Vera Tengattini

Autoantibodies in psoriatic patients treated with anti-TNF-α therapy.

TNF‐α inhibitors have been associated with induction of autoantibodies and autoimmune diseases. We retrospectively evaluated the incidence of autoantibodies ANA, ENA, anti‐dsDNA, the occurrence of clinical symptoms and possibly related treatment failure.

A 36-week retrospective open trial comparing the efficacy of biological therapies in nail psoriasis

Nail psoriasis occurs in about 50% of psoriatic patients and can be psychologically devastating since it appears on visible areas. Up to now there is no evidence about what biological drugs is the most effective on nail psoriasis.

Malignancies in bullous pemphigoid: A controversial association.

Bullous pemphigoid (BP) is an autoimmune subepidermal blistering disorder that has been reported to be associated with malignancies. Some authors described several cases of pemphigoid associated with malignancies (PAM); however, the evidence of this correlation still remains controversial. Several theories have been postulated to explain the relationship between malignant neoplasms and BP; the main theory suggests that antibodies directed against tumor‐specific antigens of malignant cells may cross‐react with antigens (like BP antigens) in the basement membrane zone leading to the formation of blisters. We performed an extensive review of the English published work focusing on the epidemiology, the pathogenetic theories and the clinical and histological aspects of the disease. We identified 40 cases of PAM: of these, seven cases were associated with hematological malignancies and 33 with solid tumors. Physicians should be aware of the existence of PAM and we suggest an oncological screening in early‐onset pemphigoid, in patients with a former oncological history, in those with signs and symptoms that could be related to a neoplasm and in BP refractory to common immunosuppressive therapy.

Retronychia in children, adolescents, and young adults: A case series

Turkey, and New Zealand reported an overall survival rate of 56% (25 of 45 patients). Eighty-three percent ofHI neonates treatedwith systemic retinoids survived, whereas the long-term survival was only 24% for those who were not given oral retinoids. Here we report the outcomes for HI in the Japan population. For a clinical survey of HI in Japan, we distributed questionnaires to 904 dermatologic or pediatrics institutes or hospitals throughout Japan in 2010 and received responses from 564 institutes or hospitals (62.4%). Clinical data between 2005 and 2010 were obtained for 16 HI patients. In total, there were 13 survivors (81.3%) and 3 deceased (18.7%). The patient’s sex was reported for 14 patients: 8 male and 6 female. Systemic retinoids were administered to 12 patients, 11 of whom survived (91.7%), whereas only 2 of the 4 patients (50%) who did not receive oral retinoids survived. Ten of 16 patients (62.5%) received intensive care in a neonatal intensive care unit (NICU). Systemic retinoids and administration in the NICU were considered to contribute to relatively good outcomes for HI patients in the Japanese population. The effects of oral retinoids in HI remains unproven, and as suggested in the commentary by Milstone and Choate, the early introduction of overall intensive therapy might have contributed to the better outcomes of the HI babies whowere given oral retinoids. In conclusion, we consider that, due to intensive neonatal care and, probably, to the early introduction of oral retinoids, HI outcomes have improved also in the Japanese population. In long-term HI survivors, epidermal keratinocytes might regain normal differentiation, and this restoration of differentiation is likely to be associated with the improvement of the skin symptoms in HI survivors. From this fact and the results of our clinical survey, we agree with the commentary by Milstone and Choate on the point that recognition of spontaneous improvement of the HI phenotype lowers the psychological hurdle and provides justification for intensive neonatal care that can improve the outcomes of HI patients. Akitaka Shibata, MD, Yasushi Ogawa, MD, PhD, Kazumitsu Sugiura, MD, PhD, Yoshinao Muro, MD, PhD, Riichiro Abe, MD, PhD, Tamio Suzuki, MD, PhD, and Masashi Akiyama, MD, PhD Department of Dermatology, Nagoya University Graduate School of Medicine; Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo; Department of Dermatology, Yamagata University Faculty of Medicine, Yamagata, Japan

Bullous pemphigoid appearing both on thermal burn scars and split-thickness skin graft donor sites

