control low‐density lipoprotein‐cholesterol, omega‐3 fatty acids should be considered as a good alternative therapy to lower lipid levels during bexarotene treatment.

Cryoinsufflation for Hurley Stage II Hidradenitis Suppurativa A Useful Treatment Option When Systemic Therapies Should Be Avoided

Report of a Case A woman in her 30s presented with hidradenitis suppurativa (HS), Hurley stage II. She was treated with oral contraceptives (drospirenone/ethinyl estradiol), spironolactone (50 mg/d), topical clindamycin, andmonthly intralesional corticosteroids (triamcinolone acetonide, 10 mg/mL). Previously, she had received rifampicin (600 mg/d), first with minocycline (100 mg/d), then with clindamycin (300 mg/d), and finally with moxifloxacin (400mg/d). After these treatments failed, she received isotretinoin (0.5 mg/kg/d) for 2 more years to achieve remission, but without success. Because shehaddecided tobecomepregnant, shewas searching for an alternative treatment, devoid of teratogenic effects, to safely replace oral contraceptives. Effective therapy was paramount because theHS seriously interferedwith sexual intercourse and indirectly with her planned pregnancy. Surgical treatmentwas offered (local incision anddrainage, deroofing, limited local orwide excision), which she declined.

Etanercept in the treatment of psoriasis and psoriatic arthritis with concomitant hepatitis C virus infection: clinical and virological study in three patients

Treatment of patients with psoriasis and concomitant hepatitis-C virus (HCV) infection poses a therapeutic challenge because most systemic drugs are associated with potential hepatotoxicity, either due to direct liver damage or to immunosuppression. Among newly available drugs for the treatment of psoriasis and psoriatic arthritis, studies investigating the effect of anti-tumour necrosis factor-α in such patients are still limited. We describe three psoriatic patients with HCV, one with concomitant alcoholic hepatitis, who were treated with etanercept monotherapy for six months. We obtained good clinical responses for both psoriasis and arthritis in all three patients. While no significant changes in viral load and transaminases were observed in two patients, alanine aminotrasferase and gamma-glutamyltransferase levels were raised during treatment in the patient with concomitant alcoholic hepatitis. At baseline, one patient was negative and two were positive for mixed-type cryoglobulins. During treatment, none of the patients developed cryoglobulinemia-related clinical symptoms, and one of the two patients positive at baseline was negative for cryoglobulins at the end of follow-up. Our results add to accumulating data suggesting that etanercept represents a valuable therapeutic option for treatment of HCV-positive psoriatic patients, with an acceptable safety profile in the short-term. However, etanercept treatment of HCV cases with concomitant alcoholic hepatitis must be undertaken with caution.

Are Anti-TNF-α Agents Safe for Treating Psoriasis in Hepatitis C Virus Patients with Advanced Liver Disease? Case Reports and Review of the Literature

Tumor necrosis factor-alpha (TNF-α) inhibitors represent an effective treatment for severe psoriasis in hepatitis C virus (HCV) patients. The literature reports mainly on short-term treatment in patients with chronic hepatitis with minimum-to-moderate activity with an acceptable safety profile. We report the first 2 cases of hepatocellular carcinoma (HCC) arising in HCV psoriatic patients with advanced liver disease during long-term treatment with etanercept. Our first patient, known to have had HCV infection for 41 years, developed an HCC after 21 months of therapy with etanercept (50 mg/week). The second patient, HCV+ for 20 years, was treated for 58 months with the same therapy, and despite no signs of liver function impairment was diagnosed with HCC. Both of them presented with cirrhosis, which was diagnosed 9 and 5 years earlier, respectively. It remains to be clarified whether there is any connection between psoriasis treatment with anti-TNF-α agents and the development of HCC in HCV-infected patients. Further long-term, follow-up studies and registries of HCV patients with mild/moderate activity may contribute to clarify this issue.

Treatment patterns with systemic antipsoriatic agents in childhood psoriasis: an Italian database analysis

BACKGROUND The majority of available systemic therapies have never been systematically investigated in moderate to severe childhood plaque psoriasis. For this reason, treatment preferences for moderate to severe psoriasis in childhood are still unknown. The aim of this study was to investigate the systemic treatment patterns of moderate to severe psoriasis in children and adolescents aged 18 or older in Italy. Additional secondary outcomes were duration of treatment and reasons for discontinuation. METHODS In order to define differences in treatment patterns, we performed a chart review of all consecutive patients treated with systemic drugs during an index period of 5 years. Consecutive sampling of all patients with psoriasis aged ≤18 years, who had been treated with at least one systemic drug over a 5-year period, was made. RESULTS The records of 58 consecutive patients, 27 males, 31 females. with moderate to severe psoriasis treated with at least one systemic therapy were reviewed. The median age (standard deviation) at the start of the first systemic treatment was 11.7±3.7 years. The most preferred first-line systemic treatment was cyclosporine, which was administered as first systemic treatment in 53.4% of patients, followed by acitretin in 22.4% of patients, etanercept and PUVA respectively in 8.6%, methotrexate in 6.8%. 48.2% of patients received a second systemic treatment due to inefficacy or side effects of the first-line therapy during the index period. Because of the small sample, and voluntary contribution, selection bias may have occurred. CONCLUSIONS A considerable variation in the management of the first-line systemic therapy in children with moderate to severe psoriasis was observed. Cyclosporine was most commonly preferred as a first-line treatment. The availability of new therapeutic agents could change the scenario of treatment patterns in childhood psoriasis.

