[Dermatomyositis-update]

Gluten Intolerance and Its Association With Skin Disorders: A Narrative Review

Gluten sensitivity is defined as a chronic intolerance to gluten ingestion in genetically predisposed individuals. The etiology is thought to be immune-mediated and has a variable dermatologic presentation. Celiac disease (CD) is one of the most common forms of gluten intolerance and encompasses a wide range of extra-intestinal pathology, including cutaneous, endocrine, nervous, and hematologic systems. Psoriasis, another long-term inflammatory skin condition, has been linked to significant symptomatic improvement with a gluten-free diet (GFD). Palmoplantar pustulosis (PP), a variant of psoriasis, and aphthous stomatitis, which causes recurrent oral ulcers, have also exhibited beneficial results after the dietary elimination of gluten. In addition to this, dermatitis herpetiformis (DH), another immune-mediated skin disorder, is genetically similar to CD and has, therefore, shown tremendous improvement with a GFD. Another highly prevalent long-term skin condition called atopic dermatitis (AD), however, has revealed inconsistent results with gluten elimination and would require further research in the future to yield concrete results. Hereditary angioedema (HA) has shown an association with gluten intolerance in some patients who had symptomatic benefits with a GFD. Similarly, vitiligo and linear IgA bullous dermatosis have also shown some clinical evidence of reversal with a GFD. On the contrary, rosacea enhances the risk of developing CD. This narrative review emphasizes the potential impact of gluten intolerance on different cutaneous conditions and the potential therapeutic effect of a GFD on various symptomatic manifestations. There is a need for additional clinical and observational trials to further expand on the underlying pathophysiology and provide conclusive and comprehensive recommendations for possible dietary interventions.

Connective tissue disorders and eye: A review and recent updates

Collagen vascular disorders (CVDs), also known as connective tissue diseases (CTDs), are a heterogeneous group of entities that affect the connective tissues and are capable of causing end-organ damage to multiple systems, primarily cardiopulmonary and musculoskeletal. However, the occurrence and severity are highly variable among patients. Ocular involvement occurs in a significant number of these disorders and may precede the onset of other extraocular features, thereby serving as an important marker in the diagnosis of these diseases. A timely and accurate diagnosis enables the management of complications. CTDs are primarily immune-mediated inflammatory diseases; however, classifications have encompassed heritable disorders affecting collagen-containing structures and disorders of vascular development. A review of literature published until 25 January 2022 and collected from various databases using the relevant keywords was conducted. All publications (original articles, review articles, as well as case reports) describing the ocular features in CTDs were studied in detail. The objective of this review is to recognize the common ophthalmic presentations of various autoimmune and heritable CTDs, distinguish them from overlapping diseases, elaborate on the prognosis and management of these varied eye presentations, and deliberate on their impact on other ophthalmic surgeries.

Systematic Review of Systemic Corticosteroid Effects on Patch Testing

ABSTRACT

Systemic corticosteroids are commonly used as a short-term management option for inflammatory skin conditions, such as contact dermatitis. The purpose of our systematic review was to compare presence and degree of patch test reactions with or without different doses of systemic corticosteroid therapy. The relationship between 20, 30, and 40 mg daily doses of prednisone and retained, diminished, and negated reactions was not linear, whereas the reaction ratings for all patches placed with or without corticosteroid therapy revealed trends toward lower intensity reactions while receiving prednisone (P < 0.0001, χ2, for all doses of prednisone). Our review provides insight into directions for future studies that examine the effect of corticosteroids on patch testing.

Charakteristika von Dermatomyositis-Patienten mit und ohne Malignom-Assoziation

HINTERGRUND

Die Dermatomyositis gehört zur Gruppe der seltenen, idiopathischen, inflammatorischen Myositiden. Für die paraneoplastische Form der Dermatomyositis wurde in der Vergangenheit ein Zusammenhang mit Malignomen erkannt. Faktoren, die für eine Malignom-Assoziation sprechen, werden bis heute untersucht.

