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Dinu M, Tatu AL, Cocoș DI, Nwabudike LC, Chirilov AM, Stefan CS, Earar K, Dumitriu Buzia O. Natural Sources of Therapeutic Agents Used in Skin Conditions. Life (Basel) 2024; 14:492. [PMID: 38672762 PMCID: PMC11051086 DOI: 10.3390/life14040492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
Skin conditions are numerous and often have a major impact on patients' quality of life, and effective and safe treatment is very important. The conventional drugs used for skin diseases are usually corticosteroids and antimicrobial products that can induce various side effects, especially with long-term use, which is why researchers are studying alternatives, especially biologically active natural products. Three products caught our attention: bee venom (BV), due to reported experimental results showing anti-inflammatory, antibacterial, antiviral, antioxidant, antimycotic, and anticancer effects, Ficus carica (FC) due to its demonstrated antioxidant, antibacterial, and anti-inflammatory action, and finally Geranium essential oil (GEO), with proven antifungal, antibacterial, anti-inflammatory, and antioxidant effects. Following a review of the literature, we produced this paper, which presents a review of the potential therapeutic applications of the three products in combating various skin conditions and for skin care, because BV, FC, and GEO have common pharmacological actions (anti-inflammatory, antibacterial, and antioxidant). We also focused on studying the safety of the topical use of BV, FC, and GEO, and new approaches to this. This paper presents the use of these natural therapeutic agents to treat patients with conditions such as vitiligo, melasma, and melanoma, as well as their use in treating dermatological conditions in patients with diabetes.
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Affiliation(s)
- Monica Dinu
- Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania; (M.D.); (C.S.S.); (K.E.); (O.D.B.)
| | - Alin Laurențiu Tatu
- Clinical Medical Department, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania;
- Dermatology Department, “Sf. Cuvioasa Parascheva” Clinical Hospital of Infectious Diseases, 800179 Galati, Romania
- Multidisciplinary Integrative Center for Dermatologic Interface Research MIC-DIR, 800010 Galati, Romania
| | - Dorin Ioan Cocoș
- Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania; (M.D.); (C.S.S.); (K.E.); (O.D.B.)
| | | | - Ana Maria Chirilov
- Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania; (M.D.); (C.S.S.); (K.E.); (O.D.B.)
| | - Claudia Simona Stefan
- Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania; (M.D.); (C.S.S.); (K.E.); (O.D.B.)
| | - Kamel Earar
- Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania; (M.D.); (C.S.S.); (K.E.); (O.D.B.)
| | - Olimpia Dumitriu Buzia
- Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania; (M.D.); (C.S.S.); (K.E.); (O.D.B.)
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Artime E, Serra E, Mert C, Díaz-Cerezo S, Huete T, Hernández-Subirá I, Lledo-Bryant L, Sicras-Mainar A. Real-World Treatment Patterns, Resource Use and Costs in Adult Patients With Atopic Dermatitis Receiving Systemic Treatment: Derma-Atopic Study in Spain. ACTAS DERMO-SIFILIOGRAFICAS 2023; 114:9-18. [PMID: 36030827 DOI: 10.1016/j.ad.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 07/27/2022] [Accepted: 08/08/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Moderate-severe atopic dermatitis (AD) has a significant impact on patients' lives, with many requiring systemic treatment to manage symptoms (e.g., pruritus). Several drugs are used off-label to treat AD. This study describes sociodemographic/clinical characteristics, treatment patterns, health resource use (HRU) and costs in adults with AD who initiated systemic treatment or phototherapy in routine practice. METHODS This retrospective observational study of electronic medical records in the BIG-PAC database identified adults with prior diagnosis of AD (ICD-9: 691.8 or 692.9) starting oral corticosteroids, immunosuppressants, biologics or phototherapy between 01/01/2012 and 31/12/2016. Patients were followed for 3 years from treatment initiation, up to 31/12/2019. Data on patient characteristics, treatment patterns, HRU and costs were analyzed descriptively. RESULTS Patients (N=1995) had a mean age of 60 years, 64% were female, with a mean time of 23 years since diagnosis (84% were ≥18 years at AD onset). Main comorbidities were anxiety (38%), arterial hypertension (36%) and dyslipidemia (35%). Most patients used oral corticosteroids as first systemic (84%; median duration 29 days) and immunosuppressants in 13% of patients (median duration 117 days, 5% cyclosporine and 4% methotrexate). Half of patients required a second line systemic and 12% a third line. The use of immunosuppressants and biologics increased with treatment lines. About 13% of patients received systemic treatments continuously over the 3-year follow-up. The average 3-year per patient cost was 3835 euros, with an average annual cost of 1278 euros. CONCLUSIONS Results suggest a high comorbidity and economic burden in this real-world adult population with AD, and the need for systemic treatments indicated for use in AD.
