Stefano Veraldi

Short contact therapy with tazarotene in psoriasis vulgaris

Background: We present the results of a multicentre, not controlled, clinical study on the tolerability and efficacy of tazarotene gel, used as short contact therapy (SCT), in psoriasis vulgaris. Objective: To evaluate whether irritant contact dermatitis caused by tazarotene was less frequent and/or less severe with SCT than with traditional therapy, and whether SCT with tazarotene was as effective as traditional therapy. Methods: Forty-three patients with plaque psoriasis were treated by SCT with 0.1% tazarotene gel (once daily application for 20 min, followed by washing with water). Treatment duration was 45 days. Results: Irritant contact dermatitis caused by tazarotene used as SCT was much less frequent and severe than traditional treatment with the same drug. SCT with tazarotene was effective in the treatment of plaque psoriasis. Conclusion: Tazarotene, used as SCT, was better tolerated than the same drug used as traditional treatment. Furthermore, SCT appeared to be as effective as traditional therapy with the same drug.

Tungiasis has reached Europe.

Tunga penetrans L. is a flea that lives in Central and Southern America, Africa and Central and Eastern Asia. In Europe, only imported cases of tungiasis have been described so far [1]. We present the first autochthonous case of tungiasis in Europe. A 26year-old Italian man, a lifeguard by profession in Forte dei Marmi (north-eastern Tyrrhenian Sea, Italy), was examined because of a papular-nodular lesion localized on the fourth toe of the left foot. The patient stated that he was in good general health and that he was not on any drug. The patient also stated that in all his life he had visited only France and Switzerland. Dermatological examination revealed a round lesion, 0.3 cm in diameter, brownish in colour, with well-defined borders, hard in consistency and painful. A close examination revealed a tiny central ulcer, from which a few drops of serohaematic fluid oozed: it contained several oval-shaped, white ‘bodies’ that, by microscopic examination, were found to be eggs of T. penetrans L. Enlarging the ulcer by means of the tip of a scalpel, it was possible to remove portions of the body of the flea, other eggs and necrotic material. The residual cavity was subjected to surgical debridement. Topical mupirocin (twice a day for 7 days) was prescribed. The patient was also subjected to antitetanus prophylaxis. General physical examination did not reveal anything pathological. Laboratory examinations were within normal ranges. The lesion healed within 10 days. As previously mentioned, this patient represents the first autochthonous case of tungiasis in Europe. The patient had never visited in all his life areas endemic for tungiasis. On the basis of the clinical history, he was most likely infected, because of his job of lifeguard, by African hawkers coming from countries endemic for tungiasis (in particular Senegal, Sierra Leone, Ghana and the Ivory Coast) who walk barefoot along the Italian beaches. It is possible that beaches of the Mediterranean Sea are a good habitat for T. penetrans L.: in fact, its natural habitat is represented by sandy and warm soil of tropical and subtropical deserts and beaches [1].

Epiluminescence microscopy in cutaneous larva migrans.

Sir, Elsner et al. (1) diagnosed cutaneous larva migrans (CLM) in a patient by means of epiluminescence microscopy (EM). We have evaluated the usefulness of this method in a group of Caucasian patients with clinically suspected CLM who had returned from trips to tropical and sub-tropical countries. We examined 18 patients (10 men and 8 women, aged 20 ± 68 years) in whom the diagnosis of CLM was based on history and clinical picture. EM (610 magni®cation) was carried out in all lesions of the patients. Skin biopsies were not performed. In 14 patients, at least 1 foot was involved. Other localizations were breast, abdomen, thighs, lumbar region, buttocks and calf. CLM was characterized by multiple tracks in 9 patients; in total, we counted approximately 60 tracks in 18 patients. One larva was observed in 1 lesion of 1 patient (5.5%). In total, EM was positive in 1 out of 60 tracks (1.6%). In the last few years, EM has been demonstrated to be a simple, non-invasive, rapid and effective method to con®rm the clinical diagnosis of parasitic diseases of the skin, in particular scabies (2). However, on the basis of our results, EM appears not to be useful to con®rm the clinical diagnosis of CLM. At least 4 hypotheses may be advanced to explain these observations: (a) larvae were already dead when EM was performed; (b) living larvae were localized in deeper layers of the skin, beyond the resolution power of EM; (c) 610 magni®cation is not suf®cient to detect the larvae (this is the most likely hypothesis); and (d) we are unable to use EM properly! We believe that careful clinical history and dermatological examination remain today the most important ®ndings to make a diagnosis of CLM.

