[Anti-TNF alpha-induced eruptive nevi: Three cases]

BACKGROUND

Eruptive melanocytic nevi (EMN) are a rare phenomenon characterized by simultaneous rapid onset of multiple nevi. The condition has been described in different contexts: immunosuppression, immunosuppressive drugs, targeted therapies, bullous diseases, and chemical melanocytic stimulation. We report 3 cases of EMN following anti-TNF alpha treatment.

PATIENTS AND METHODS

Case 1 - A 51-year-old female patient was receiving adalimumab for spondyloarthritis (the first treatment for this patient). A few months after the start of treatment, multiple nevi were noted on the 4 limbs, and in particular on the right palm. The patient confirmed the absence of these lesions before initiation of treatment. A diagnosis was made of adalimumab-induced EMN. Case 2 - A 49-year-old male patient was receiving etanercept for spondyloarthritis (the first biologic in this patient). Multiple small nevi developed on the trunk in the months after the start of treatment. The patient indicated that these lesions had appeared after the start of treatment. A diagnosis was made of etanercept-induced EMN. Case 3 - A 20-year-old woman with hidradenitis suppurativa was treated with infliximab. After 1.5 months, she reported the outbreak of various pigmented lesions 2-3mm in diameter on the trunk and one lesion on her right palm. The clinical diagnosis was EMN. After follow-up of 4 months to 5 years, no transformation to melanoma was noted in any of these 3 patients.

CONCLUSION

EMN remains a rare phenomenon in patients on anti-TNF alpha. These cases, associated with the description of a moderate increased risk of developing cutaneous carcinoma under anti-TNF alpha, underscore the need for dermatological follow-up and increased sun protection in patients receiving this treatment.

[Misdiagnosis of hidradenitis suppurativa continues to be a major issue. The R-ENS Verneuil study]

OBJECTIVE

To provide physicians with an understanding of the factors behind significant delays in the diagnosis of hidradenitis suppurativa (HS) in France.

PATIENTS AND METHODS

This prospective multicentre national study conducted from October 2015 to March 2016 included all patients consulting for HS. Patient data were collected by means of a standardized questionnaire. Univariate and multivariate analyses were conducted to collect factors associated with a significant time to diagnosis of at least 5.5years, defined as the period between the onset of initial clinical signs and the time of formal diagnosis.

RESULTS

The 16 participating centres enrolled 312 patients (62% women), of average age 35years. The average age at onset of HS was 22years. Before formal diagnosis by a dermatologist (64% of cases), 170 (54%), 114 (37%) and 45 (15%) patients had previously consulted at least 3, 5 and 10 general physicians, respectively. The average time between the initial clinical signs of HS, the first dermatology visit and the definitive diagnosis was 6.2 and 8.4 years, respectively. Active smoking (OR adjusted 1.85; P=0.027) and disease onset at a younger age (adjusted OR 0.92; P<0.001) were both associated with significant delays in diagnosis.

CONCLUSION

These results emphasized misdiagnosis among HS patients but did not evidence any association between either sociodemographic or economic characteristics and the existence of significant times to diagnosis.

Non-surgical treatments for hidradenitis suppurativa: A systematic review

INTRODUCTION

The management of hidradenitis suppurativa is multidisciplinary, involving general measures, medical treatment and surgery. Non-surgical treatments, often first-line procedures, mainly concern forms of low-to-moderate severity or, conversely, very severe forms in non-operable patients or those refusing surgery. While many treatments have been attempted, few randomized controlled trials have been conducted, so the choice of treatments is most often based on the personal experience of the clinicians. The objective of this systematic review is to propose a synthetic analysis of the currently available non-surgical procedures.

METHODS

This systematic review of the literature was conducted in accordance with the PRISMA criteria. We searched for articles in the Medline^®, PubMed Central, Embase and Cochrane databases published between January 2005 and September 2015.

RESULTS

Sixty-four articles were included. They generally had a low level of evidence; indeed, the majority of them were retrospective observational studies. They involved biotherapy (44%), dynamic phototherapy (16%), antibiotics (11%), Laser (8%), retinoids (6%) and immunosuppressive therapies, anti-inflammatory drugs, zinc, metformin, gammaglobulins and fumarates.

CONCLUSIONS

None of the non-surgical treatments can treat all stages of the disease and offer long-term remission. Antibiotics and biotherapy seem to have real effectiveness but their effect remains suspensive and the disease is almost certain to reappear once they are stopped. As regards antibiotics, no association has shown their superiority in a study with a high level of evidence. And while some biotherapies seem quite effective, due to their side effects they should be reserved for moderate-to-severe, resistant or inoperable forms of the disease. Randomized controlled studies are needed before valid conclusions can be drawn. In the resistant or disabling forms, it is consequently advisable to orientate to the greatest possible extent towards radical surgery, which is the only treatment allowing hope for cure.

[What's new in clinical dermatology?]

Zika virus: what the dermatologist should know. Probably a new vaccine against herpes zoster and postherpetic neuralgia in older adults. Defining moderate, significant and extensive types of pemphigus with ABSIS et PDAI scores. Biologic Therapies and serious infections in patients with psoriasis. We can be cautiously optimistic, in that tuberculosis is rare but still occurs despite adherence to tuberculosis prevention guidelines. Others serious infections are rare, mainly pneumonia and cellulitis. Hidradenitis suppurativa: an unrecognized paradoxical effect of biologic agents. There is an association between Inflammatory Bowel Disease (IBD) and Hidradenitis suppurativa (HS), mostly with Crohn's disease, suggesting the need to look for signs and symptoms of IBD in HS patients. A study of 550 twins found that genetic and environmental factors each contribute to approximately half of the score of rosacea. Telangiectasia Macularis Eruptiva Perstans is a difficult to diagnose type of mastocytosis, often with a delay and which is associated with a systemic involvement in 50% of cases. Vitiligo. Management and development of new scores for the dermatologist and the patient. Livedoid vasculopathy. Anticoagulation with new molecules could prove an efficient means of treatment. Pyoderma Gangrenosum. Don't forget the toxic etiology. Daily practice: Laboratory monitoring for liver function tests and serum lipid profile during isotretinoin therapy for acne is currently recommended at baseline and every 3 months, depending on the results. Daily practice: Mikailov and al., challenge our habits by their medico economic study and propose an empirical treatment with terbinafine for patients with suspected onychomycosis that is cost effective with minimal effect on patient safety as terbinafine-induced liver injury is very rare. It makes think and especially propose studies to update our recommendations.