Evidence for a 'window of opportunity' in hidradenitis suppurativa treated with adalimumab: a retrospective, real-life multicentre cohort study

BACKGROUND

The anti-tumour necrosis factor (TNF)-α adalimumab is the only licenced biologic for moderate-to-severe hidradenitis suppurativa (HS). No predictors of response have been identified so far.

OBJECTIVES

To identify clinical parameters predicting response to adalimumab and confirm its efficacy/safety.

METHODS

The data of 389 patients with HS treated with adalimumab in 21 Italian centres were reviewed. Sex, age at onset/diagnosis/baseline, body mass index, smoking, phenotype, previous treatments, concomitant antibiotics and 'therapeutic delay', defined as the time from HS onset to adalimumab initiation, were assessed. Response to adalimumab and its impact on quality of life (QoL) were evaluated using the Hidradenitis Suppurativa Clinical Response (HiSCR) and the Dermatology Life Quality Index (DLQI) or the Visual Analogue Scale for pain (VAS pain), respectively. Logistic regression analysis was performed.

RESULTS

The therapeutic delay correlated to lack of response to adalimumab at week 16 [odds ratio (OR) 1·92 for therapeutic delay > 10 years; 95% confidence interval (CI) 1·28-2·89; P = 0·0016). HiSCR was achieved in 43·7% and 53·9% patients at week 16 and 52, respectively. Significant reductions in both DLQI and VAS pain were found between week 16 vs. baseline (P < 0·0001 for both) and week 52 vs. baseline (P < 0·0001 for both). Previous immunosuppressants inversely correlated to HiSCR at week 52 (OR = 1·74, 95% CI 1·04-2·91, P = 0·0342).

CONCLUSIONS

Inverse correlation between therapeutic delay and clinical response was found, supporting early adalimumab use and providing evidence for a 'window of opportunity' in HS treatment. Adalimumab efficacy and safety were confirmed, along with patients' QoL improvement. Immunosuppressants could negatively influence the response to adalimumab inducing a switch to non-TNF-α-driven pathways.

Measuring the horizontal and vertical growth rates of superficial spreading melanoma: a pilot study with sequential digital dermoscopy

BACKGROUND

Some authors have hypothesized that the initial kinetics of the primary melanoma (MM) growth could reflect its biologic aggressiveness. The aim of this study was to pilot a measure of the horizontal vs. vertical growth of superficial spreading melanomas (SSM).

METHODS

The dermoscopic images of twenty-three consecutive MMs (17 SSMs and 6 MMs in situ), excised after digital sequential dermoscopy, were reviewed. We built up two indexes: 1) dROG (digital Rate of Growth) defined as Breslow thickness/(t1-tR), where t1 was the reported time of the first dermoscopic image acquisition and tR was the reported time of the acquisition before the lesion excision; 2) lHGR (linear Horizontal Growth Rate) took into account the greater axis of the lesion at two time points, at the time (t1) of the first image acquisition (D1) and before (tR) lesion excision (DR). The index was computed as (DR-D1)/(t1-tR). We built up the Composite Rate of Growth index (cROG) calculated as dROG/lHRG. If the value of cROG is <1 the superficial growth is prevalent on the vertical growth, and if the value is >1 the vertical growth is prevalent on the superficial growth.

RESULTS

In 82.6% of lesions the horizontal growth was prevalent on the vertical growth, and in 17.4% of cases the vertical growth was equal or prevalent on the superficial growth.

CONCLUSIONS

A small proportion of SSMs with a slow horizontal growth could have a precocious vertical growth. Other larger studies are needed to confirm this observation.

Tuscan consensus on the use of UVBnb phototherapy in the treatment of psoriasis

Psoriasis (PSO) is traditionally defined as an immune-mediated, inflammatory dermatological disease characterized by a chronic-relapsing course and associated with multifactorial inheritance (genetic predisposition and influence of various environmental factors). Considered until recently a dermatological disease only, today PSO is correctly known as a systemic one because of the involvement of multiple organs with important impact on social life and relationships. PSO is found in the 0.3-4.6% of the world's population, while its prevalence in the Italian population is estimated at 2.8%. Therefore, if we consider that in Tuscany more than 100,000 people out of 3,672,202 suffer of psoriasis, it is of paramount importance to focus on a shared clinical and therapeutic protocol to manage the disease. With the aim of ensuring diagnostic-therapeutic suitability, high levels of care and standardization of treatment, a unique clinical-therapeutic management model has been developed and validated in Tuscany, involving all accredited regional dermatological centers. Among the possible alternatives to be implemented in the treatment of patients with mild, moderate-severe psoriasis, UVBnb phototherapy is widely used alone or in association with other systemic and non-systemic devices. Despite this, there is still no universally shared therapeutic protocol. In this context the CO.FO.TO working group (Consensus Fototerapia Toscana) is born with the aim of defining and validating the main guidelines in the use of phototherapy with UVBnb in psoriasis; the guidelines are based both on the real-life experience of the different centers of reference in the region and on the revision of the recent literature.