PATIENTEN UND METHODIK

Es wurden retrospektiv über einen Zeitraum von 15 Jahren die Daten von 63 Patienten mit Dermatomyositis analysiert.

ERGEBNISSE

Folgende Faktoren gaben einen Hinweis für eine Dermatomyositis mit Malignom-Assoziation: ein höheres Patientenalter (> 52 Jahre [P = 0,001], > 65 Jahre [P = 0,002], ≥ 75 Jahre [P = 0,002]), eine kürzere Zeit zwischen Erstmanifestation und Erstdiagnose (Malignom-Gruppe: 59 Tage vs. Nicht-Malignom-Gruppe: 137 Tage [P = 0,022]), eine Hautbeteiligung in Form von Gottron-Zeichen (P = 0,045), zentrofazialen Erythemen (P = 0,036) oder typischen Erythemen an den Ober-/Unterarmen (P = 0,019), eine oropharyngeale Beteiligung (P = 0,015) und eine GPT-Erhöhung (P = 0,031). Folgende Faktoren sprachen eher gegen eine Malignom-Assoziation: ein jüngeres Patientenalter (≤ 52 Jahre [P = 0,001], 40-65 Jahre [P = 0,045]) und Juckreiz (P = 0,026).

SCHLUSSFOLGERUNGEN

In der Literatur finden sich heterogene Ergebnisse zu den genannten Faktoren hinsichtlich ihrer Eignung als Marker für eine Malignom-Assoziation. Erschwert ist die Faktorenfindung aufgrund kleiner Studienpopulationen, wenigen prospektiven und kontrollierten Studien, die Einordnung von Populationen als Myositis-Patienten ohne Differenzierung und eine inkonsistente Verwendung der Nomenklatur. Mit unserer Studie wollen wir einen wichtigen Beitrag zur Identifizierung von Risikofaktoren bei Dermatomyositis mit Malignom-Assoziation leisten.

Characteristics of dermatomyositis patients with and without associated malignancy

BACKGROUND

Dermatomyositis belongs to the rare idiopathic, inflammatory myositis group. A previously postulated link between some cases of dermatomyositis and malignancy has been established in recent years. Criteria suggestive of a malignancy association are still being explored.

PATIENTS AND METHODS

We retrospectively analyzed data from 63 patients with dermatomyositis over a period of 15 years.

RESULTS

The following criteria argue for cancer-associated dermatomyositis: older age (> 52 years [P = 0.001], > 65 years [P = 0.002], ≥ 75 years [P = 0.002]), shorter time between manifestation and diagnosis of dermatomyositis (malignancy group: 59 days vs. non-malignancy group: 137 days [P = 0.022]), typical skin involvement such as Gottron sign (P = 0.045), centrofacial erythema (P = 0.036) and typical erythema on the upper arms and forearms (P = 0.019), oropharyngeal involvement (P = 0.015) and increased ALT (P = 0.031). The following criteria argue for non-cancer-associated dermatomyositis: younger age (≤ 52 years [P = 0.001], 40-65 years [P = 0.045]) and pruritus (P = 0.026).

CONCLUSIONS

The aforementioned criteria have been documented in the literature, but reported findings are heterogenous concerning the suitability of their markers for malignancy association. Small study populations, few prospective controlled studies, summarization of different forms of myositis and inconsistent use nomenclature contribute to biased results. Our study aims to make an important contribution toward the identification of risk factors in cancer-associated dermatomyositis.

Endocannabinoid system and its modulation of brain, gut, joint and skin inflammation

The discovery of endogenous cannabinoid receptors CB₁ and CB₂ and their endogenous ligands has generated interest in the endocannabinoid system and has contributed to the understanding of the role of the endocannabinoid system. Its role in the normal physiology of the body and its implication in pathological states such as cardiovascular diseases, neoplasm, depression and pain have been subjects of scientific interest. In this review the authors focus on the endogenous cannabinoids, and the critical role of cannabinoid receptor signaling in neurodegeneration and other inflammatory responses such as gut, joint and skin inflammation. This review also discusses the potential of endocannabinoid pathways as drug targets in the amelioration of some inflammatory conditions. Though the exact role of the endocannabinoid system is not fully understood, the evidence found much clearly points to a great potential in exploiting both its central and peripheral pathways in disease management. Cannabinoid therapy has proven promising in several preclinical and clinical trials.