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Affiliation(s)
- E Artime
- Medical Department, Lilly, Madrid, Spain.
| | - E Serra
- Dermatology Service, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - C Mert
- HaaPacs GmbH, Schriesheim, Germany
| | | | - T Huete
- Medical Department, Lilly, Madrid, Spain
| | | | - L Lledo-Bryant
- Health Economics and Outcomes Research, Barcelona, Spain
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Artime E, Serra E, Mert C, Díaz-Cerezo S, Huete T, Hernández-Subirá I, Lledo-Bryant L, Sicras-Mainar A. Real-World Treatment Patterns, Resource Use and Costs in Adult Patients With Atopic Dermatitis Receiving Systemic Treatment: Derma-Atopic Study in Spain. ACTAS DERMO-SIFILIOGRAFICAS 2023; 114:T9-T18. [PMID: 36368579 DOI: 10.1016/j.ad.2022.08.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 08/08/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Moderate-severe atopic dermatitis (AD) has a significant impact on patients' lives, with many requiring systemic treatment to manage symptoms (e.g., pruritus). Several drugs are used off-label to treat AD. This study describes sociodemographic/clinical characteristics, treatment patterns, health resource use (HRU) and costs in adults with AD who initiated systemic treatment or phototherapy in routine practice. METHODS This retrospective observational study of electronic medical records in the BIG-PAC database identified adults with prior diagnosis of AD (ICD-9: 691.8 or 692.9) starting oral corticosteroids, immunosuppressants, biologics or phototherapy between 01/01/2012 and 31/12/2016. Patients were followed for 3 years from treatment initiation, up to 31/12/2019. Data on patient characteristics, treatment patterns, HRU and costs were analyzed descriptively. RESULTS Patients (N = 1995) had a mean age of 60 years, 64% were female, with a mean time of 23 years since diagnosis (84% were ≥18 years at AD onset). Main comorbidities were anxiety (38%), arterial hypertension (36%) and dyslipidemia (35%). Most patients used oral corticosteroids as first systemic (84%; median duration 29 days) and immunosuppressants in 13% of patients (median duration 117 days, 5% cyclosporine and 4% methotrexate). Half of patients required a second line systemic and 12% a third line. The use of immunosuppressants and biologics increased with treatment lines. About 13% of patients received systemic treatments continuously over the 3-year follow-up. The average 3-year per patient cost was 3835 euros, with an average annual cost of 1278 euros. CONCLUSIONS Results suggest a high comorbidity and economic burden in this real-world adult population with AD, and the need for systemic treatments indicated for use in AD.
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Affiliation(s)
- E Artime
- Departamento Médico, Lilly, Madrid, España.
| | - E Serra
- Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Mert
- SpaincHaaPacs GmbH, Schriesheim, Alemania
| | | | - T Huete
- Departamento Médico, Lilly, Madrid, España
| | | | - L Lledo-Bryant
- Health Economics and Outcomes Research, Atrys Health, Barcelona, España
| | - A Sicras-Mainar
- Health Economics and Outcomes Research, Atrys Health, Madrid, España
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Hemrajani C, Negi P, Parashar A, Gupta G, Jha NK, Singh SK, Chellappan DK, Dua K. Overcoming drug delivery barriers and challenges in topical therapy of atopic dermatitis: A nanotechnological perspective. Biomed Pharmacother 2022; 147:112633. [PMID: 35030434 DOI: 10.1016/j.biopha.2022.112633] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/29/2021] [Accepted: 01/07/2022] [Indexed: 02/07/2023] Open
Abstract
Atopic dermatitis (AD) is an inflammatory disorder centered around loss of epidermal barrier function, and T helper 2 (Th2) immune responses. The current understanding of disease heterogeneity and complexity, limits the rational use of existing topical, systemic therapeutic agents, but paves way for development of advanced therapeutic agents. Additionally, advanced nanocarriers that deliver therapeutics to target cells, seem to offer a promising strategy, to overcome intrinsic limitations and challenges of conventional, and traditional drug delivery systems. Ever-evolving understanding of molecular target sites and complex pathophysiology, adverse effects of current therapeutic options, inefficient disease recapitulation by existing animal models are some of the challenges that we face. Also, despite limited success in market translatibility, nanocarriers have demonstrated excellent preclinical results and have been extensively studied for AD. Detailed research on behavior of nanocarriers in different patients and tailored therapy to account for phenotypic variability of the disease are the new research avenues that we look forward to.
