Linkage between patients' characteristics and prescribed systemic treatments for psoriasis: a semantic connectivity map analysis of the Swiss Dermatology Network for Targeted Therapies registry

BACKGROUND

Several treatment options are currently available for the treatment of psoriasis.

OBJECTIVE

To explore the main associations between patients' characteristics and systemic treatments prescribed for psoriasis in a large group of patients observed in real-life clinical practice.

METHODS

This was a retrospective analysis of baseline data collected within the Swiss Dermatology Network for Targeted Therapies registry in Switzerland between March 2011 and December 2017. Semantic map analysis was used in order to capture the best associations between variables taking into account other covariates in the system.

RESULTS

A total of 549 patients (mean age 46.7 ± 14.7 years) were included in the analysis. Conventional therapies such as retinoids and methotrexate were associated with no previous systemic therapies for psoriasis, a moderate quality of life (QoL) at therapy onset and older age (≥60 years). Fumaric acid derivatives were associated with mild psoriasis (psoriasis area severity index < 10) and long disease duration (≥20 years). On the other side, cyclosporine and psoralen and ultraviolet A/ultraviolet B treatments were linked to a more severe condition, including impaired QoL, hospitalization and inability to work. Regarding biological therapies, both infliximab and adalimumab were connected to the presence of psoriatic arthritis, severe disease condition and other comorbidities, including chronic liver or kidney diseases and tuberculosis. Etanercept, ustekinumab and secukinumab were all connected to a complex history of previous systemic treatments for psoriasis, moderate disease condition, overweight and university education.

CONCLUSIONS

The analysis shows multifaceted associations between patients' characteristics, comorbidities, disease severity and systemic treatments prescribed for psoriasis. In particular, our semantic map indicates that comorbidities play a central role in decision-making of systemic treatments usage for psoriasis. Future studies should further investigate specific connections emerging from our data.

Swiss S1 guideline for the treatment of rosacea

Rosacea (in German sometimes called 'Kupferfinne', in French 'Couperose' and in Italian 'Copparosa') is a chronic and frequently relapsing inflammatory skin disease primarily affecting the central areas of the face. Its geographic prevalence varies from 1% to 22%. The differential diagnosis is wide, and the treatment is sometimes difficult and varies by stage of rosacea. For erythematous lesions and telangiectasia, intense pulsed light (IPL) therapy and lasers are popular treatment option. In addition, a vasoconstrictor agent, brimonidine, has recently been developed. For papulopustular rosacea, topical antibiotics, topical and systemic retinoids, as well as systemic antibiotics are used. A topical acaricidal agent, ivermectin, has undergone clinical development and is now on the market. In the later stages, hyperplasia of the sebaceous glands develops, resulting in phymatous growths such as the frequently observed bulbous nose or rhinophyma. Ablative laser treatments have largely replaced classical abrasive tools. Here, we reviewed the current evidence on the treatment of rosacea, provide a guideline (S1 level) and discuss the differential diagnosis of rosacea.

Genetic susceptibility to cutaneous melanoma in southern Switzerland: role of CDKN2A, MC1R and MITF

BACKGROUND

Nearly 10% of all cases of cutaneous melanoma (CM) occur in patients with a personal or family history of the disease.

OBJECTIVES

To obtain information about genetic predisposition to CM in Ticino, the southern region of Switzerland, a zone with moderate-to-high CM incidence.

METHODS

We identified germline mutations in highly CM-associated genes (CDKN2A and CDK4) and low/medium-penetrance variants (MC1R and MITF) in patients with multiple primary CMs or individuals with one or more CM and a positive family history for CM or pancreatic cancer among first- or second-degree relatives. Healthy blood donors (n = 146) were included as a control group.

RESULTS

From July 2010 to July 2012, 57 patients (41 pedigrees) were included. Twenty-six were melanoma-prone families (with at least two cases) and 15 had multiple CMs. Pancreatic cancer was found in six families. The CDKN2A mutation p.V126D was identified in seven patients (four families) with a founder effect, whereas CDKN2A A148T was detected in seven cases (five families) and seven healthy donors (odds ratio 2·76, 95% confidence interval 0·83-9·20). At least one MC1R melanoma-associated polymorphism was detected in 32 patients (78%) and 97 healthy donors (66%), with more than one polymorphism in 12 patients (29%) and 25 healthy donors (17%). The MITF variant p.E318K was identified in four patients from three additional pedigrees (7%) and one healthy control (0·7%).

