Pain Control during the Treatment of Primary Palmar Hyperhidrosis with Botulinum Toxin A by a Topical Application of Liposomal Lidocaine: Clinical Effectiveness

Primary palmar hyperhidrosis (PPH) constitutes a debilitating condition that profoundly impacts the social, functional, and occupational aspects of individuals. The intradermal administration of botulinum toxin type A (BoNT-A) stands as an established therapeutic approach for PPH, albeit one frequently accompanied by considerable pain, posing challenges for patient tolerance. Our study aimed to assess the efficacy of combining cryoanalgesia spray (CA) with topical anesthesia utilizing a cream containing liposomal lidocaine at a concentration of 40 mg/g, with the objective of mitigating the pain associated with intradermal BoNT-A injection for PPH treatment. Nineteen participants, aged ≥18 years and afflicted with severe PPH, were enrolled in a double-blind randomized vehicle-controlled trial. Patient-perceived pain during the procedure was quantified using the Numeric Rating Scale (NRS). Statistical analysis was applied to the collected data. The combination of CA and the topical application of liposomal lidocaine during BoNT-A treatment for PPH resulted in diminished pain compared to CA alone and the combination of CA with the application of a basic cream. Topical anesthesia through the application of a liposomal lidocaine-containing cream emerged as a facile, secure, and efficacious approach for alleviating the pain associated with intradermal BoNT-A injection in PPH treatment. Furthermore, it demonstrated compatibility with CA, thereby offering a comprehensive strategy for pain management during BoNT-A administration.

Ocean warming and acidification detrimentally affect coral tissue regeneration at a Mediterranean CO2 vent

Among the main phenomena that are causing significant changes in ocean waters are warming and acidification, largely due to anthropogenic activities. Growing evidence suggests that climate change is having more substantial and rapid effects on marine communities than on terrestrial ones, triggering several physiological responses in these organisms, including in corals. Here we investigated, for first time in the field, the combined effect of increasing seawater acidification and warming on tissue regeneration rate of three Mediterranean scleractinian coral species characterized by different trophic strategies and growth modes. Balanophyllia europaea (solitary, zooxanthellate), Leptopsammia pruvoti (solitary, non-zooxanthellate) and Astroides calycularis (colonial, non-zooxanthellate) specimens were transplanted, during a cold, intermediate, and warm period, along a natural pH gradient generated by an underwater volcanic crater at Panarea Island (Mediterranean Sea, Italy), characterized by continuous and localized CO2 emissions at ambient temperature. Our results show a decrease in regenerative capacity, especially in the zooxanthellate species, with increasing seawater temperature and acidification, with demonstrated species-specific differences. This finding suggests that increasing seawater temperature and acidification could have a compounding effect on coral regeneration following injury, potentially hindering the capacity of corals to recover following physical disturbance under predicted climate change.

Efficacy and Safety of Botulinum Toxin B in Focal Hyperhidrosis: A Narrative Review

Botulinum toxin type B (BoNT-B), known as Myobloc® in the United States and as Neurobloc® in Europe, is a new therapeutically available serotype among the botulinum toxin family. During the last years several data have been reported in literature investigating its efficacy and safety, as well as defining the dosing and application regiments of BoNT-B in the treatment of hyperhidrosis. Moreover, recent studies have been examining its safety profile, which may be different from those known about BoNT-A. The aim of this review is to provide information about what is currently known about BoNT-B in regards to the treatment of focal hyperhidrosis.

Should we be concerned about gastrointestinal-related adverse events in patients with plaque psoriasis receiving secukinumab therapy? A retrospective, real-life study

Real-world secukinumab gastrointestinal-related adverse events (GIRAE) data in psoriatic patients treated with secukinumab are lacking. A descriptive, retrospective study was performed by reviewing the medical records of patients who received secukinumab for plaque psoriasis for at least 1 year and who made a follow-up visit to the dermatology clinic of "Ospedali Riuniti Umberto I" in Ancona between December 1, 2021, and March 31, 2022. The patients' medical history and clinical data were collected at T0, before treatment, and at T1, corresponding to the last follow-up visit. Special attention was given to gastrointestinal adverse events (GIRAE). A total of 108 patients were included in the study. At baseline median PASI was 14.8 (range 2.2-27, SD 6.1), and median DLQI was 9.3 (5-16, SD 2.6). The median PASI for treated patients was 0.7 (0-3, SD 0.8; p < 0.00) 1and median DLQI was 0.3 (0-1, SD 0.5; p < 0.001). At T1 54/114 patients (50%) reached PASI100, of the other 54, 48 (88.9%) reached PASI 90 while the other six discontinued for secondary ineffectiveness. Only three patients reported a GIRAE (diarrhea), however, when screened, no IBD was found. Consistent with data in the literature, secukinumab is an effective and safe drug for the treatment of plaque psoriasis also in a real-life experience context. There should be no concern in choosing the drug for fear of possible IBDs-related GIRAE if there is no personal history or familiarity for IBDs.