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Affiliation(s)
- Chetna Hemrajani
- School of Pharmaceutical Sciences, Shoolini University of Biotechnology and Management Sciences, Solan 173212, India.
| | - Poonam Negi
- School of Pharmaceutical Sciences, Shoolini University of Biotechnology and Management Sciences, Solan 173212, India.
| | - Arun Parashar
- School of Pharmaceutical Sciences, Shoolini University of Biotechnology and Management Sciences, Solan 173212, India.
| | - Gaurav Gupta
- School of Pharmacy, Suresh Gyan Vihar University, Jagatpura, Jaipur, India.
| | - Niraj Kumar Jha
- Department of Biotechnology, School of Engineering and Technology, Sharda University, Knowledge Park III, Greater Noida 201310, Uttar Pradesh, India.
| | - Sachin Kumar Singh
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India.
| | - Dinesh Kumar Chellappan
- Department of Life Sciences, School of Pharmacy, International Medical University (IMU), Bukit Jalil, 57000 Kuala Lumpur, Malaysia.
| | - Kamal Dua
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, NSW 2007, Australia; Faculty of Health, Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Ultimo, Australia.
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Cosmetic Applications of Bee Venom. Toxins (Basel) 2021; 13:toxins13110810. [PMID: 34822594 PMCID: PMC8625659 DOI: 10.3390/toxins13110810] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/07/2021] [Accepted: 11/10/2021] [Indexed: 12/15/2022] Open
Abstract
Bee venom (BV) is a typical toxin secreted by stingers of honeybee workers. BV and BV therapy have long been attractive to different cultures, with extensive studies during recent decades. Nowadays, BV is applied to combat several skin diseases, such as atopic dermatitis, acne vulgaris, alopecia, vitiligo, and psoriasis. BV is used extensively in topical preparations as cosmetics and used as dressing for wound healing, as well as in facemasks. Nevertheless, the safety of BV as a therapeutic choice has always been a concern due to the immune system reaction in some people due to BV use. The documented unfavorable impact is explained by the fact that the skin reactions to BV might expand to excessive immunological responses, including anaphylaxis, that typically resolve over numerous days. This review aims to address bee venom therapeutic uses in skin cosmetics.
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Kumar S, Ashraf MU, Kumar A, Bae YS. Therapeutic Potential of microRNA Against Th2-associated Immune Disorders. Curr Top Med Chem 2021; 21:753-766. [PMID: 33655864 DOI: 10.2174/1568026621666210303150235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/17/2020] [Accepted: 11/28/2020] [Indexed: 11/22/2022]
Abstract
MicroRNAs (miRNAs) are short ~18-22 nucleotide, single-stranded, non-coding RNA molecules playing a crucial role in regulating diverse biological processes and are frequently dysregulated during disease pathogenesis. Thus, targeting miRNA could be a potential candidate for therapeutic invention. This systemic review aims to summarize our current understanding regarding the role of miRNAs associated with Th2-mediated immune disorders and strategies for therapeutic drug development and current clinical trials.