CONCLUSIONS

Inclusion criteria for the Ticino population for genetic assessment should follow the rule of two (two affected individuals in a family or a patient with multiple CMs), as we detected a CDKN2A mutation in almost 10% of our pedigrees (four of 41), MITF p.E318K in 7% (three of 41) and a higher number of MC1R variants than in the control population.

The clinical spectrum of syphilitic balanitis of Follmann: report of five cases and a review of the literature

BACKGROUND

Eugène Follmann first described syphilitic balanitis as a manifestation of primary syphilis in 1948 and since then it has been known as syphilitic balanitis of Follmann (SBF). So far, SBF has rarely been described in literature.

OBJECTIVES

We are reporting five additional cases of SBF considering the broad differential diagnosis of balanitis.

METHODS

A review of the available literature of SBF was performed and five additional cases analyzed.

RESULTS

In our case series, the clinical appearance of SBF shows a heterogeneous spectrum varying from painful oedematous balanoposthitis with beginning paraphimosis to superficial erosive balanitis and even to painless induration of the glans.

CONCLUSIONS

SBF might be seen more frequently than has been described due to misinterpretation. Therefore primary syphilis should be included in the differential diagnosis of balanitis and balanoposthitis.

Precalcaneal congenital fibrolipomatous hamartomas: report of 3 additional cases and discussion of the differential diagnosis

We report 3 cases of otherwise healthy infants with nodules on their soles. The nodules were present at birth or developed in early childhood. This condition has first been described in 1977 and was termed precalcaneal congenital fibrolipomatous hamartoma (PCFH). Since then the same entity has been reported under various denominations. The incidence of PCFH is underestimated, and it is important to recognize the benign nature of this disorder.

Localized Childhood Vulval Pemphigoid Treated with Tacrolimus Ointment

BACKGROUND

Localized vulval childhood pemphigoid is a rare variant within the pemphigoid group. Although its prognosis seems favorable, the best therapeutic strategy remains unclear.

OBSERVATION

We here describe the case of an 8-year-old girl presenting with a 5-year history of relapsing vulval pain and lesions suggestive of lichen sclerosus. Clinical features, light microscopy and direct immunofluorescence microscopy were consistent with vulval cicatricial pemphigoid, although the autoantigen(s) involved could not be characterized. Her disease responded to treatment with topical tacrolimus ointment 0.1% within 3 months without any evidence for disease activity, except for slight residual scarring. After 12 months, her treatment was stopped without relapse.

CONCLUSION

This observation suggests that in this rare immune-mediated blistering disease topical tacrolimus is an interesting therapeutic option without the adverse effects associated with topical steroids.

Classical (HIV-negative) cutaneous Kaposi's sarcoma: a case report and a short review of the literature

Classical Kaposi's sarcoma is a sporadic disease with a markedly higher incidence in the Mediterranean area. The two original forms of this disease, the Caucasian (classical) and the African, are now well-documented entities. The immunosuppression-related form is a new, recently described subset of the disease, arising from the human immune deficiency virus (HIV) infection and/or the widespread use of immunosuppressive treatments. Cutaneous lesions are the most common manifestation of classical Kaposi's sarcoma. The case described in the present report is characterised by a history of slowly evolving disease affecting the lower extremities without spread to thoracic or abdominal organs, a lengthy remission following initial radiation therapy, and local relapse with a further remission after a second course of radiation. Current treatments, in particular radiation therapy, achieve disease control or at least control of disease-related symptoms (mainly pain) in most cases, even when cure is not possible.

Eradication of Borrelia burgdorferi infection in primary marginal zone B-cell lymphoma of the skin

Primary cutaneous B-cell lymphomas have been associated with Borrelia burgdorferi, the spirochete responsible for Lyme disease. Recently, cutaneous marginal zone B-cell lymphoma has been proposed as a distinct clinical-pathological entity. We report a case of primary cutaneous marginal zone lymphoma, associated with B burgdorferi infection. Polymerase chain reaction (PCR) amplification of the third complementarity determining region (CDR3) of the immunoglobulin heavy chain gene showed the presence of a monoclonal lymphoproliferation, therefore strengthening the histological diagnosis of a malignant process. B burgdorfer-specific hbb gene sequences were detected by PCR in the lymphoma tissue at diagnosis but not after antibiotic treatment. A nearly complete clinical and histological regression was observed after B burgdorferi eradication, with immunohistochemistry studies showing disappearance of plasma cell differentiation and a marked decline in the number of CD3+ T cells and Ki-67+ cells. Our case confirms the link between B burgdorferi and some cutaneous lymphomas. The disappearance of the microorganism accompanied by the unequivocal decrease of most indicators of active T- and B-cell immune response strongly supported a pathogenetic role for B burgdorferi in sustaining an antigen-driven development and growth of this cutaneous marginal zone lymphoma. Antibiotic therapy (analogous to Helicobacter pylori infection in gastric MALT lymphoma) might be helpful with the aim of averting or at least deferring the indication for more aggressive treatment.