Notalgia paresthetica: factors associated with its perceived severity, duration, side, and localization

Notalgia paresthetica (NP) is a disorder characterized by pruritus localized to the patients back. Little is known about predictors of severity, duration, side, and localization.

Cutaneous ulceration induced by leflunomide in a psoriatic patient.

names – pseudoépithélioma cutané, pyodermitis chronica vegetans of Azua, pseudoepithelioma of Azua, mycosis-like pyoderma, blastomycosis-like pyoderma, hyperinflammatory proliferative pyoderma, and pyoderma vegetans. It is likely that pyodermatitis–pyostomatitis vegetans represents a variant of the condition, mostly associated with inflammatory bowel disease. It may be viewed as a part of a wider spectrum of reactive neutrophilic dermatoses, such as Sweet’s syndrome and pyoderma gangrenosum. The list of associated conditions is long: inflammatory bowel diseases, diffuse T-cell lymphoma, alcoholism with malnutrition, diabetes mellitus, primary immunodeficiency, human immunodeficiency virus (HIV) infection, chronic myeloid leukemia, pulmonary granuloma, chronic granulocytic leukemia, arthritis treated with azathioprine and prednisone, psoriatic arthritis, colon carcinoma, seminoma, areas of tattoos, foreign body lesions, and halogen therapy. A patient with pyoderma vegetans, elevated serum IgE, and a history of hidradenitis suppurativa has also been described. Rarely, no underlying disorder can be found in patients with pyoderma vegetans. The histopathologic features of pyoderma vegetans include marked epidermal (pseudoepitheliomatous) hyperplasia, intraepidermal and/or subepidermal neutrophilic microabscesses, and a dense dermal inflammatory infiltrate. Cultures from skin lesions yield at least one pathogenic bacterium, usually Staphylococcus aureus, but rarely they may be sterile or contain only saprophytic bacteria, such as Staphylococcus epidermidis. The diagnosis of pyoderma vegetans is based on clinical and histologic findings: large verrucous plaques with elevated borders studded with pustules, and pseudoepitheliomatous hyperplasia with intraepidermal neutrophilic abscesses. Positive bacteriologic cultures may also be helpful. Other clinically similar conditions should be excluded with appropriate cultures (deep fungal infections and infections with atypical mycobacteria), immunofluorescence (pemphigus vegetans), history (halogenoderma), and histology (keratoacanthoma, pyoderma gangrenosum, squamous cell carcinoma). It may be difficult to distinguish pyoderma vegetans from a vegetating variant of pyoderma gangrenosum (superficial and granulomatous form) – the latter is characterized by abscesses/granuloma formation, plasmacytosis, and negative bacteriologic findings. The treatment of patients with pyoderma vegetans relies on systemic and topical antimicrobials, but corticosteroids, curettage, wet compresses, carbon dioxide laser debridement, azathioprine, dapsone, cyclosporine, acitretin, and tumor necrosis factor-α (TNF-α) inhibitors (etanercept) may be tried if the lesions are resistant to antimicrobial therapy, or if an associated illness requires additional treatment. Our patient shows that myelodysplastic syndrome, specifically RAEB-2, may also underlie pyoderma vegetans.

Claimed Effects, Outcome Variables and Methods of Measurement for Health Claims Proposed Under European Community Regulation 1924/2006 in the Framework of Maintenance of Skin Function

Evidence suggests a protective role for several nutrients and foods in the maintenance of skin function. Nevertheless, all the requests for authorization to use health claims under Article 13(5) in the framework of maintenance of skin function presented to the European Food Safety Authority (EFSA) have received a negative opinion. Reasons for such failures are mainly due to an insufficient substantiation of the claimed effects, including the choice of inappropriate outcome variables (OVs) and methods of measurement (MMs). The present paper reports the results of an investigation aimed at collecting, collating and critically analyzing the information with relation to claimed effects (CEs), OVs and MMs related to skin health compliance with Regulation 1924/2006. CEs, OVs and MMs were collected from both the EFSA Guidance document and from the authorization requests of health claims under Article 13(5). The critical analysis of OVs and MMs was based on a literature review, and was aimed at defining their appropriateness (alone or in combination with others) in the context of a specific CE. The results highlight the importance of an adequate choice of OVs and MMs for an effective substantiation of the claims.

Living with Chronic Spontaneous Urticaria in Italy: A Narrative Medicine Project to Improve the Pathway of Patient Care

Chronic spontaneous urticaria (CSU) is perceived as a difficult to manage disease with negative impact on quality of life. The aim of this study was to highlight how to improve the care of people with CSU, using the methodology of narrative medicine. From June 2014 to March 2015, CSU-diagnosed patients and their physicians were asked to record their experiences of the condition in writing. Fourteen healthcare teams participated: 41% considered CSU as a challenge to overcome, while 22% experienced CSU as a big commitment. The number of professional involved was evaluated as insufficient in 11 hospitals. Seventy-five percent of the 190 Italian patients had visited 3 or more physicians before receiving a final diagnosis, with a perceived waste of time and resources. The therapeutic pathways were described as unsatisfactory in 83% of cases. As a result, anger and frustration were life-dominant emotions in 92% of patients. The critical points of the care pathway are related to organizational issues and lack of awareness.