[Paraneoplastic autoimmune dermatoses]

Paraneoplastic skin manifestations associated with malignancies are extremely polymorphous. Clinicians should be familiar with paraneoplastic dermatoses to establish an early diagnosis of the underlying neoplasm. Lack of familiarity with cutaneous clues for internal malignancies may delay diagnosis and treatment of cancer. In this review, we describe several paraneoplastic autoimmune dermatoses, including paraneoplastic autoimmune multiorgan syndrome, paraneoplastic bullous pemphigoid, and paraneoplastic dermatomyositis.

Aberrant expression of cell-free nucleosomes in dermatomyositis/polymyositis

Nucleosomes are typically located intracellularly, and extracellular levels of nucleosomes indicated the degree of cell death. We postulated aberrant nucleosomes expression in dermatomyositis (DM) and polymyositis (PM). To assess the aberrant expression of circulating nucleosomes in DM and polymyositis. 76 consecutive DM and PM patients from 1 September 2017 to 31 October 2018 were enrolled in this study, in addition to 20 healthy controls. The levels of circulating nucleosomes, with 16 kinds of detectable myositis-specific antibodies (MSAs) were detected in IIMs patients using enzyme-linked immunosorbent assay kit (ELISA). Receiver operating characteristic (ROC) curve analysis was performed for evaluating the ability of this candidate marker for detecting DM/PM. The results showed that the levels of circulating nucleosomes in DM/PM patients were significantly higher than that in normal individuals. Specifically, elevated levels of nucleosomes were associated with MDA5 Ab, ARS, and TIF1γAb. In addition, elevated levels of circulating nucleosomes correlated with skin eruption. This study has evidenced nucleosomes as a potential new biomarker of DM/PM. Aberrant nucleosomes expression occurs in myositis patients and the difference in nucleosomes expression between patients with and without skin eruption is statistically significant. A unique expression profile of elevated serum nucleosomes was detected in DM/PM-MDA5 Ab(+), ASS, and TIF1γAb(+).

Paraneoplastic Dermatoses: A Brief General Review and an Extensive Analysis of Paraneoplastic Pemphigus and Paraneoplastic Dermatomyositis

Skin manifestations of systemic disease and malignancy are extremely polymorphous. Clinicians should be familiarized with paraneoplastic dermatoses in order to perform an early diagnosis of the underlying neoplasm. Lack of familiarity with cutaneous clues of internal malignancy may delay diagnosis and treatment of cancer. In this review, we described several paraneoplastic dermatoses and discussed extensively two paradigmatic ones, namely paraneoplastic pemphigus and paraneoplastic dermatomyositis.

Skin inflammation associated with arthritis, synovitis and enthesitis. Part 2: rheumatoid arthritis, reactive arthritis, Reiter's syndrome, Lyme borreliosis, dermatomyositis and lupus erythematosus

Syndromes associated with concurrent skin and joint inflammation frequently pose a therapeutic challenge for both dermatologists and rheumatologists. In part 1 of this review, we discussed psoriatic arthritis as well as the autoinflammatory disorders SAPHO syndrome, Still's disease and Behçet's disease. Part 2 will address rheumatoid arthritis, reactive arthritis, Reiter's syndrome and Lyme borreliosis. In addition, we will discuss dermatomyositis and lupus erythematosus, two common autoimmune disorders that frequently present with both cutaneous and joint involvement. For each of the aforementioned disorders, we will highlight aspects of epidemiology, pathogenesis, clinical presentation, diagnosis and treatment.