MRSA and Skin Infections in Psoriatic Patients: Therapeutic Options and New Perspectives

Psoriatic patients present various infectious risk factors, but there are few studies in the literature evaluating the actual impact of psoriasis in severe staphylococcal skin infections. Our narrative review of the literature suggests that psoriatic patients are at increased risk of both colonization and severe infection, during hospitalization, by S. aureus. The latter also appears to play a role in the pathogenesis of psoriasis through the production of exotoxins. Hospitalized psoriatic patients are also at increased risk of MRSA skin infections. For this reason, new molecules are needed that could both overcome bacterial resistance and inhibit exotoxin production. In our opinion, in the near future, topical quorum sensing inhibitors in combination with current anti-MRSA therapies will be able to overcome the increasing resistance and block exotoxin production. Supplementation with Vitamin E (VE) or derivatives could also enhance the effect of anti-MRSA antibiotics, considering that psoriatic patients with metabolic comorbidities show a low intake of VE and low serum levels, making VE supplementation an interesting new perspective.

A Systematic Review of Atopic Dermatitis: The Intriguing Journey Starting from Physiopathology to Treatment, from Laboratory Bench to Bedside

Atopic dermatitis (AD) is a common chronic inflammatory and immune-mediated skin disease with a complex pathophysiology and still represents a therapeutic challenge, owing to limited responses to available treatments. However, recent advances in the understanding of AD pathophysiology have led to the discovery of several new potential therapeutic targets, and research in the field of new molecules with therapeutic perspectives is boiling, with more than 70 new promising drugs in development. The aim of this systematic review is to provide the state of the art on the current knowledge concerning the pathophysiology of the disease and on novel agents currently being investigated for AD, and to highlight which type of evolution is going to take place in therapeutic approaches of atopic dermatitis in the coming years.

Latest combination therapies in psoriasis: Narrative review of the literature

Biological therapies revolutionized the treatment of many chronic inflammatory skin diseases, first of all psoriasis, thanks to their high efficacy and the reduced number of side effects. However, the use of a single biologic drug does not always provide complete control of the disease or associated comorbidities over time. The first biological drugs used for the treatment of psoriasis, tumor necrosis factor alpha inhibitors, have long been used in combination with traditional topical and systemic therapies to induce a complete remission of the disease that could not be achieved with innovative drug alone. Even with the advent of new biological therapies with more precise molecular targets, the challenge of using combination therapies remained. Psoriatic patients often have major comorbidities, such as arthritis, inflammatory bowel disease, uveitis or have other concomitant conditions such as chronic spontaneous urticaria and atopic dermatitis, which may require different biologic treatments than those indicated in psoriasis. The objective of this article is, through a comprehensive revision of the literature, to analyze in which cases the use of the combination of the latest therapies for psoriasis may be useful.

Atypical Scleroderma-like Chronic GVHD in a Liver Transplant Patient, Clinical and MRI Correlations

Dear Editor, cutaneous chronic graft versus host disease (cGVHD) is a pathological process consisting of donor-derived T-cells aimed at the antigens of the recipient. It exhibits a large range of clinical presentations resembling morphea and deep sclerosis/fasciitis, all characterized by both inflammation and progressive dermal and hypodermic fibrosis (1). Although classic scleroderma-like lesions in cGVHD are nummular or irregular plaques and linear bundles associated with hypo- or hyperpigmentation (2), we report an atypical case with ulcerative presentation. No other case-reports of morphea-like or scleroderma-like cGVHD with an ulcerated appearance after liver transplantation (LT) and magnetic resonance imaging (MRI) correlation have been found in the literature. CASE REPORT Ten months after LT due to an end-stage cirrhosis associated with multifocal hepatocarcinoma (HCC), a 61-year-old man on immunosuppressive therapy with Tacrolimus (1 mg) and Everolimus (10 mg) presented to our clinic for a skin lesion in the right scapular region. We observed a flat ulcerated plaque with areas of sclerosis, minimal necrosis, and well-defined slightly erythematous margins (Figure 1, a). On palpation, the plaque had a hard consistency and was slightly painful. The skin lesion had been preceded by subjective discomfort with stinging sensation for seven months before its onset. Gradually lesion developed starting from a small, flat, oval purplish plaque associated with a progressive increase in pain. Patient denied dysphagia, retrosternal heartburn, Raynaud's phenomenon, arthralgia, and dyspnea. A previous MRI (Figure 2, a,b) showed subcutaneous and muscle edema. Blood tests showed abnormal liver function indexes due to extrahepatic cholestasis, while C-reactive protein, erythrocyte sedimentation rate, and leukocytes were within normal ranges. Self-reactive antibodies were negative. Histological examination (Figure 1, b) identified rare dyskeratotic keratinocytes and basal lymphocyte infiltrate, a dermal dense fibrosis with the disappearance of the skin appendages, and large fibrous septa in the adipose panniculus. It led to the diagnosis of scleroderma/morphea, based on the patient's clinical history. The diagnosis of graft versus host disease scleroderma-like post liver transplant was established. The lesion was treated by topical application of 0.05% clobetasol once a day. We did not use systemic immunosuppressive therapy in order to prevent HCC recurrence. The patient is currently in clinical follow-up to identify worsening or neoplastic degeneration. CASE DISCUSSION Cutaneous cGVHD often presents clinically as an ulcerative evolution in the context of fibrosis and diffuse skin atrophy (2), but very rarely initially appears as a well-delimited ulcerated plaque. Only few cases of ulcer have been found in literature, all in patients undergoing hematopoietic stem cell transplantation (HSCT), which is associated with the highest risk of developing GVHD, 20-50% (3,4), while LT has quite low incidence, at 0.5-2% (5). To our knowledge, this is the first case report of a scleroderma-like cGVHD lesion with ulcer appearance in LT. Our patient underwent two MRIs during post-transplant follow-up, which allowed us to evaluate the deep disease evolution. The T2-weighted MRI (Figure 2, c,d) performed approximately 1 year after transplantation, demonstrated fibrous septa in the subcutaneous fat and fascial thickening, with associated muscle hypotrophy and edema. The previous MRI, performed seven months after transplantation, already showed subcutaneous tissues and fascial edema, highlighting active inflammation. This evidence suggests that MRI could identify the lesion location before clinical manifestations, providing an opportunity to intervene promptly. To the best of our knowledge, this is the first reported case of cGVHD with atypical scleroderma-like presentation in a liver transplant patient whose clinical and MRI correlations have been traced. Our suggestions are supported by the results of other previous studies (6,7) evaluating MRI performance for assessing disease extent and activity, as well as therapeutic response in HSCT.