Psychological factors involved in prurigo nodularis: A pilot study

Abstract Emotional stresses and psychological disorders seem to be concurrent factors in some cases of prurigo nodularis (PN), a chronic skin condition with a difficult therapeutic approach. In order to improve the therapeutic strategies, we performed a psychometric study on 20 patients affected by generalized and histological proven PN. Specific questionnaires were employed to examine the hypotheses (General Health Questionnaire, State Trait Anxiety Inventory – form Y, Beck Depression Inventory-II, and Eysenck Personality Questionnaire). The results show that symptoms of anxiety and depression associated with PN are more severe than in the control group and that some specific traits of personality are more frequently represented in such subjects. The results of our study represent a first attempt to analyze the psychological problems and the personality dimensions which seem to characterize PN patients. Such evidence supports the importance of a psychological approach in the clinical management of PN, which should always include psychological assessment and treatment together with the other therapeutic options.

One-week therapy with oral albendazole in hookworm-related cutaneous larva migrans: A retrospective study on 78 patients

Abstract We evaluated retrospectively the efficacy and tolerability of oral albendazole (400 mg/day for 1 week) in 78 patients with hookworm-related cutaneous larva migrans characterized by multiple and/or extensive lesions. The diagnosis was based on history and the clinical picture. Neither topical or systemic drugs nor physical treatments were used. All patients were followed-up for at least 3 months after the therapy. All patients were cured at the end of the therapy. The disappearance of pruritus was reported after 2–3 days and skin lesions after 5–7 days of therapy. One patient reported nausea and abdominal pain; another patient reported worsening of pruritus: in both cases it was not necessary to stop the therapy. No recurrences were observed during follow-up. One week of therapy with 400 mg/day oral albendazole is very effective (cure rate: 100%) in patients with cutaneous larva migrans characterized by multiple and/or extensive lesions. This therapeutical regimen is not accompanied by the appearance of new and/or more severe side effects.

Paederus fuscipes dermatitis: a report of nine cases observed in Italy and review of the literature

Paederus sp. is a beetle belonging to Staphylinidae family and Coleoptera order. Its distribution is worldwide, especially in hot climates. Over 600 species of Paederus are known, approximately 50 are able to cause an irritant contact dermatitis. When the beetle is accidentally crushed on the skin, it releases pederin, a potent toxin with vesicating action. In Europe, only anecdotical cases of Paederus sp. dermatitis have been reported. Since 1993, we have observed approximately 25 patients with suspected Paederus sp. dermatitis. In 9 the clinical diagnosis was confirmed because Paederus fuscipes were found. The case list includes 6 males and 3 females, ages ranging from 6 to 53 years (mean age: 26.3 years). Six patients presented with one lesion and 3 with 2 lesions. Eyelids (3 patients), shoulders (3), neck (2), cheek (1), breast (1), back (1) and calf (1) were involved. All patients showed erythema, 2 oedema, 2 blisters, 1 vesicles, 1 pustules and 1 crusts. In the patient with pustules, bacteriological examinations were negative. A biopsy was carried out in 4 patients. In the early stages, spongiosis with exocytosis of neutrophils was observed. Vesicles with neutrophils and necrosis of the epidermis were typical of the advanced stage. Oedema of the dermis and a mixed infiltrate, with eosinophils, neutrophils and lymphocytes, in the papillary and upper reticular dermis, were also observed. Direct immunofluorescence was negative in all patients. Paederus sp. should also be considered in temperate climates as a possible aetiological agent in cases of acute dermatitis.

Leishmaniasis of the lip.

