Stefania Zauli

Diagnostic delay in hidradenitis suppurativa is a global problem.

DEAR EDITOR, Hidradenitis suppurativa (HS) is clinically defined with recognized diagnostic criteria and recognizable physical characteristics. Untreated, the disease causes significant morbidity. The prevalence varies between 0 0003% and 4% depending on the study population. Estimates from insurance databases suggest a prevalence of < 0 1%. This variation strongly suggests a significant selection bias or misclassification, and it may be speculated that not all patients present for care. This is reinforced by clinical experience and published evidence indicating a significant delay in diagnosis. This study explores the delay in diagnosis for patients with HS on an international level. The study (survey) was conducted in 2013. Observational data were collected during routine visits or extracted from case records. Because of the simple and obvious symptomatology of recurrent painful lesions present in restricted welldefined areas of the body, patients’ self-reported history was considered valid regarding onset of symptoms. Consecutive patients with HS and psoriasis were included from each participating centre during a period of 4 months or less. The data were anonymized by removing any names, addresses and social security numbers, and included age, sex, age at disease onset, age at diagnosis, delay in diagnosis, time from onset of symptoms to first physician contact, age at first medical contact, number of physicians seen prior to the diagnosis, family history and disease severity. If the diagnosis was made by a primary care physician or by a specialist other than a dermatologist prior to seeing a dermatologist, this was recorded as the date of the diagnosis. Individual centres were responsible for and obtained any locally required permissions and signed informed consent forms, for example ethics committee approval, in accordance with national registry and data protection rules. Patients diagnosed with HS or psoriasis (and confirmed by the investigator) were included. The primary outcome was quantification of the delay in diagnosis. Additionally, documentation was made of both the delay in visiting a physician (and so gaining access to specialist treatment) and the relative delay in diagnosis of HS compared with psoriasis with/without a family history. The severity of HS was determined by Hurley’s staging criteria: stage I, mild; stage II, moderate and stage III, severe. In patients with psoriasis, severity was evaluated by the Psoriasis Area and Severity Index: score < 7, mild; 7–12, moderate and > 12, severe. The t-test, Wilcoxon rank sum test and v-test were used where appropriate. Univariate and multivariate logistic regression analyses were used to identify factors predictive of significant diagnostic delay. Diagnostic delay > 2 years was defined as significant. Diagnosis, sex, age of onset, family history and disease severity were selected as potentially important

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.

Retinoids in the chemoprevention of non-melanoma skin cancers: why, when and how

Introduction: The chemoprevention refers to the use of various types of chemical agents for preventing carcinogenic progression. Systemic retinoids are the most studied chemopreventive agents due to their capacity to regulate cell proliferation and their demonstrated efficacy in several clinical studies. Objectives: The aim of the authors was to give precise indications regarding the use of the systemic retinoid in the chemoprevention of non-melanoma skin cancer (NMSC). Methods: The authors reviewed the literature found through a search to MEDLINE (from 2001 to December 2011). Results: Both acitretin and isotretinoin are effective for the prevention of NMSC. Isotretinoin is preferred in xeroderma pigmentosum and nevoid basal cell carcinoma syndrome, whereas acitretin is more used in transplant recipients, psoriasis and severe sun damage. Conclusion: Despite numerous studies of the literature concerning retinoids in chemoprevention of NMSC, precise details of the type of retinoid to use, dosage and the duration of this preventive treatment and how to manage side effects in the case of long-lasting treatment are still not uniform and comparable. Moreover, neither guidelines nor approval by Food and Drug Administration exist to regulate the use of retinoids in chemoprevention.

Onychomadesis following hand, foot, and mouth disease: a case report from Italy and review of the literature.

Hand, foot, and mouth disease (HFMD) is a relatively common and highly contagious enteroviral infection that occurs in small epidemics, usually in autumn or spring. The illness primarily affects young children and is clinically characterized by vesicular and erosive stomatitis in combination with vesicular eruption of the palms and soles, and, sometimes, a maculopapular rash. Outbreaks of HFMD have been caused mainly by coxsackie virus (CV) A16 and enterovirus 71, but CV strains A5, A7, A9, A10, B1, B2, B3 and B5 have also been associated with the illness. We report two cases of HFMD-related onychomadesis in Italy and review the published data concerning this emergent condition.

Overweight, diabetes and disease duration influence clinical severity in Hidradenitis Suppurativa ‐ Acne Inversa. Evidence from the national Italian Registry