Mesenchymal Stem Cells Profile in Adult Atopic Dermatitis and Effect of IL4-IL13 Inflammatory Pathway Inhibition In Vivo: Prospective Case-Control Study

Atopic dermatitis (AD) is an inflammatory disease that typically begins in childhood and may persist into adulthood, becoming a lifelong condition. The major inflammatory mediators of AD are known to be interleukin IL4 and IL13, so Dupilumab, which is able to inhibit both interleukins by blocking the shared IL4Rα subunit, has become an attractive option for treating AD. Mesenchymal stem cells (MSCs) are involved in the onset and development of AD by secreting specific interleukins. The aim of this study was to isolate MSCs from healthy controls (C-MSCs) and patients with AD before (AD-MSCs T0) and after 16 weeks of treatment with Dupilumab (AD-MSCs T16); to evaluate the expression mainly of IL4 and IL13 and of other inflammatory cytokines in C-MSCs, AD-MSCs at T0 and at T16; and to evaluate the efficacy of Dupilumab on MSCs immunobiology. C- and AD-MSCs (T0, T16) were isolated from skin specimens and characterized; the expression/secretion of IL4 and IL13 was evaluated using immuno-cytochemistry (ICC), indirect immune-fluorescence (IIF) and an ELISA test; secretion of IL2, IL4, IL5, IL6, IL10, IL12, IL13, IL17A, Interferon gamma (IFNγ), Tumor necrosis factor alpha (TNFα), Granulocyte Colony-Stimulating Factor (G-CSF), and Transforming Growth Factor beta1 (TGFβ1) were measured with ELISA. IL13 and IL6 were over-expressed, while IL4 was down-regulated in AD-MSCs at T0 compared to C-MSCs. IL6 and IL13 expression was restored after 16 weeks of Dupilumab treatment, while no significant effects on IL4 expression were noted. Finally, IL2, IL5, IL10, IL12, IL17A, INFγ, TNFα, G-CSF, and TGFβ1 were similarly secreted by C- and AD-MSCs. Although Dupilumab blocks the IL4Rα subunit shared by IL4 and IL13, it is evident that its real target is IL13, and its ability to target IL13 in MSCs reinforces the evidence, already known in differentiated cells, of the central role IL13 rather than IL4 in the development of AD. The inflammatory cascade in AD begins at the mesenchymal level, so an upstream therapeutic intervention, able to modify the immunobiology of atopic MSCs, could potentially change the natural history of the disease.

THE PHARMACOLOGICAL TREATMENT AND MANAGEMENT OF HYPERHIDROSIS

INTRODUCTION

Idiopathichyperhidrosis is a dysfunctional disorder involving eccrine sweat glands and its impact on patients' daily quality of life is well-known. Unlike some years ago, when only poor effective and safe therapeutic alternatives were available, nowadays, several emerging pharmacological active substances have gained significant space as treatment options.

AREAS COVERED

The authors report on, in this narrative review, the emerging data from the literature focusing on the pharmacological treatments to draw up a drug treatments flow-chart for patients with idiopathic hyperhidrosis, taking into consideration specific differences among axillary, palmoplantar and craniofacial hyperhidrosis.

EXPERT OPINION

Idiopathic hyperhidrosis, regardless of the site of involvement, remains a functional disorder that places a significant burden on patients. After balancing efficacy against adverse events, systemic therapy, although off-label for all forms of hyperhidrosis can represent an additive therapeutic option for patients with insufficient response to topical treatment according to a step wise therapeutic approach. Until the pathophysiological mechanisms underlying hyperhidrosis are clear, and the etiological therapeutic approach become realistic, the greatest challenge in the therapeutic management of hyperhidrotic patients seems to be the search for the most convenient combination between different therapeutic modalities (topical and systemic agents, and botulinum toxins) to achieve long-term control of the disease symptoms.