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Affiliation(s)
- Sunil Kumar
- Department of Biological Sciences, Science Research Center (SRC) for Immune Research on Non-lymphoid Organ (CIRNO), Sungkyunkwan University, Jangan-gu, Suwon, Gyeonggi-do 16419, South Korea
| | - Muhammad Umer Ashraf
- Department of Biological Sciences, Science Research Center (SRC) for Immune Research on Non-lymphoid Organ (CIRNO), Sungkyunkwan University, Jangan-gu, Suwon, Gyeonggi-do 16419, South Korea
| | - Anil Kumar
- Amity Institute of Biotechnology, Amity University Haryana, Amity Education Valley, Gurugram-122413, India
| | - Yong-Soo Bae
- Department of Biological Sciences, Science Research Center (SRC) for Immune Research on Non-lymphoid Organ (CIRNO), Sungkyunkwan University, Jangan-gu, Suwon, Gyeonggi-do 16419, South Korea
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Kahremany S, Hofmann L, Harari M, Gruzman A, Cohen G. Pruritus in psoriasis and atopic dermatitis: current treatments and new perspectives. Pharmacol Rep 2021; 73:443-453. [PMID: 33460006 DOI: 10.1007/s43440-020-00206-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/11/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023]
Abstract
Psoriasis and atopic dermatitis (AD) are two common chronic inflammatory skin diseases. Although showing different etiology and clinical manifestations, patients with either disease suffer from low health-related quality of life due to pruritus (dermal itch). Recent studies have revealed that more than 85% of psoriasis patients suffer from pruritus, and it is also the dominating symptom of AD. However, as this is a non-life treating symptom, it was partly neglected for years. In this review, we focus on current findings as well as the impact and potential treatments of pruritus in these two skin diseases. We first distinguish the type of itch based on involved mediators and modulators. This clear delineation between the types of pruritus based on involved receptors and pathways allows for precise treatment. In addition, insights into recent clinical trials aimed to alleviate pruritus by targeting these receptors are presented. We also report about novel advances in combinatorial treatments, dedicated to the type of pruritus linked to a causal disease. Altogether, we suggest that only a focused treatment tailored to the primary disease and the underlying molecular signals will provide fast and sustained relief of pruritus associated with psoriasis or AD.
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Affiliation(s)
- Shirin Kahremany
- Department of Chemistry, Faculty of Exact Sciences, Bar-Ilan University, 5290002, Ramat Gan, Israel. .,The Skin Research Institute, The Dead Sea and Arava Science Center, 86910, Masada, Israel.
| | - Lukas Hofmann
- Department of Chemistry, Faculty of Exact Sciences, Bar-Ilan University, 5290002, Ramat Gan, Israel
| | - Marco Harari
- Medical Climatotherapy Unit, The Dead Sea and Arava Science Center, 86910, Masada, Israel
| | - Arie Gruzman
- Department of Chemistry, Faculty of Exact Sciences, Bar-Ilan University, 5290002, Ramat Gan, Israel
| | - Guy Cohen
- The Skin Research Institute, The Dead Sea and Arava Science Center, 86910, Masada, Israel.,Ben Gurion University of the Negev, Eilat Campus, 8855630, Eilat, Israel
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Loh TY, Hsiao JL, Shi VY. Therapeutic Potential of Lebrikizumab in the Treatment of Atopic Dermatitis. J Asthma Allergy 2020; 13:109-114. [PMID: 32104006 PMCID: PMC7023853 DOI: 10.2147/jaa.s211032] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/29/2020] [Indexed: 02/02/2023] Open
Abstract
Background Atopic dermatitis (AD) is a chronic, relapsing skin condition with a wide disease spectrum. Moderate-to-severe cases often need systemic treatment. Conventional immunosuppressants have extensive side effect profiles and require close monitoring. In recent decades, there has been increasing interest in developing targeted systemic immunomodulators for AD, as they have been shown to have efficacy for AD as well as favorable safety profiles. Herein, we review the recent data on lebrikizumab, an interleukin (IL)-13 inhibitor, and its potential role in the treatment of AD. Objective Review the mechanism of action, and available data on the efficacy and safety of lebrikizumab for the treatment of AD. Methods PubMed, Google Scholar, and clinicaltrials.gov searches were performed with the following terms: “atopic dermatitis,” “dermatitis,” “eczema,” “lebrikizumab,” “IL-4,” and “IL-13.” Results Two Phase II randomized controlled clinical trials have been conducted to evaluate the use of lebrikizumab in a total of 289 patients with moderate-severe AD and inadequate response to topical corticosteroids. Patients treated with lebrikizumab experienced significantly more improvement in their AD compared to placebo, as measured by Eczema Area and Severity Index (EASI)-50 and EASI-75 scores, pruritus scores, and reduction in body surface area (BSA). Its clinical efficacy appears to be dose-dependent, and it has a favorable side effect profile and is generally well tolerated. Conclusion Lebrikizumab appears to be a promising emerging targeted biologic for the treatment of moderate-to-severe AD. Further Phase III studies investigating optimal dosing regimens and safety profile are needed.