Topical haemotherapy for leg ulcers

Several growth factors, present in the plasma or delivered by blood cells, are involved in wound healing. We have treated 15 chronic atonic leg ulcers by topical application of autologous heparinized blood under a hydrocolloidal dressing. This 'topical haemotherapy' (THT) was applied every other day. After the first THT, 30% of the fibrinonecrotic material had already been removed. After a mean of 9 THT applications (range: 5-18), granulation tissue covered up to 75% of the surface of the ulcer (range: 30-100%) allowing autologous skin grafting. No local or systemic side-effects occurred during the treatment. THT is feasible and well tolerated; it is an easy and inexpensive treatment of chronic leg ulcers that rapidly induces granulation tissue. Growth factors and proteases produced by the blood cells could play a relevant role in this process.

L-tryptophan-induced eosinophilia-myalgia syndrome associated with primary cutaneous malignant fibrous histiocytoma and extraabdominal desmoid tumor

A 57-year-old woman with L-tryptophan-induced eosinophilia-myalgia syndrome, 23 months after the onset of symptoms, experienced development of a parasternal malignant fibrous histiocytoma on previously scleroderma-like skin areas and, almost concurrently, an extraabdominal desmoid tumor of the left arm muscle fascia. The malignant fibrous histiocytoma was treated by surgical excision without sign of recurrence or metastasis 19 months later. Radiation therapy was performed on the extraabdominal desmoid tumor. We suspect that these two connective tissue tumors in this patient were related to the exposure to contaminated L-tryptophan, which interfered with connective tissue metabolism.

Pulse of methylprednisolone in alopecia areata

In an attempt to stop the evolution of recent-onset severe alopecia areata (AA), we tested pulse corticotherapy on 9 patients. Acceptance into the study was based on the following criteria: recent-onset AA (< 1 year), AA in an active state, bald surface > 30% of the scalp, no contraindication to pulse corticotherapy. Each patient was given 250 mg i.v. of methylprednisolone twice a day on 3 successive days. In 8 patients the course of the ongoing episode of AA was stopped. At the 6-month follow-up, a regrowth on 80-100% of the bald surface was observed in 6 patients. One patient did not respond to treatment, and 2 had less than 50% of regrowth. This open study suggests that pulse corticotherapy: (1) can stop the course of severe AA in an active state, (2) is well tolerated without major side effects and (3) does not permit a stable control of AA of more than 1 year duration. This treatment seems to be indicated for severe AA of recent onset.

Hip surgery skin cellulitis

Of 583 erysipelas/cellulitis seen in our Department between 1981 and 1991, six (1.04%) were localized to the buttock and hip. Five patients had had a dynamic hip screw implanted for coxarthritis on the side where the skin infection developed. This does not appear to be secondary to superinfection of the surgical wound as the erysipelas/cellulitis occurred weeks (7 to 520) after surgery. The possible surgical compromise of the venous/lymphatic circulation appears to be the causative factor. In all patients, the course was satisfactory upon systemic antibiotic therapy and no recurrence was seen after a mean follow up of 28 months.

[Cutaneous manifestations of tuberculosis]

Tuberculous lesions of the skin occur rarely nowadays. We therefore have mostly lost the knowledge to recognize this entity. Furthermore, the great variability of the clinical and particularly dermatologic manifestations of the disease can tax the most astute clinician. The challenge is even greater, when the patient has an intercurrent condition such as a malignancy or AIDS. In order to make understanding easier, we replace all descriptive terms, some carried over from the last century, by a useful pathogenetic and clinical, algorithmic classification. Finally the necessity of biopsy and specific cultures for proper diagnosis and treatment of any skin lesion consistent with skin tuberculosis is emphasized.