Tetraspanin CD9 Expression Predicts Sentinel Node Status in Patients with Cutaneous Melanoma

The tetraspanin CD9 is considered a metastasis suppressor in many cancers, however its role is highly debated. Currently, little is known about CD9 prognostic value in cutaneous melanoma. Our aim was to analyse CD9 expression in melanocytic nevi and primary cutaneous melanomas through immunohistochemistry and immunofluorescence approaches to determine its correlation with invasiveness and metastatic potential. CD9 displayed homogeneous staining in all melanocytic nevi. In contrast, it showed a complete loss of reactivity in all thin melanomas. Interestingly, CD9 was re-expressed in 46% of intermediate and thick melanomas in small tumor clusters predominantly located at sites of invasion near or inside the blood or lymphatic vessels. The most notable finding is that all CD9 stained melanomas presented sentinel node positivity. Additionally, a direct association between CD9 expression and presence of distant metastasis was reported. Finally, we confirm that CD9 expression is consistent with an early protective role against tumorigenesis, however, our data endorse in melanoma a specific function of CD9 in vascular dissemination during late tumor progression. The presence of CD9 hotspots could be essential for melanoma cell invasion in lymphatic and endothelial vessels. CD9 could be a valid prognostic factor for lymph node metastasis risk.

Moderate to severe atopic dermatitis in adolescents treated with dupilumab: a multicenter Italian real-world experience

Background

Moderate‐to‐severe atopic dermatitis (AD) in the adolescence is a high burden disease, and its treatment can be very challenging due to paucity of approved systemic drugs for this age and their side‐effects. Dupilumab was recently approved for treatment of adolescent AD.

Objectives

A multicentre, prospective, real‐world study on the effectiveness and safety of dupilumab in adolescents (aged from ≥12 to <18 years) with moderate‐to‐severe AD was conducted. The main AD clinical phenotypes were also examined.

Methods

Data of adolescents with moderate‐to‐severe AD treated with dupilumab at label dosage for 16 weeks were collected. Treatment outcome was assessed by EASI, NRS itch, NRS sleep loss and CDLQI scores at baseline and after 16 weeks of treatment. The clinical scores were also evaluated according to clinical phenotypes.

Results

One hundred and thirty‐nine adolescents were enrolled in the study. Flexural eczema and head and neck eczema were the most frequent clinical phenotypes, followed by hand eczema and portrait‐like dermatitis. Coexistence of more than 1 phenotype was documented in 126/139 (88.5%) adolescents. Three patients (2.1%) contracted asymptomatic SARS‐CoV‐2 infection and 1 of the discontinued dupilumab treatment before the target treatment period. A significant improvement in EASI, NRS itch, NRS sleep loss and CDLQI was observed after 16 weeks of treatment with dupilumab. This outcome was better than that observed in clinical trials. Dupilumab resulted effective in all AD phenotypes, especially in diffuse eczema. Twenty‐eight (20.1%) patients reported adverse events, conjunctivitis and flushing being the most frequent. None of patients discontinued dupilumab due to adverse event.

Conclusions

Dupilumab in adolescent AD showed excellent effectiveness at week 16 with consistent improvement of all clinical scores. Moreover, dupilumab showed a good safety profile also in this COVID‐19 pandemic era.

Certolizumab Pegol: A New Therapeutic Approach for Acrodermatitis Continua of Hallopeau

Introduction

Acrodermatitis continua of Hallopeau (ACH) is a rare, chronic, and recurrent form of pustular psoriasis (PP) localized to one or more digits. Due to the rarity of ACH, no clear treatment guidelines are currently available, making the therapeutic approach more complex.

Case Presentation

We report the first case of a young woman with ACH who was successfully treated with certolizumab pegol (CZP).

Discussion/Conclusion

PP and ACH are difficult to treat, and biologics may be an option more manageable than cyclosporine. CZP is the safest biologic therapy during pregnancy, so there is low risk in prescribing it in women with childbearing potential. However, continuing biological therapy during pregnancy always involves an assessment of the clinical benefits, which must outweigh the risks.

Trichorhinophalangeal syndrome: a case report and brief literature review

Trichorhinophalangeal syndrome is an autosomal dominant disease caused by mutations in TRPS gene, characterized by skeletal, skin appendage, and endocrinological manifestations. Clinical presentation may vary widely, and the syndrome frequently remains undiagnosed. The diagnosis is mainly clinical, supported by radiographic images, and is confirmed by genetic investigation. Familiarity with this genetic disorder is crucial for providing correct and early identification, and for determining adequate supportive management, especially to prevent orthopedic complications.