DEAR EDITOR, Hidradenitis suppurativa–acne inversa (HS-AI) is a chronic inflammatory skin condition that involves the folliculopilosebaceous units. Histopathological studies have suggested that the occlusion of the follicular infundibulum and both innate and adaptive immunity play central roles. Limited data regarding the clinical aspects and prognosis of HS-AI are available. This paper presents data collected within the newly implemented Italian registry of patients with HS-AI. This was a cross-sectional study on baseline data of a cohort of consecutive patients with a new diagnosis of HS-AI, prospectively observed within a network of Italian dermatology departments. Presence and recurrence, for at least 6 months, of nodules, abscesses, draining sinuses and secondary retracting scars localized on the axillae, suband intermammary areas, inguinal folds, buttocks and perianal areas were considered as inclusion criteria. Written informed consent was obtained from the patients, or from their parents for subjects younger than 18 years, before inclusion in the registry. The study was approved by the ethics committee of the Sant’Anna Hospital in Ferrara. The information collected, using a standardized data collection form, included demographic data, anthropometric measures, selected personal habits, clinical history of the disease, clinical features at entry and follow-up, presence of comorbidities, and therapies prescribed for at least 1 month. The severity of HS-AI was assessed by a physician using the Sartorius score. A short course was run among participants to harmonize Sartorius score calculation, and the inter-rater agreement of independent measures obtained by participants on a small series of patients was judged satisfactory (data not shown). Age-standardized prevalence rates were computed using the 2011 Italian population as a reference. The frequency distribution of selected variables within the HS-AI sample was compared with the distribution in the general population using standardized prevalence ratios along with their 95% confidence intervals (CIs). The Mann–Whitney U-test and Kruskal–Wallis test were used to assess differences across different levels of selected variables for HS severity. To assess which factors were independently associated with HS severity, baseline variables with a P-value < 0 10 in the univariate analysis were evaluated in multivariate linear regression models with forward stepwise selection algorithms. The effects of selected factors were expressed in terms of standardized (Pearson) correlation coefficients (q) along with their 95% CIs and P-values. All tests were considered significant at P < 0 05. From January 2009 to June 2013, 245 patients in seven Italian referral centres for HS-AI were included in the registry; 59 6% of patients were female, and the age at entry was between 6 and 85 years (mean 33 4 13 0), with a mean age at first diagnosis by a physician of 28 2 11 8 years, and a mean Sartorius score of 78 4 66 1 (Table 1). The mean age at onset of the disease was 21 3 10 2 years, and the main affected locations at baseline were the groin/genitals (44 1%), axillae (34 7%), buttocks (10 2%) and trunk (9 0%). The most frequently reported comorbidities were acne (5 7%), thyroid diseases (4 5%) and diabetes (4 1%). Compared with the general Italian population, adult patients (aged ≥ 18 years) with HS-AI were more frequently overweight or obese (age-standardized prevalence ratio 1 4, 95% CI 1 1–1 9), and the prevalence of current smokers was substantially higher (age-standardized prevalence ratio 2 5, 95% CI 1 9–3 4). There were some significant variations between sexes. Age at onset was higher in male patients (24 2 12 7 vs. 19 4 7 6, P = 0 003), while groin/genital involvement was more frequent in female patients (50 7% vs. 34 3%, P = 0 01). In the univariate analysis, age, duration of disease, diagnostic delay, body mass index (BMI), smoking habits and presence of diabetes were all associated with an increased severity of the disease at baseline (Table 2). In the multivariate analysis, duration of disease ≥ 5 years, obesity (BMI ≥ 30 kg m ) and the presence of diabetes were maintained as independent factors directly associated with HS-AI severity. Further analysis showed that smoking correlated with both duration of disease and BMI, with a significant linear trend across different levels of the variables (data not shown). Our data show that the implementation of a registry for HS-AI is feasible and could provide useful data to direct disease management. Smoking and obesity have been proposed as risk factors either to trigger or to exacerbate HS-AI. In our cohort approximately 70% of the patients were current smokers (65 7%) or ex-smokers (8 6%), and the number of current smokers was higher than in the general Italian population. However, we lacked a control group of smokers matched for BMI. Smoking has been associated with increased severity of HS-AI in some studies but not others. In our study smoking

Is hormonal treatment still an option in acne today

Hormonal treatment is indicated in cases of papulopustular, nodular and conglobate acne in females with identified hyperandrogenism, in adult women who have monthly flare‐ups and when standard therapeutic options are unsuccessful or inappropriate. This review summarizes the latest information on hormonal therapies including: combined oral contraceptives; anti‐androgens, such as cyproterone acetate, spironolactone and flutamide; low‐dose glucocorticoids and gonadotropin‐releasing hormone agonists. It also shares the authors’ recommendations for treatment based on the studies discussed here, and personal experience.

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.

Cyclosporine treatment of severe Hidradenitis suppurativa – A case series

Abstract Background: Hidradenitis suppurativa (HS) is an overlooked but common disease severely affecting both genders. HS is generally perceived as difficult to treat and although a number of treatments are available, the need for more effective treatment is apparent. Objectives: Cyclosporine A (CsA) has been suggested as an effective treatment in four smaller case series. It was therefore decided to review a larger series of cases, reporting all outcomes in order to provide a less biased base for evaluating the potential of CsA for use in HS. Methods: An exploratory retrospective review of case notes was performed at three departments of dermatology with a special interest in HS, where HS had been treated with CsA in the period 2009–2012. Results: In total, 18 HS patients treated with CsA were identified and analysed and 50% reported some benefit. All patients had previously been treated with multiple various other modalities. Limitations: This is an exploratory retrospective review with a limited number of patients. Conclusions: This retrospective review found some effect of CsA in the recalcitrant cases studied, mainly reported as “slight improvement”. This may be due to a number of factors which may have overestimated (e.g. concommitant therapy) or underestimated (e.g. case selection of recalcitrant cases) the effect, and indicates the need for prospective evaluation of the claims. The present data provide a basis for power calculations in future studies investigating the potential for treating HS with CsA in a randomised controlled trial.