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Zouboulis CC, Bechara FG, Fritz K, Goebeler M, Hetzer FH, Just E, Kirsten N, Kokolakis G, Kurzen H, Nikolakis G, Pinter A, Podda M, Rosinski K, Schneider-Burrus S, Taube KM, Volz T, Winkler T, Kristandt A, Presser D, Zouboulis VA. S2k‐Leitlinie zur Therapie der Hidradenitis suppurativa/Acne inversa – Kurzfassung. J Dtsch Dermatol Ges 2024; 22:868-892. [PMID: 38857106 DOI: 10.1111/ddg.15412_g] [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: 12/03/2023] [Accepted: 02/27/2024] [Indexed: 06/11/2024]
Abstract
ZusammenfassungDie S2k‐Leitlinie der Hidradenitis suppurativa/Acne inversa (HS/AI) soll eine akzeptierte Entscheidungshilfe für die Auswahl/Durchführung einer geeigneten/suffizienten Therapie liefern. Hidradenitis suppurativa/Acne inversa ist eine chronisch‐rezidivierende, entzündliche, potenziell mutilierende Hauterkrankung des terminalen Haartalgdrüsenapparats, mit schmerzhaften, entzündlichen Läsionen in den apokrinen drüsenreichen Körperregionen. Ihre Punktprävalenz in Deutschland ist 0,3%, sie wird mit einer Verspätung von 10,0 ± 9,6 Jahren diagnostiziert. Abnormale Differenzierung der Keratinozyten des Haartalgdrüsenapparats und eine begleitende Entzündung bilden die zentrale pathogenetische Grundlage. Primäre HS/AI‐Läsionen sind entzündliche Knoten, Abszesse und drainierende Tunnel. Rezidive in den letzten 6 Monaten mit mindestens zwei Läsionen an den Prädilektionsstellen verweisen auf eine HS/AI mit einer 97‐prozentigen Genauigkeit. HS/AI‐Patienten leiden an einer deutlichen Einschränkung der Lebensqualität. Zur korrekten Therapieentscheidung sollen Klassifikation und Aktivitätsbewertung mit einem validierten Instrument erfolgen, wie dem International Hidradenitis Suppurativa Severity Scoring System (IHS4). Hidradenitis suppurativa/Acne inversa wird nach der Ausprägung der nachweisbaren Entzündung in zwei Formen eingeteilt: aktive, entzündliche (milde, mittelschwere und schwere nach IHS4) und vorwiegend inaktive, nicht entzündliche (Hurley‐Grad‐I, ‐II und ‐III) HS/AI. Orale Tetrazykline oder eine 5‐tägige intravenöse Therapie mit Clindamycin sind mit der Effektivität von Clindamycin/Rifampicin vergleichbar. Subkutan applizierbares Adalimumab, Secukinumab und Bimekizumab sind für die Therapie der HS/AI zugelassen. Für die vorwiegend nicht entzündliche Erkrankungsform stehen verschiedene operative Verfahren zur Verfügung. Medikamentöse/chirurgische Kombinationen gelten als ganzheitliches Therapieverfahren.
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Affiliation(s)
- Christos C Zouboulis
- Hochschulklinik für Dermatologie, Venerologie und Allergologie, Immunologisches Zentrum, Städtisches Klinikum Dessau, Medizinische Hochschule Brandenburg Theodor Fontane und Fakultät für Gesundheitswissenschaften Brandenburg, Dessau, Deutschland
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
| | - Falk G Bechara
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Klinik für Dermatologie, Venerologie und Allergologie, Ruhr-Universität Bochum, Bochum, Deutschland
| | - Klaus Fritz
- Zentrum für Dermatologie, Laser und Ästhetische Medizin, Landau, Deutschland
- Dermatologie II, Colentina Klinik, Carol-Davila-Universität für Medizin und Pharmazie, Bukarest, Rumänien
| | - Matthias Goebeler
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | | | - Elke Just
- Deutsche Akne Inversa Patientenvereinigung in Gründung, Kreis Coesfeld, Deutschland
| | - Natalia Kirsten
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Institut für Versorgungsforschung (IVDP), Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg, Deutschland
| | - Georgios Kokolakis
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Klinik für Dermatologie, Venerologie und Allergologie, Charité-Universitätsmedizin Berlin, Berlin, Deutschland
| | - Hjalmar Kurzen
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Haut- und Laserzentrum, Freising, Deutschland
| | - Georgios Nikolakis
- Hochschulklinik für Dermatologie, Venerologie und Allergologie, Immunologisches Zentrum, Städtisches Klinikum Dessau, Medizinische Hochschule Brandenburg Theodor Fontane und Fakultät für Gesundheitswissenschaften Brandenburg, Dessau, Deutschland
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
| | - Andreas Pinter
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland
| | - Maurizio Podda
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Hautklinik, Klinikum Darmstadt, Deutschland
| | | | - Sylke Schneider-Burrus
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Zentrum für Dermatochirurgie, Havelklinik Berlin, Berlin, Deutschland
| | - Klaus-M Taube
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Thomas Volz
- Klinik für Dermatologie und Allergologie, Technische Universität München, München, Deutschland
| | | | - Anna Kristandt
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Deutschland
| | - Dagmar Presser
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Viktor A Zouboulis
- Hidradenitis Suppurativa Foundation e.V., Dessau, Deutschland
- Medizinische Fakultät, Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg, Deutschland