Baricitinib: The First Jak Inhibitor Approved in Europe for the Treatment of Moderate to Severe Atopic Dermatitis in Adult Patients

Background: Atopic dermatitis (AD) is an inflammatory skin disease characterized by a wide phenotypic variety with a very complex pathophysiological mechanism that has led to the identification of new therapeutic targets, such as janus kinasis (JAK) inhibitors. Objectives: To evaluate the efficacy and safety of baricitinib, the first JAK 1 and 2 inhibitor approved in Europe for the treatment of adult patients with moderate-to-severe AD. Methods: The efficacy and safety data available from the Phase III studies belonging to the BREEZE AD program are presented. Results: Results from BREEZE-AD1, AD2, AD4, and AD7 showed the efficacy of Baricitib 4 mg, administered orally, once daily, as monotherapy or in combination with topical corticosteroid (TCS), with a significant proportion of patients achieving primary endpoints IGA 0-1 (16.4% vs. 4.8%; 13.8% vs. 4.5%; 21.7% vs. 9.7%; 30.6% vs. 14.7%) and EASI75 (24.8% vs. 8.8%; 21.1% vs. 6.1%; 31.5% vs. 17.2%; 47.7% vs. 22.9%) at week 16 (W16) compared to placebo, respectively. Baricitinib showed rapid improvement in symptoms, starting from week 1 of treatment at 4 mg dosage, with a good safety profile. Nasopharyngitis, upper respiratory tract infections (URIs), creatine phosphokinase (CPK) elevations, and headache were the most frequently reported adverse events. Conclusions: Following the efficacy and safety data on W 16 from the phase III BREEZE-AD studies, baricitinib has recently been approved in Europe for the treatment of moderate to severe AD in adult patients. Further data to evaluate long-term efficacy and safety in a real-life setting are needed.

New Perspectives on Old and New Therapies of Staphylococcal Skin Infections: The Role of Biofilm Targeting in Wound Healing

Among the most common complications of both chronic wound and surgical sites are staphylococcal skin infections, which slow down the wound healing process due to various virulence factors, including the ability to produce biofilms. Furthermore, staphylococcal skin infections are often caused by methicillin-resistant Staphylococcus aureus (MRSA) and become a therapeutic challenge. The aim of this narrative review is to collect the latest evidence on old and new anti-staphylococcal therapies, assessing their anti-biofilm properties and their effect on skin wound healing. We considered antibiotics, quorum sensing inhibitors, antimicrobial peptides, topical dressings, and antimicrobial photo-dynamic therapy. According to our review of the literature, targeting of biofilm is an important therapeutic choice in acute and chronic infected skin wounds both to overcome antibiotic resistance and to achieve better wound healing.

Long-term efficacy and safety of apremilast in the treatment of plaques psoriasis: A real-world, single-center experience

Apremilast is a small molecule approved for the treatment of plaques psoriasis and adult psoriatic arthritis. Pivotal studies have demonstrated short and long term efficacy and safety of apremilast but few data in real life are still available. The aim of this study is to report the efficacy and safety results of apremilast in clinical practice in patients with moderate-to-severe plaque psoriasis, focusing on therapeutic results obtained after 24 and 52 weeks of treatment. From May 2018 to December 2018, 40 patients with plaques psoriasis have been enrolled. Psoriasis Area Severity Index (PASI), body surface area, Physician Global Assessment, and Dermatology Life Quality Index (DLQI) were performed at baseline at 24 (W24) and 52 (W52) weeks after treatment initiation. Primary endpoint was to evaluate the percentage of patient that achieved PASI 75, PASI 90 and PASI 100 at week 24 and 52 of treatment. Additional measure of efficacy was percentage of patients reaching the minimal disease activity (MDA = PGA0/1 and DLQI 0/1) after 24 and 52 weeks of treatment. As secondary endpoint, we evaluated the percentage of patient that achieved DLQI 0-1 at W24 and W52, and long-term safety of apremilast. The percentage of patients who achieved PASI75, PASI90 and PASI100 was 47.5%, 30% and 10% and 25%, 35% and 10% at W24 and W52 respectively. About the half of the reported patients reached MDA at W24 (n = 21) and at W52 (n = 20). The 60% of patients achieved and maintained DLQI 0-1 at W24 until W52. Diarrhea, nausea, headache, insomnia, and other AEs have been reported by 28 patients. Apremilast in real life experience confirmed the levels of efficacy and safety obtained in pivotal trials. In particular, the good initial response to the treatment is predictive of the maintenance or improvement of the outcome over W52. The efficacy is supported by an excellent safety profile even in frail patients.

Psoriasis as an Immune-Mediated and Inflammatory Systemic Disease: From Pathophysiology to Novel Therapeutic Approaches

Psoriasis is an immune-mediated inflammatory disease, with a chronic relapsing-remitting course, which affects 2–3% of the worldwide population. The progressive acquisitions of the inflammatory pathways involved in the development of psoriasis have led to the identification of the key molecules of the psoriatic inflammatory cascade. At the same time, psoriasis therapy has radically evolved with the introduction of target molecules able to modify the natural history of the disease, acting specifically on these inflammatory pathways. For these reasons, biologics have been demonstrated to be drugs able to change the disease’s natural history, as they reduce the inflammatory background to avoid irreversible organ damage and prevent systemic complications. However, several issues related to the use of biologics in patients with systemic comorbidities, remain open. All these data reflect the extraordinary potentiality of biologics, but also the unmet medical need to improve our knowledge on the long-term risk related to continuous use of these drugs, and their administration in special populations. This narrative review aims to highlight both the efficacy and safety profile of biologics in psoriasis, starting from pathophysiology and moving towards their clinical application.