Treatment of psoriasis with topical agents: Recommendations from a Tuscany Consensus

Psoriasis is a chronic and relapsing inflammatory skin disease, clinically characterized by erythematous and scaly plaques. Treatment approach is mainly driven by disease severity, though several factors should be considered in order to identify the optimal therapeutic choice. Mild psoriasis may be treated with a wide array of topical agents including corticosteroids, vitamin D analogs, keratolytics, and calcipotriol/betamethasone propionate compound. Because guidelines may not provide practical indications regarding the therapeutic approach, the use of topical agents in psoriasis is more individually tailored. In order to homogenize the standard of care, at least in a local setting, we collected the real-life-based recommendations for the use of topical therapies from an expert panel, the Tuscany Consensus Group on Psoriasis, representing all leading centers for psoriasis established in Tuscany. With this document, this consensus group sought to define principles guiding the selection of therapeutic agents with straightforward recommendations derived from a real-life setting.

Thick melanoma in Tuscany

BACKGROUND

The epidemiologic trends of cutaneous melanoma are similar in several countries with a Western-type lifestyle, where there is a progressively increasing incidence and a low but not decreasing mortality - even increasing in selected cases, especially in the older age groups. Also in Tuscany there is a steady rise in the incidence with prevalence of in situ and invasive thin melanomas, with also an increase of thick melanomas. It is necessary to reduce the frequency of thick melanomas to reduce specific mortality. The objective of the current survey has been to compare, in the Tuscany population, by a case-case study, thin and thick melanoma cases, trying to find out those personal and tumor characteristics which may help to customize preventive interventions.

METHODS

The study included nine centers involved in the melanoma diagnosis. A consecutive series of incident invasive melanomas diagnosed in a period of about 18 months (July 2010 to December 2011) was collected and matched according in a ratio of one thick melanoma (cutoff thickness: 1 mm) every two thin melanomas. The investigators filled in a questionnaire on patients' self-reported sun exposure, way of melanoma detection, awareness and performance of self-skin examination, as well as propensity to prevention in general.

RESULTS

The results of this survey confirm that older age and the lower education level are associated with a later detection. The habit of performing skin self-examination is crucial in the early diagnosis of thick melanoma. The results of this survey seem to suggest that population aged over 50 years, with few total and few atypical nevi, and limited sun exposure and burning are at higher risk of late diagnosis. It can be assumed that part of the population is not effectively reached by prevention campaigns because they do not recognize themselves as being at risk for skin cancers.

CONCLUSIONS

In order to achieve a higher rate of early diagnosis of skin melanoma, a new strategy must be implemented. It could be useful to rethink educational campaigns - which seem to unintentionally leave out subjects more at risk for melanoma - and to renew the active involvement of the general practitioners.

Tuscan consensus on the diagnosis, treatment and follow-up of moderate-to-severe psoriasis

BACKGROUND

Psoriasis is traditionally defined as an inflammatory chronic-relapsing disease of the skin. As widely demonstrated, this disease is also associated with multiple comorbidities: arthropathy, inflammatory bowel disease, metabolic, cardiovascular, ocular and psychological disorders. The disease also has a significant impact on patients' quality of life, whose work ability decreases considerably with clear consequences for the social costs. Therefore, if we consider that in Tuscany, more than 100,000 people out of 3,672,202 suffer from psoriasis, it is of paramount importance focusing the attention on a rational model of clinical and therapeutic management of the disease. All the leading experts in Tuscany have come together with the aim of defining unanimously accepted regional guidelines for the diagnosis, treatment, follow-up and management of psoriasis, and of providing practical guidance/protocol on diagnosis, treatment, follow-up and management of special cases of moderate-to-severe plaque psoriasis.

METHODS

In a working group formed ad hoc, the main topics have been discussed and approved by plenary vote.

RESULTS

Diagnosis must include a proper general health condition overview, a careful evaluation of skin and joints, the assessment and management of other comorbidities and the definition of disease severity. With regards to the therapy the best time to start a systemic treatment, the therapeutic goal, the most appropriate drug and blood tests to be performed in case of moderate severe-psoriasis have been taken into account. During follow-up, proper monitoring of systemic therapy and its management in the long term has also been suggested. Eventually, the experts have addressed the problem of how to manage the disease in special conditions, such as during surgery, pregnancy, in children and in case of infections (HBV, HCV, HIV).