Cannabinoids in the Pathophysiology of Skin Inflammation

Cannabinoids are increasingly-used substances in the treatment of chronic pain, some neuropsychiatric disorders and more recently, skin disorders with an inflammatory component. However, various studies cite conflicting results concerning the cellular mechanisms involved, while others suggest that cannabinoids may even exert pro-inflammatory behaviors. This paper aims to detail and clarify the complex workings of cannabinoids in the molecular setting of the main dermatological inflammatory diseases, and their interactions with other substances with emerging applications in the treatment of these conditions. Also, the potential role of cannabinoids as antitumoral drugs is explored in relation to the inflammatory component of skin cancer. In vivo and in vitro studies that employed either phyto-, endo-, or synthetic cannabinoids were considered in this paper. Cannabinoids are regarded with growing interest as eligible drugs in the treatment of skin inflammatory conditions, with potential anticancer effects, and the readiness in monitoring of effects and the facility of topical application may contribute to the growing support of the use of these substances. Despite the promising early results, further controlled human studies are required to establish the definitive role of these products in the pathophysiology of skin inflammation and their usefulness in the clinical setting.

The skin in autoimmune diseases-Unmet needs

Treatment of skin manifestations in systemic lupus erythematosus (SLE), systemic sclerosis (SSc), and dermatomyositis (DM) is based on the results of only few randomized controlled trials. The first-line treatment for disfiguring and widespread cutaneous involvement in SLE is antimalarials, but some patients are therapy resistant. Recently, the monoclonal antibody belimumab was approved for SLE as an adjunct therapy for patients with autoantibody-positive disease who despite standard therapy show high disease activity, intolerance of other treatments, or an unacceptably high need for corticosteroids. However, a validated skin score has not been used to confirm the efficacy of belimumab on mucocutaneous manifestations. In SSc, another multi-systemic progressive disease, involvement of the lung, kidney, and the heart is frequently treated with corticosteroids and immunosuppressives, but therapeutic modalities for cutaneous lesions, such as skin sclerosis and digital ulcers, are limited. In the past years, treatment with the endothelin-receptor antagonist bosentan has been proven to reduce the occurrence of new digital ulcers in SSc patients but has no or limited effect on healing of digital ulcers. DM is an idiopathic autoimmune disease characterized by inflammation of the muscles and skin, which is treated with immunosuppressives. Corticosteroids are the first-line treatment for muscle involvement in DM, but skin lesions often flare by reduction or discontinuation. In summary, there is a high unmet need for new therapeutic strategies focusing on skin involvement in systemic autoimmune diseases. Therefore, innovative designs of randomized controlled trials with validated skin scores are warranted to develop new therapeutic strategies for patients with cutaneous manifestations.

[Molecular diagnosis of collagen vascular diseases and vasculitides]

Collagen vascular diseases and vasculitides comprise various diseases, which may affect virtually every organ system. Therefore, their diagnosis and management is often an interdisciplinary challenge. Because of the heterogeneous symptoms, these diseases have significant overlap, which interferes with the clinical diagnosis and may require additional investigation. Therefore, a rational and comprehensive diagnostic work-up should be performed at the initial presentation before initiation of therapy. The detection of antinuclear (ANA) or anticell antibodies by indirect immunofluorescence microscopy on Hep2 cells is used to screen for autoantibodies in collagen vascular diseases. The molecular specificity of autoantibodies should be further characterized using immunoassays with recombinant or purified protein. When systemic autoimmune disease is suspected, the function of the frequently affected organs should be evaluated. The immunopathological findings should always be interpreted in the context of clinical, histological, and imaging data. The detection of autoantibodies is helpful for the initial diagnosis, provides prognostic information, may indicate involvement of organs or systems and some parameters may also be used for disease monitoring. The clinical significance of autoantibodies is emphasized by the fact that their detection constitutes diagnostic criteria for most collagen vascular diseases and several vasculitides. The screening for ANCA may be performed using immunoassays with recombinant myeloperoxidase and proteinase 3 or by indirect immunofluorescence microscopy on granulocytes. In this article, the current diagnostic tools and their relevance for the diagnosis and monitoring of systemic autoimmune diseases with primary skin involvement are reviewed.