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Zouboulis CC, Bechara FG, Fritz K, Goebeler M, Hetzer FH, Just E, Kirsten N, Kokolakis G, Kurzen H, Nikolakis G, Pinter A, Podda M, Rosinski K, Schneider-Burrus S, Taube KM, Volz T, Winkler T, Kristandt A, Presser D, Zouboulis VA. S2k guideline for the treatment of hidradenitis suppurativa / acne inversa - Short version. J Dtsch Dermatol Ges 2024; 22:868-889. [PMID: 38770982 DOI: 10.1111/ddg.15412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/27/2024] [Indexed: 05/22/2024]
Abstract
The S2k guideline on hidradenitis suppurativa/acne inversa (HS/AI) aims to provide an accepted decision aid for the selection/implementation of appropriate/sufficient therapy. HS/AI is a chronic recurrent, inflammatory, potentially mutilating skin disease of the terminal hair follicle-glandular apparatus, with painful, inflammatory lesions in the apocrine gland-rich regions of the body. Its point prevalence in Germany is 0.3%, it is diagnosed with a delay of 10.0 ± 9.6 years. Abnormal differentiation of the keratinocytes of the hair follicle-gland apparatus and accompanying inflammation form the central pathogenetic basis. Primary HS/AI lesions are inflammatory nodules, abscesses and draining tunnels. Recurrences in the last 6 months with at least 2 lesions at the predilection sites point to HS/AI with a 97% accuracy. HS/AI patients suffer from a significant reduction in quality of life. For correct treatment decisions, classification and activity assessment should be done with a validated tool, such as the International Hidradenitis Suppurativa Severity Scoring System (IHS4). HS/AI is classified into two forms according to the degree of detectable inflammation: active, inflammatory (mild, moderate, and severe according to IHS4) and predominantly inactive, non-inflammatory (Hurley grade I, II and III) HS/AI. Oral tetracyclines or 5-day intravenous therapy with clindamycin are equal to the effectiveness of clindamycin/rifampicin. Subcutaneously administered adalimumab, secukinumab and bimekizumab are approved for the therapy of HS/AI. Various surgical procedures are available for the predominantly non-inflammatory disease form. Drug/surgical combinations are considered a holistic therapy method.
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Affiliation(s)
- Christos C Zouboulis
- Departments of Dermatology, Venereology, Allergology and Immunology, Staedtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, Dessau, Germany
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
| | - Falk G Bechara
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Department of Dermatology, Venereology and Allergology, Ruhr-University Bochum, Bochum, Germany
| | - Klaus Fritz
- Dermatology and Laser Consultation Center, Landau, Germany
- Dermatology II, Colentina Clinical Hospital, Carol-Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Matthias Goebeler
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Department of Dermatology, Venereology and Allergology, Würzburg University Hospital, Würzburg, Germany
| | | | - Elke Just
- German Acne Inversa Patient Association in Formation, Kreis Coesfeld, Germany
| | - Natalia Kirsten
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Georgios Kokolakis
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hjalmar Kurzen
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Freising Skin and Laser Center, Freising, Germany
| | - Georgios Nikolakis
- Departments of Dermatology, Venereology, Allergology and Immunology, Staedtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, Dessau, Germany
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
| | - Andreas Pinter
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Maurizio Podda
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Department of Dermatology, Medical Center Darmstadt, Darmstadt, Germany
| | | | - Sylke Schneider-Burrus
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Center for Dermatosurgery, Havelklinik Berlin, Berlin, Germany
| | - Klaus-M Taube
- Department of Dermatology and Venereology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Thomas Volz
- Department of Dermatology and Allergology, Technical University of Munich, Munich, Germany
| | | | - Anna Kristandt
- Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Dagmar Presser
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Department of Dermatology, Venereology and Allergology, Würzburg University Hospital, Würzburg, Germany
| | - Viktor A Zouboulis
- Hidradenitis Suppurativa Foundation e.V., Dessau, Germany
- Faculty of Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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Current Medical and Surgical Treatment of Hidradenitis Suppurativa-A Comprehensive Review. J Clin Med 2022; 11:jcm11237240. [PMID: 36498816 PMCID: PMC9737445 DOI: 10.3390/jcm11237240] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease presenting with recurrent inflammatory lesions in intertriginous body regions. HS has a pronounced impact on patients' quality of life and is associated with a variety of comorbidities. Treatment of HS is often complex, requiring an individual approach with medical and surgical treatments available. However, especially in moderate-to-severe HS, there is an urgent need for new treatment approaches. In recent years, increased research has led to the identification of new potential therapeutic targets. This review aims to give a comprehensive and practical overview of current treatment options for HS. Furthermore, the clinically most advanced novel treatment approaches will be discussed.