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Affiliation(s)
- Tiffany Y Loh
- University of Arizona, Division of Dermatology, Tucson, AZ, USA
| | - Jennifer L Hsiao
- University of California Los Angeles, Division of Dermatology, Los Angeles, CA, USA
| | - Vivian Y Shi
- University of Arizona, Division of Dermatology, Tucson, AZ, USA
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Nalbuphine, a kappa opioid receptor agonist and mu opioid receptor antagonist attenuates pruritus, decreases IL-31, and increases IL-10 in mice with contact dermatitis. Eur J Pharmacol 2019; 864:172702. [PMID: 31568781 DOI: 10.1016/j.ejphar.2019.172702] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/25/2019] [Accepted: 09/26/2019] [Indexed: 12/13/2022]
Abstract
Chronic itch is one of the disturbing symptoms of inflammatory skin diseases. Kappa opioid receptor agonists are effective in suppressing scratching in mice against different pruritogens. Nalbuphine, a nonscheduled kappa opioid receptor agonist and mu opioid receptor antagonist, has been in clinical use for post-operative pain management since the 1980s and recently has been in clinical trials for chronic itch of prurigo nodularis (https://www.trevitherapeutics.com/nalbuphine). We studied whether nalbuphine is effective against chronic scratching induced by rostral neck application of 1-fluoro-2,4-dinitrobenzene (DNFB), an accepted mouse model of contact dermatitis to study pruritoceptive itch. Mice were treated once a week with either saline or nalbuphine 20 min before the third, fifth, seventh, and ninth sensitizations with DNFB and the number of scratching bouts was counted for 30 min. Skin samples from the neck of mice at week 4 were used to measure protein levels and mRNA expressions of chemokines and cytokines. Different sets of mice were used to study sedation and anhedonic-like behavior of nalbuphine. We found that: nalbuphine (a) antagonized scratching in a dose- and time-dependent manner without affecting locomotion, b) decreased IL-31, and increased anti-inflammatory IL-10, and c) induced more elevations in the levels of CCL2, CCL3, CCL12, CXCL1, CXCL2, CXCL9, CXCL10, IL-1β, IL-16, TIMP-1, M-CSF, TREM-1 and M1-type macrophages compared to saline. Increases in chemokines and cytokines and M1 macrophages by nalbuphine suggest an inflammatory phase of healing in damaged skin due to scratching. Our data indicate that nalbuphine is an effective antipruritic in murine model of pruritoceptive itch.
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Ferrara G, Petrillo MG, Giani T, Marrani E, Filippeschi C, Oranges T, Simonini G, Cimaz R. Clinical Use and Molecular Action of Corticosteroids in the Pediatric Age. Int J Mol Sci 2019; 20:ijms20020444. [PMID: 30669566 PMCID: PMC6359239 DOI: 10.3390/ijms20020444] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 01/14/2019] [Accepted: 01/15/2019] [Indexed: 12/19/2022] Open
Abstract
Corticosteroids are the mainstay of therapy for many pediatric disorders and sometimes are life-saving. Both endogenous and synthetic derivatives diffuse across the cell membrane and, by binding to their cognate glucocorticoid receptor, modulate a variety of physiological functions, such as glucose metabolism, immune homeostasis, organ development, and the endocrine system. However, despite their proved and known efficacy, corticosteroids show a lot of side effects, among which growth retardation is of particular concern and specific for pediatric age. The aim of this review is to discuss the mechanism of action of corticosteroids, and how their genomic effects have both beneficial and adverse consequences. We will focus on the use of corticosteroids in different pediatric subspecialties and most common diseases, analyzing the most recent evidence.
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Affiliation(s)
| | - Maria Grazia Petrillo
- Signal Transduction laboratory, NIEHS, NIH, Department of Health and Human Services, Research Triangle Park, Durham, NC 27709, USA.
| | - Teresa Giani
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
- Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy.
| | | | - Cesare Filippeschi
- Department of Dermatology, Anna Meyer Children's University Hospital, 50139 Florence, Italy.
| | - Teresa Oranges
- Department of Dermatology, Anna Meyer Children's University Hospital, 50139 Florence, Italy.
| | - Gabriele Simonini
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
| | - Rolando Cimaz
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
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