Bullous pemphigoid (BP) is a common subepidermal autoimmune bullous disease. A number of external agents have been associated with its development, including trauma, thermal burns, skin grafts, radiotherapy, ultraviolet exposure (UVB, PUVA), photodynamic therapy, surgery, vaccination and cutaneous infections. An 85-year-old woman presented with a two-month history of blistering lesions on the back, legs and abdomen (Figure 1). She complained generalized itch and had widespread erosions and crusts on erythematous skin. Remarkably, all the lesions appeared on thermal burn scars (some of which had been covered with meshed split-thickness autografts 20 months before) and on donor sites. Her medical history included hypertension and atrial fibrillation and she had been treated with a calcium channel blocker and warfarin for several years. Skin biopsies from both scar area and donor site revealed a subepidermal detachment and superficial dermal infiltrate consisting of lymphocytes and eosinophils. Direct immunofluorescence showed linear deposits of IgG and C3 at the basement membrane and BP180 ELISA was positive, confirming the diagnosis of localized BP. Clinical Letters The patient was treated topically with clobetasol and with prednisone 50 mg daily, achieving complete resolution of the lesions within two weeks. Prednisone was tapered by halving the dose once every three weeks. No further blistering has occurred since. BP is the most common subepidermal autoimmune blistering disease, classically seen in the elderly. Even though the etiology is still unknown, in some cases skin injuries, including burns [1–4], can trigger BP. Rare cases of BP arising in skin grafts and/or their donor sites have been reported [1–4], with time since onset ranging between a few weeks to 20 years after the skin grafting [4]. Various hypotheses have been proposed to explain the possible trigger mechanisms which lead to trauma-induced BP. A possible scenario is that skin injury causes an alteration of the basement membrane structures, permitting the exposure of BP antigens to the immune system and increasing the likelihood of an autoimmune attack [3–5]. Furthermore the alteration of the skin integrity could promote a rapid blister formation [4]. Also local changes due to the wound healing process may facilitate presentation of the BP antigens [3] perhaps explaining why blistering often occurs some weeks after grafting [2]. Trauma can also modify vascular permeability and stimulate the deposition of autoantibodies at the basement membrane in patients with “sub-clinical BP” [5]. In our case BP was induced by surgical therapy, so we think it can be considered as an example of “immunocompromised district”. This expression implicates heterogeneous clinical conditions (among which areas of thermal burn) characterized by a destabilization of the local immune control system. The involved district may show either reduced or

Multipoint and multilevel injection technique of botulinum toxin A in facial aesthetics.

Botulinum toxin represents one of the most frequently requested cosmetic procedures. We treated 223 patients with facial wrinkles using a new technique of injection of botulinum toxin A (BTA) called multipoint and multilevel injection technique (MMIT). The aim of MMIT was to relax the muscle and not paralyze it. Patient satisfaction was evaluated by Facial Line Treatment Satisfaction Questionnaire (FTSQ). Treatment with botulinum toxin determined a good response in all patients. Facial rhytids were completely resolved in case of young skin and well reduced in case of aged skin, leaving a natural aspect both in static and dynamic wrinkles. Patient mean overall satisfaction evaluated with FTSQ was 6.4 ± 1.1. In our experience, the use of botulin toxin by MMIT consents a better calibration of action with a soft and natural result. This can be achieved by distributing the BTA dose through various injection points for each area (“multipoint injections”). Furthermore, injections can be performed at different levels (“multilevel injections”). The level of injections regulates the potency of effect on the muscle: if the level is deep (intramuscular), the effect will be strong while if it is medium or superficial (subcutaneous and intradermal), the effect will be soft. This consents a fine calibration of action on muscle activity with a personal aesthetic result.

Interdigital Psoriasis of the Feet (Psoriasis Alba): Not a Distinct Form of Psoriasis

Background: Interdigital psoriasis (IP) of the feet is often missed and is commonly mistaken for interdigital fungal infection. Objective: To assess the characteristics and the clinical presentation of IP, in order to better understand if IP should be considered a distinct form of psoriasis or not. Methods: We performed a 1-year observational study on 164 psoriatic patients, affected by moderate to severe cutaneous psoriasis and undergoing systemic therapy, examining each patient between the digits of both feet. In every suspected case of IP, differential diagnosis with interdigital fungal infection was excluded by direct microscopic examination of skin scrapings, by culture and by skin biopsy. Results: We suspected IP in 7 of the 164 patients. IP was confirmed in 6 patients and in the other one a diagnosis of tinea pedis was made. Conclusion: IP proved to be not rare or atypical since IP localized between the toes usually presents as characteristic whitish and sodden plaques or patches. Such a diagnosis should be considered in all patients presenting characteristic lesions especially if these have a negative fungal culture, are resistant to antimycotic treatment and involve patients with a history of psoriasis.