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Fougerousse AC, Maccari F, Guillem P, Reguiai Z. Antibiotic Treatment for Hidradenitis Suppurativa in France: A Practice Survey. Clin Cosmet Investig Dermatol 2022; 15:2641-2645. [DOI: 10.2147/ccid.s374643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/13/2022] [Indexed: 12/12/2022]
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Ghanian S, Yamanaka-Takaichi M, Naik HB, Alavi A. Medical Management of Hidradenitis Suppurativa with Non-Biologic Therapy: What's New? Am J Clin Dermatol 2022; 23:167-176. [PMID: 34990004 PMCID: PMC9131893 DOI: 10.1007/s40257-021-00667-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 11/25/2022]
Abstract
Hidradenitis suppurativa (HS) is a severe chronic relapsing inflammatory disorder of the hair follicle unit that can cause painful abscesses, nodules, tunnels, and tracts in intertriginous parts of the body. The disease can often result in disfigurement and adversely impact patient quality of life. The management of HS has expanded significantly over the past decade to include multiple modalities, including topical therapies, systemic therapies (non-biologics and biologics), surgical therapies, lifestyle changes, and management of comorbidities. Management can often be clinically challenging and may involve the combination of medical and surgical approaches for optimal results. The purpose of this review is to present an update on non-biologic and non-interventional modalities published in 2019-2021 in the clinical management of HS. With emerging therapies, ongoing clinical trials, and heightened awareness about HS, there is hope that new treatment options will revolutionize the management of patients suffering from HS.
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Affiliation(s)
- Soha Ghanian
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Haley B Naik
- Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
| | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.
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Haferland I, Wallenwein CM, Ickelsheimer T, Diehl S, Wacker MG, Schiffmann S, Buerger C, Kaufmann R, Koenig A, Pinter A. Mechanism of anti-inflammatory effects of Rifampicin in an ex vivo culture system of Hidradenitis Suppurativa. Exp Dermatol 2022; 31:1005-1013. [PMID: 35048417 DOI: 10.1111/exd.14531] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 01/12/2022] [Accepted: 01/14/2022] [Indexed: 11/30/2022]
Abstract
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease of the hair follicles leading to painful lesions, associated with increased levels of pro-inflammatory cytokines. Numerous guidelines recommend antibiotics like clindamycin and rifampicin in combination, as first-line systemic therapy in moderate to severe forms of inflammation. HS has been proposed to be mainly an auto-inflammatory disease associated with but not initially provoked by bacteria. Therefore, it has to be assumed that the pro-inflammatory milieu previously observed in HS skin is not solely dampened by the bacteriostatic inhibition of DNA-dependent RNA polymerase. To further clarify the mechanism of anti-inflammatory effects of rifampicin, ex vivo explants of lesional HS from 8 HS patients were treated with rifampicin, and its effect on cytokine production, immune cells as well as the expression of Toll-like receptor 2 (TLR2) were investigated. Analysis of cell culture medium of rifampicin treated HS explants revealed an anti-inflammatory effect of rifampicin that significantly inhibiting interleukin (IL)-1β, IL-6, IL-8, IL-10, and tumour necrosis factor (TNF) -α production. Immunohistochemistry of the rifampicin-treated explants suggested a tendency for it to reduce the expression of TLR2 while not affecting the number of immune cells.