CONCLUSIONS

The main aim of this Consensus was to find agreement on the criteria for diagnosis, treatment and follow-up of psoriasis, shared by all the Dermatologic Therapy Units of Tuscany. A need to create an easier way for the patient to access specialized dermatology outpatient services, and to reduce the waiting list and costs related to the management of psoriasis has been stressed. Most importantly, during the Consensus all of the participants agreed on the central role of the patient, and on the need of a multidisciplinary management of the disease which requires communication among specialists and regional centers in order to build on existing experience.

To what extent is quality of life impaired in vitiligo? A multicenter study on Italian patients using the dermatology life quality index

BACKGROUND

It is believed that vitiligo has an impact on the overall patient quality of life (QoL).

OBJECTIVE

To estimate QoL in a fairly large sample of Italian vitiligo patients by using the Dermatology Life Quality Index (DLQI) questionnaire.

METHODS

One hundred and sixty-one vitiligo patients referred to 9 dermatological centers were offered to participate by filling in the Italian version of the DLQI questionnaire.

RESULTS

The mean total DLQI score was 4.3 (SD ±4.9; range: 0-22). In multivariate analysis, DLQI >5 was associated with female gender, stability of the disease over time and involvement of the face at disease onset.

CONCLUSIONS

The impairment of QoL is overall limited in Italian vitiligo patients, especially if it is compared with results from other available studies. This could be due to cultural and ethnic characteristics of the sample.

Circulating autoantibodies and autoimmune comorbidities in vitiligo patients: a multicenter Italian study

BACKGROUND

Autoimmune comorbidities and circulating autoantibodies have been observed in vitiligo patients, but differences in rate are present according to countries in which the studies were performed, perhaps owing to ethnic diversities or different trigger factors.

OBJECTIVE

To estimate the prevalence of circulating autoantibodies and overt autoimmune diseases in a fairly large sample of Italian vitiligo patients.

METHODS

175 outpatients affected by vitiligo and referred to nine dermatological centers were included in the study. Patients were offered routine blood test, serological testing for thyroid function and search for autoantibodies.

RESULTS

At least one circulating autoantibody was detected in 61 (41.8%) of 146 subjects who underwent laboratory tests. Anti-thyroperoxidase (25.6%), anti-thyroglobulin (23.4%), antinuclear antibodies (16.8%) and anti-gastric parietal cell antibodies (7.8%) were the most noticed autoantibodies. 74 (41.5%) autoimmune comorbidities, mainly autoimmune thyroiditis (37%), were reported.

CONCLUSION

The prevalence of autoimmune comorbidities and circulating autoantibodies in this study was in agreement with other surveys conducted on Caucasian patients.

[Solar ultraviolet radiation risk in outdoor workers: a specific project of Tuscany Region (Italy)]

OBJECTIVE

The aims of Tuscany Regional project were: to study the sun protection attitude of outdoor workers; to measure solar ultraviolet (UV) exposure in work environment; to describe the frequency of photoaging, precancerous lesions, and skin cancers in outdoor workers; to collect information on solar ultraviolet radiation exposure from incident cases of Non-Melanoma Skin Cancer (NMSC) recruited from Tuscany Cancer Registry.

DESIGN

Outdoor workers completed a questionnaire devoted to collect information on sun protection attitudes during a typical summer working week. Environmental and personal measurements were carried out. Expert dermatologists examined outdoor workers to assess the frequency of photoaging, precancerous lesions, and skin cancer. A structured questionnaire was mailed to incident cases of NMSC. Information were collected on personal habits and working history, focusing on solar ultraviolet radiation exposure.

SETTING AND PARTICIPANTS

Agriculture, construction, quarrying and fishing activities were considered: 292 employees responded to questions about the type of clothing used in the morning and in the afternoon,while working outdoors; 637 outdoor workers underwent skin examination. We contacted 743 cases of NMSC occurred in 2004; 498 subjects accepted to participate in this study.

RESULTS

The clothing worn by surveyed subjects was often inadequate compared to the high level of exposure to UV. The skin examination of 637 outdoor workers highlighted 2 melanomas, 7 epitheliomas and 35 actinic keratoses. Among the 498 cases of NMSC, 135 (27%) were diagnosed in outdoor workers. Most represented economic activity sectors were: agriculture, construction, transport, sports.

CONCLUSION

The characterization of outside workers revealed unsatisfactory sun protection behaviours. Moreover, previously undetected skin cancers were diagnosed. The study on MNSC confirms the complexity of studying the exposure to UV radiation. The Tuscany Regional project provided useful information on the risk of solar ultraviolet radiation in outdoor workers. Prevention programs are needed.