1. Evans EG, Sigurgeirsson B. Double-blind, randomised study of continuous terbina® ne compared with intermittent itraconazole in treatment of toenail onychomycosis. BMJ 1999; 318: 1031 ± 1035. 2. Roberts DT. Prevalence of dermatophyte onychomycosis in the United Kingdom: results of an omnibus survey. Br J Dermatol 1992; 126 Suppl 39: 23 ± 27. 3. HeikkilaÈ H, Stubb S. The prevalence of onychomycosis in Finland. Br J Dermatol 1995; 133: 699 ± 703. 4. Gupta AK, Lynde CW, Jain HC, Sibbald RG, Elewski BE, Daniel CR, 3rd, et al. A higher prevalence of onychomycosis in psoriatics compared with nonpsoriatics: a multicentre study. Br J Dermatol 1997; 136: 786 ± 789. 5. Gupta AK, Konnikov N, MacDonald P, Rich P, Rodger NW, Edmonds MW, et al. Prevalence and epidemiology of toenail onychomycosis in diabetic subjects: a multicentre survey. Br J Dermatol 2000; 139: 665 ± 671. 6. Gudnadottir G, Hilmarsdottir I, Sigurgeirsson B. Onychomycosis in Icelandic swimmers. Acta Derm Venereol 1999; 79: 376 ± 377. 7. Levy LA. Epidemiology of onychomycosis in special-risk populations. J Am Podiatr Med Assoc 1997; 87: 546 ± 550. 8. Sais G, Jucgla A, Peyri J. Prevalence of dermatophyte onychomycosis in Spain: a cross-sectional study. Br J Dermatol 1995; 132: 758 ± 761. 9. Sigurgeirsson B, Billstein S, Rantanen T, Ruzicka T, di Fonzo E, Vermeer BJ, et al. L.I.ON. Study: ef® cacy and tolerability of continuous terbina® ne (Lamisil) compared to intermittent itraconazole in the treatment of toenail onychomycosis. Lamisil vs. itraconazole in onychomycosis. Br J Dermatol 1999; 141 Suppl. 56: 5 ± 14. 10. Hull PR, Gupta AK, Summerbell RC. Onychomycosis: an evaluation of three sampling methods. J Am Acad Dermatol 2000; 39: 1015 ± 1017. 11. Hilmarsdottir I, Haraldsson H, Sigurdardo ttir A, Sigurgeirsson B. Dermatophyte contamination in an Icelandic swimming pool (poster). Societe Francaise de mycologie medicale, 1998. 12. Watanabe K, Taniguchi H, Katoh T. Adhesion of dermatophytes to healthy feet and its simple treatment. Mycoses 2000; 43: 45 ± 50. 13. Kamihama T, Kimura T, Hosokawa JI, Ueji M, Takase T, Tagami K. Tinea pedis outbreak in swimming pools in Japan. Public Health 1997; 111: 249 ± 253. 14. Zaias N, Tosti A, Rebell G, Morelli R, Bardazzi F, Bieley H, et al. Autosomal dominant pattern of distal subungual onychomycosis caused by Trichophyton rubrum. J Am Acad Dermatol 1996; 34: 302 ± 304. 15. Cribier B, Mena ML, Rey D, Partisani M, Fabien V, Lang JM, et al. Nail changes in patients infected with human immunode® ciency virus. A prospective controlled study. Arch Dermatol 2000; 134: 1216 ± 1220. Letters to the Editor 469

Multifocal cutaneous leishmaniasis: a new clinical presentation of the disease.

Sir, Cutaneous leishmaniasis (CL) is an infection caused by protozoa belonging to the genus Leishmania (L.). The disease is transmitted by sandflies: Phlebotomus (P.) spp. and Lutzomyia spp. are the most frequently involved. Disease reservoirs are represented by dogs, mice, rats, wild rodents and, more rarely, humans. CL is very frequent in the Mediterranean Basin, especially in Sicily. L. infantum, transmitted by P. pappatasi, P. perfiliewi and P. perniciosus, is responsible for all cases observed in Sicily. From the clinical point of view, CL in the Mediterranean Basin is usually characterized by a single, polymorphous lesion located on exposed areas, in particular the face, followed by the upper limbs. In the last few years, we have observed several patients with CL characterized clinically by multiple, monomorphous, slightly inflammatory, papular or papulo-nodular lesions. Some of these lesions appeared as “twin lesions”. We believe that this presentation represents a new clinical variety of CL, which has been called “multifocal CL” by other authors (1–3). The hypothesis of a new carrier involvement is advanced.

Tungiasis in a beach volleyball player: a case report.

Tungiasis is an infestation caused by penetration of the skin by the gravid female of the flea Tunga penetrans Linnaeus 1758 (Insecta, Siphonaptera: Tungidae). Tunga penetrans is currently found in Central and South America, sub-Saharan Africa, and Central Asia. Prevalence is very high in Brazil. We present a case of tungiasis in an Italian beach volleyball player who acquired the infestation in Brazil.

Cutaneous Lymphoid Hyperplasia Associated with Leishmania panamensis Infection

Cutaneous leishmaniasis (CL) is an infection caused by protozoa from the genus Leishmania. The disease is transmitted by sandflies. Reservoirs are dogs, mice, wild rodents and, more rarely, humans. CL is clinically characterized by a single, polymorphous lesion, usually localized on the face or limbs. Nowadays, CL is more frequently seen among travellers returning from tropical and subtropical countries (1). Cutaneous lymphoid hyperplasia (CLH), also known as pseudolymphoma, is a reactive proliferation, probably secondary to persistent antigenic stimulation. We present here a case of CLH associated with L. panamensis infection.