How to fight SARS-COV-2 vaccine hesitancy in patients suffering from chronic and immune-mediated skin disease: four general rules

All public health ministries have implemented strategies to contain the spread of COVID-19 worldwide. Vaccines against SARS-CoV-2 still represent the most effective weapon to combat the circulation of the virus, in order to decrease the impact of COVID-19 on the general health of the population, to prevent the emergence of new SARS-CoV-2 variants and avoid excessive hospitalization. However, the success of a vaccination campaign largely depends on the penetrance of the message addressed to general population, which takes on an even more strategic value when vaccine candidates suffer from chronic diseases. In this view, patients suffering from immune-mediated skin diseases could represent a "weak link in the vaccine chain." Our main objective is to focus attention on four main elements in support of vaccination strategy in order to promote the patients' awareness to be at highest risk of negative consequences in case of SARS-Cov-2 infection, and to build, strengthen and maintain trust in vaccines' efficacy and safety.

Vaccines Against SARS-CoV-2 in Psoriasis Patients on Immunosuppressive Therapy: Implications of Vaccination Nationwide Campaign on Clinical Practice in Italy

More than 12 months have passed since the World Health Organization (WHO) declared Coronavirus Disease 19 (COVID-19), caused by the SARS-CoV2 virus, to be a pandemic on 11 March 2020. The entire world scientific community agrees that at this time vaccine is the most promising weapon to combat the infection and the severity of the disease. According to the document “Draft landscape of COVID-19 candidate vaccines” by WHO, 272 vaccines against SARS-CoV-2 virus are in development, although only four of these, produced by Pfizer-BioNTech (Pfizer, Inc. and BioNTech), Moderna, AstraZeneca, and Janssen companies, respectively, have been approved by European Medicines Agency and Italian Medicines Agency and subsequently distributed nationwide for use. These vaccines are the result of highly innovative procedures and are quite different from each other in terms of composition. Even clinicians in various medical fields may be unfamiliar with the effects of these vaccines. There is the strong emerging need for dermatologists to understand the crucial role of vaccines, with a focus on the need to vaccinate patients suffering from immune-mediated skin diseases, such as psoriasis, while taking the ongoing treatment into consideration regarding the timing of vaccination. Similarly, psoriasis patients aware of having an immune-mediated and inflammatory disease are increasingly asking the dermatologist information about the efficacy and safety of vaccines against SARS-CoV-2 virus. In this narrative review of the literature and critical analysis of the recommendations of the Italian Ministry of Health, we analyze the implications of the vaccination campaign on dermatological patients with psoriasis undergoing immunosuppressive treatment.

Psoriasis and its management in women of childbearing age: tools to increase awareness in dermatologists and patients

Psoriasis is a common, chronic inflammatory disease with a multifactorial pathogenesis. Mean age at presentation of psoriasis is 28 years in women, which is almost the height of fertility age. Since women of childbearing potential represent a significant proportion of psoriatic patients, the impact of psoriasis and its treatment on fertility, pregnancy, and breastfeeding should be highlighted for a proper management. Therefore, when approaching to a psoriatic woman of childbearing age, Healthcare Providers should be adequately informed and ready to provide the patients with answers to the most frequently asked questions. The Italian Society of Dermatology and Venereology (SIDeMaST) has fostered a Task Force named "Psoriasis in Women of Childbearing Age" which is composed by a group of Italian female dermatologists with a high expertise in psoriasis treatment. The aims of the Task Force are to increase awareness of the disease and its treatment in patients of childbearing age among both dermatologists and women affected by psoriasis and to encourage counselling on family planning. With the aim of providing a real support for the proper management of the delicate journey to motherhood, the Italian Task Force has published two different informative booklets addressed to patients and dermatologists which focus on the main issues regarding psoriasis in women of childbearing age.

Saliva Proteomics as Fluid Signature of Inflammatory and Immune-Mediated Skin Diseases

Saliva is easy to access, non-invasive and a useful source of information useful for the diagnosis of serval inflammatory and immune-mediated diseases. Following the advent of genomic technologies and -omic research, studies based on saliva testing have rapidly increased and human salivary proteome has been partially characterized. As a proteomic protocol to analyze the whole saliva proteome is not currently available, the most common aim of the proteomic analysis is to discriminate between physiological and pathological conditions. The salivary proteome has been initially investigated in several diseases: oral squamous cell carcinoma and oral leukoplakia, chronic graft-versus-host disease, and Sjögren's syndrome. Otherwise, salivary proteomics studies in the dermatological field are still in the initial phase, thus the aim of this review is to collect the best research evidence on the role of saliva proteomics analysis in immune-mediated skin diseases to understand the direction of research in this field. The results of PRISMA analysis reported herein suggest that human saliva analysis could provide significant data for the diagnosis and prognosis of several immune-mediated and inflammatory skin diseases in the next future.