Eczema craquelé, an uncommon clinical manifestation of myxedema.

eine 32-jährige Frau stellte sich mit einer einjährigen Vorgeschichte von oberflächlichen Rissen und Fissuren an beiden Beinen vor, ohne Anzeichen einer Veneninsuffizienz (Abbildung 1). Weder lag ein Pruritus noch ein Ödem vor. Sowohl die persönliche als auch familiäre Anamnese war unauffällig, vor allem bezüglich atopischer Erkrankungen. Die Patientin gab darüber hinaus an, keine aggressiven Reinigungsmittel oder Peelings verwendet zu haben. Es gab keine Hinweise auf eine saisonal bedingte Verschlechterung der kutanen Symptome. Die Anwendung verschiedener Feuchtigkeitsund Pflegecremes sowie typischer Kortikosteroide und topischer Anwendung von Tacrolimus brachte klinisch keinerlei Verbesserung. Wir diagnostizierten folglich ein Eczema craquelé. Die Patientin unterzog sich einer 4 mm-Stanzbiopsie an einer ihrer Läsionen des Beines. Der histologische Befund zeigte eine Parakeratose, ein Schachbrettmuster (Abbildung 2), sowie die Homogenisierung von Kollagenbündeln, welche durch Muzin-Depots sowohl in der papillären als auch der retikulären Dermis geteilt wurden. Dies konnte durch Alzianblau-Färbung bestätigt werden (Abbildung 3). Die Laborergebnisse, unter anderem großes Blutbild, klinische Chemie und biochemische Analysen, lagen alle im normalen Bereich. Während Clinical Letter

Elephantasis Nostras Verrucosa and Psoriasis: Only a Coincidence?

Sir, A 60-year-old man came to our observation because of hyperkeratotic plaques on the lower limbs, of 8 weeks duration. On physical examination, his legs showed indurated, cobblestone-like, grayish lesions, pink verrucous projections, and nonpitting edema (Figure 1). Kaposi–Stemmer sign was evident. Few psoriatic plaques were present on the trunk and the upper limbs. The patient was affected by morbid obesity (body mass index 41 kg/m). His medical history was relevant for heart failure, venous insufficiency, lymphedema, autoimmune hypothyroidism, and psoriasis. At the time of the first visit, he was receiving furosemide 25 mg/d, enalapril 20 mg/d, thyroxine 100 μg/d, citalopram 20 mg/d, acetyl salicylic acid 100 mg/d, omeprazole 20 mg/d, acitretin 10 mg/d, emollients, and calcipotriol/betamethasone dipropionate ointment. The patient referred a worsening of the peripheral edema and effort dyspnea in the past week. A chest X-ray was taken and revealed pulmonary congestion due to congestive heart failure. He was hospitalized and blood tests were all within normal limits, except for an elevated reactive C protein (45 mg/L). An arteriovenous color Doppler ultrasonography (model MyLab40, Esaote, Genova, Italy) using a 7.5 to 12 MHz linear array transducer confirmed mild to moderate venous insufficiency. Filarial elephantiasis was excluded on the basis of the anamnesis and a diagnosis of elephantiasis nostras verrucosa (ENV) was made. Intravenous furosemide treatment was started, followed after 72 hours by the oral administration of the drug, in association with the increase of oral acitretin to 50 mg/d (0.4 mg/kg/d). Daily cleaning of the legs with chlorhexidine 2% aqueous solution was done to prevent over-infections. The patient initially used compressive bandages and after 2 weeks began to carry graduated support stockings (compression index 23-32 mm Hg). At follow-up visit, 2 months later, the patient had lost 15 kg and the lesions had resolved almost completely (Figure 2). Elephantiasis nostras verrucosa is a rare condition considered an exaggerated form of secondary lymphedema that usually involves lower extremities, deformed by progressive fibrosis of the skin. The term “nostras” refers to elephantiasis involving individuals resident in areas where filariasis is not endemic. ENV is clinically characterized by hard, thick, warty, or papillomatous projections and cobblestone-like lesions, with nonpitting edema. ENV mainly affects the lower limbs, even though it has been reported in external genitals, abdomen, buttocks, upper limbs, and face. The diagnosis of ENV is based on clinical history and physical examination. Skin biopsy, computed tomography, magnetic resonance imaging, lymphangiography, and 486156 IJLXXX10.1177/1534734613486156The International Journal of Lower Extremity WoundsSavoia et al research-article2013

Clubbing/Pseudoclubbing only in Fingernails Previously Affected by Psoriasis

We report a case of fingernails clubbing in a 55-year-old man suffered since the age of 40 from cutaneous psoriasis. The patient had no clubbing before and had no familial cases of clubbing. Cardiological and pneumological visits revealed no abnormalities. All laboratory tests were within normal limits and X-rays excluded the presence of pachyodermoperiostosis. We made the diagnosis of atypical clubbing exclusively in the fingernails previously affected by psoriasis. It may be that a common mechanism lies at the root of these two phenomena.