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Affiliation(s)
- Isabel Haferland
- Department of Dermatology, Venerology and Allergology, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Chantal M Wallenwein
- Fraunhofer Insitute for Translational Medicine and Pharmacology ITMP, Frankfurt am Main, Germany
| | - Tanja Ickelsheimer
- Department of Dermatology, Venerology and Allergology, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Sandra Diehl
- Department of Dermatology, Venerology and Allergology, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Matthias G Wacker
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
| | - Susanne Schiffmann
- Fraunhofer Insitute for Translational Medicine and Pharmacology ITMP, Frankfurt am Main, Germany
| | - Claudia Buerger
- Department of Dermatology, Venerology and Allergology, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Roland Kaufmann
- Department of Dermatology, Venerology and Allergology, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Anke Koenig
- Department of Dermatology, Venerology and Allergology, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Andreas Pinter
- Department of Dermatology, Venerology and Allergology, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
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Amat-Samaranch V, Agut-Busquet E, Vilarrasa E, Puig L. New perspectives on the treatment of hidradenitis suppurativa. Ther Adv Chronic Dis 2021; 12:20406223211055920. [PMID: 34840709 PMCID: PMC8613896 DOI: 10.1177/20406223211055920] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/08/2021] [Indexed: 12/25/2022] Open
Abstract
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by the presence of painful nodules, abscesses, chronically draining fistulas, and scarring in apocrine gland-bearing areas of the body. The exact pathogenesis of HS is not yet well understood, but there is a consensus in considering HS a multifactorial disease with a genetic predisposition, an inflammatory dysregulation, and an influence of environmental modifying factors. Therapeutic approach of HS is challenging due to the wide clinical manifestations of the disease and the complex pathogenesis. This review describes evidence for effectiveness of current and emerging HS therapies. Topical therapy, systemic treatments, biological agents, surgery, and light therapy have been used for HS with variable results. Adalimumab is the only US Food and Drug Administration (FDA) approved biologic agent for moderate-to-severe HS, but new therapeutic options are being studied, targeting different specific cytokines involved in HS pathogenesis. Comparing treatment outcomes between therapies is difficult due to the lack of randomized controlled trials. Treatment strategy should be selected in concordance to disease severity and requires combination of treatments in most cases.
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Affiliation(s)
- Victoria Amat-Samaranch
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Mas Casanovas 90, 08041, Barcelona, Spain
| | - Eugènia Agut-Busquet
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Mas Casanovas 90, 08041, Barcelona, Spain
| | - Eva Vilarrasa
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Mas Casanovas 90, 08041, Barcelona, Spain
| | - Lluís Puig
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Mas Casanovas 90, 08041 Barcelona, Spain
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Iannone M, Janowska A, Bartolomei G, Puntoni M, Oranges T, Romanelli M, Dini V. Systemic antibiotics in hidradenitis suppurativa: efficacy and effects of body mass index and smoking pack-year on the response to therapy. Dermatol Ther 2021; 34:e14919. [PMID: 33634552 DOI: 10.1111/dth.14919] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/27/2021] [Accepted: 02/22/2021] [Indexed: 01/10/2023]
Abstract
The combination of oral clindamycin with rifampicin is recommended by European guidelines as a first-line treatment in moderate-to-severe hidradenitis suppurativa (HS). Recent studies highlight that oral clindamycin in monotherapy (CM) may be a useful alternative treatment. We included 36 patients with a diagnosis of moderate-to-severe HS. A total of 19 patients were treated with combination oral clindamycin plus rifampicin (C + R) and 17 with oral CM for 12 weeks. The efficacy of CM vs C + R was analyzed by multilinear regression models which showed a higher reduction in mSartorius (Δ = -13.2, P = .058) and AISI (Δ = -4.91, P = .034) in the C + R group. In the C + R group, smoking pack-year was positively correlated with AISI (Spearman's rho = 0.51, P = .036) and with DLQI (0.47, P = .061). In the CM group, a positive correlation was found between BMI and AISI (0.47, P = .041). The data on the efficacy of C + R combination therapy are in line with guidelines, evidence-based approaches, and recommendations from the HS ALLIANCE working group. The rationale for combining these two drugs is to increase bactericidal action and to reduce rifampicin resistance, as rifampicin is highly mutagenic. Our results suggest that the antibiotic combination of C + R is still the treatment of choice in moderate-to-severe HS with abscesses, draining fistulae and ≥ 5 inflammatory nodules. High BMI and smoking habits seem to be predictive factors of a poor response to antibiotics. Further multicenter studies and prospective randomized controlled trials are needed to confirm these results. Potential alternative antibiotic therapies should also be investigated.
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Affiliation(s)
| | - Agata Janowska
- Department of Dermatology, University of Pisa, Pisa, Italy
| | | | - Matteo Puntoni
- Clinical trial office, Scientific directorate, E.O. Ospedali Galliera, University of Genoa, Genoa, Italy
| | - Teresa Oranges
- Department of Dermatology, University of Pisa, Pisa, Italy
| | | | - Valentina Dini
- Department of Dermatology, University of Pisa, Pisa, Italy
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