Recommendations for dermatologists treating patients with atopic dermatitis during the Covid-19 pandemic: a look into the past for a conscious vaccination management

Atopic dermatitis (AD) is a chronic inflammatory skin disease that affects approximately 20% of children and 10% of adults. The implication of vaccines as a trigger for the de novo onset of AD in children or as a cause of exacerbation in individuals with a history of AD has long been debated. We present a brief review of the literature on AD and traditional vaccinations, proposing in addition the main recommendations for the management of patients with AD undergoing the vaccine against the SARS-COV-2 virus. Live attenuated vaccines seem to be associated with a relapse of AD and/or complications, such as eczema vaccinatum. For non-live vaccines, no adverse events are noted in atopic subjects. Since the Covid-19 vaccine is mRNA or viral vectored vaccine and there are no other currently used vaccines of this type, the same recommendations are applied as for all other non-live vaccines.

Vaccines for COVID-19 in patients with atopic dermatitis: three things every dermatologist should know

Almost 13 months have passed since the World Health Organization (WHO) declared the coronavirus disease 19 (COVID-19) pandemic, caused by the SARS-CoV-2, on March 11th, 2020. During this period, we have realized that the most effective weapon we have to prevent SARS-CoV-2 infection, or to make it less aggressive, is vaccines. Currently, according to the WHO document "Draft landscape of COVID-19 candidate vaccines," there are 275 vaccines in development against the virus, although at the moment there are four preparations in distribution in the United States and in Europe. The characteristics of these vaccines are quite different from each other and may even be unfamiliar in the medical field. In particular, among dermatologists, knowledge of vaccines is of fundamental importance, especially in atopic dermatitis. Atopic patients are aware of having a predisposition to develop allergies, and so they are asking dermatologists about the safety of the vaccines currently available against the SARS-CoV-2. This article provides an up-to-date overview of this topic by reviewing current literature and sharing our personal experience.

The effect of dupilumab in an HBV-HIV coinfected atopic patient: a case report

Atopic dermatitis (AD) is a chronic immune-mediated inflammatory disease typical of childhood that can also affect adults. AD is clinically characterized by intensely pruritic eczematous lesions. The burden of this disease and its impact on quality of life are often substantial. Dupilumab is a fully humanized monoclonal antibody against interleukin 4 (IL-4) receptor α, capable of blocking IL-4 and IL-13 signaling. This novel therapy represents the first biologic approved for the treatment of moderate to severe AD. Our report describes the case of a 39-year-old adult patient affected by severe chronic AD with associated allergic and viral comorbidities for whom conventional systemic therapies proved ineffective or contraindicated. The main source of interest in this case is hepatitis B virus (HBV) and human immunodeficiency virus (HIV) coinfection because, to our knowledge, this is the first case of an adult atopic patient treated with dupilumab in the simultaneous presence of these comorbidities. Regarding coinfections, the patient was on antiretroviral therapy for HBV and HIV before starting dupilumab. Efficacy and safety data after 24 weeks of therapy are reported in detail.

Safety and Efficacy of Vaccines during COVID-19 Pandemic in Patients Treated with Biological Drugs in a Dermatological Setting

The BNT162b2 and mRNA-1273 vaccines, consisting of mRNA, have recently become available. The absolute novelty of these vaccines introduces questions about their safety and efficacy, especially in patients who are treated with biological drugs in dermatology. The aim of our review was to provide a broad overview of the current use of all available vaccinations in concomitance with biological therapy and to suggest indications for the new mRNA Covid-19 vaccines. We conducted a narrative review of the literature regarding the indications and safety of the various types of vaccines currently available in dermatological patients treated with biological therapy. The safety and efficacy of administering inactivated vaccines in patients undergoing biological therapy with inhibitors of TNF-α, IL-17, IL-12/23, and IL-4/13 was confirmed. Inactivated vaccines can be administered during therapy with inhibitors of IL-23 and IgE, taking into account that the level of evidence is lower due to the lack of specific studies. Live attenuated vaccines were contraindicated in concomitance with all biological therapies considered, except omalizumab. According to this evidence, we assume that there are currently no contraindications to the administration of the new Covid-19 BNT162b2 and mRNA-1273 vaccines during biological therapy with inhibitors of TNF-α, IL-17, IL-12/23, IL-23, and IL-4/13, since these vaccines are comparable to inactivated ones. For patients with chronic urticaria or allergic asthma treated with omalizumab, we currently recommend caution in using the mRNA Covid-19 vaccines (30 min observation). The only contraindications were a previous history of hypersensitivity to the Covid-19 vaccines themself or to their excipients. In conclusion, further randomized clinical trials are needed to evaluate the efficacy of the antibody response in these patients.

Novel Therapeutic Approaches and Targets for Treatment of Psoriasis

BACKGROUND

Psoriasis is a multifactorial immune-mediated inflammatory disease, with a chronic relapsing-remitting course, which affects 2-3% of the worldwide population. Psoriasis involves skin, joints, or both, and it is associated with several comorbidities, including metabolic, rheumatological, cardiovascular, psychiatric complications, and other chronic inflammatory diseases, which are the expression of the complex underlying pathogenetic mechanism. An accurate characterization of the immune pathways involved in psoriasis led to recognize the new molecules, (IL)17 and 23, which become the new target of biologic therapy for moderate-to-severe plaque psoriasis.

OBJECTIVE

The aim of this study is to collect data of literature about IL-17 and IL-23 inhibitors.

METHODS

A descriptive review was conducted to identify the main data in the literature evaluating novel biologic treatments currently available: IL-17 inhibitors (secukinumab, ixekizumab and brodalumab) and IL-23 inhibitors (guselkumab, tildrakizumab and risankizumab).

RESULTS

Dosing regimens, administration, efficacy, real-life efficacy and safety of IL-17 and IL-23 inhibitors are discussed in detail.

CONCLUSION

Currently approved novel biologic therapies for moderate to severe psoriasis revealed increasing effectiveness compared to previous biological therapy and a good safety profile.

Therapeutic Use of Botulinum Neurotoxins in Dermatology: Systematic Review

Botulinum toxin is a superfamily of neurotoxins produced by the bacterium Clostridium Botulinum with well-established efficacy and safety profile in focal idiopathic hyperhidrosis. Recently, botulinum toxins have also been used in many other skin diseases, in off label regimen. The objective of this manuscript is to review and analyze the main therapeutic applications of botulinum toxins in skin diseases. A systematic review of the published data was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Botulinum toxins present several label and off-label indications of interest for dermatologists. The best-reported evidence concerns focal idiopathic hyperhidrosis, Raynaud phenomenon, suppurative hidradenitis, Hailey–Hailey disease, epidermolysis bullosa simplex Weber–Cockayne type, Darier’s disease, pachyonychia congenita, aquagenic keratoderma, alopecia, psoriasis, notalgia paresthetica, facial erythema and flushing, and oily skin. Further clinical trials are still needed to better understand the real efficacy and safety of these applications and to standardize injection and doses protocols for off label applications.

Telogen effluvium related to post severe Sars-Cov-2 infection: Clinical aspects and our management experience

Telogen effluvium (TE) is one of the most common form of hair loss in women. Many triggers have been identified, as stress, drugs, trauma, endocrine disease, nutritional deficiencies, and febrile states. We report three cases of TE occurred after severe Sars‐Cov‐2 infection and provide our clinical management, according to Sars‐Cov‐2 hygiene measures. Only one case report has been found in the literature associating anagen effluvium during severe Sars‐Cov‐2 infection. Other studies reported the exacerbation of a preexisting TE, correlated to the stress of lockdown. In our cases, patients never had a TE diagnosis before and did not report previous evident hair loss. TE can be associated with post severe Sars‐Cov‐2 infection. From our revision of the literature, this is the first case‐series describing TE in post severe Sars‐Cov‐2 patients. Further studies are needed to evaluate the relationship between TE and Sars‐Cov‐2 infection.

Management of patients with hidradenitis suppurativa during the COVID-19 pandemic: Risk and benefit of immunomodulatory therapy

Coronavirus disease 2019 (COVID-19) is a clinical syndrome caused by a new coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Italy has been the first nation affected by the coronavirus pandemic and is the second in the number of reported deaths in the European Union. In the United Hospital of Ancona, a specialist outpatient clinic dealing with diagnosis and treatment of immunomediated skin diseases has been operating since 1985, and 291 patients with hidradenitis suppurativa (HS) are currently being treated. Several cutaneous immunomediated diseases, including HS, are treated with biologic and nonbiologic immunosuppressive and immunomodulatory drugs. Since the end of February 2020, when the SARS-CoV-2 pandemic had already spread in most of Italy, a task force comprised of seven specialists has been set up with the aim of addressing problems relating to the specific risk for this class of patients in relation to SARS-CoV-2 infection and immunosuppressive ongoing therapy. In this article, the management of HS disease during the COVID-19 pandemic is discussed. The main goal was to evaluate the risk/benefit in modulating treatment taking into consideration patients' risk of exposure to SARS-CoV-2 virus.

Global coronavirus pandemic ( SARS‐CoV ‐2): Past , present , and future of pediatric dermatology

Two months have passed since the World Health Organization (WHO) declared the pandemic of the Coronavirus Disease 19 (COVID‐19), caused by the SARS‐CoV‐2 virus, on 11 March 2020. Medical and healthcare workers have continued to be on the frontline to defeat this disease, however, continual changes are being made to their working habits which are proving to be difficult. Although the skin is not the main target of the SARS‐CoV‐2 infection, it is strongly involved both directly and indirectly, in many aspects of dermatological disease management, and particularly in pediatric dermatology. In this manuscript, our goal was to provide a “up‐to‐date” account on this topic, through analysis of current literature and sharing our experiences during this pandemic.

Active implications for dermatologists in 'SARS-CoV-2 ERA': Personal experience and review of literature

Linked articles: COVID‐19 SPECIAL FORUM. J Eur Acad Dermatol Venereol 2020; 34: e346–e380.