Discrepancies in the management of acquired cold contact urticaria: Results of a French-speaking urticaria experts questionnaire survey

Acquired cold contact urticaria (ACU) is a putatively serious condition, because of the risk of anaphylactic shock whenever patients are massively exposed to cold atmosphere/water, raising the question of the prescription of an “emergency kit” with oral antihistamines and epinephrine auto-injector. We performed an online survey to evaluate how French-speaking urticaria experts manage ACU. According to the 2016 consensus recommendations on chronic inducible urticarias, all the participants perform at least 1 of the available provocation tests and 84.2%, 77.8%, and 88.9% prescribe on-label use of second generation anti-H1 antihistamines (2GAH1) as a first line treatment, updosed 2GAH1 as a second line treatment, and omalizumab as a third line treatment, respectively. Interestingly, 44.4% of the practitioners always prescribe a continuous background treatment, versus 11.1% prescribing only on-demand therapy. Also, 11.7% of participants always prescribe an epinephrine auto-injector, 70.6% sometimes do, and 17.6% never do. Finally, 89.5% authorize swimming under strict conditions but 36.8% and 68.4% contra-indicate other water sports and occupational cold exposure, respectively.

[DRUGS-INDUCED URTICARIA AND ANGIOEDEMA]

Drug-induced urticaria and/or angioedema is a frequent issue encountered in family medicine. A specific collection of the anamnesis and of the general context is very important to appreciate the involved mechanism, allergic or not, and potential cofactors. If in doubt about an allergic mechanism, tests will be conducted, mostly under a hospital setting. Bradykinin-mediated angioedema, so much rare than histamine-mediated one, has to be known, because it is potentially lethal. It is often iatrogenic (ACE inhibitors especially). At the end of the allergology work-up, a course of action is proposed to the patient and his family practitioner as far as the rechallenge of the drug is concerned, In case of non-allergic urticaria, much more frequent than allergy, taking the drug is possible with a premedication with antihistamines.

[Histaminergic angioedema and chronic urticaria]

Most angioedemas are histaminergic and correspond to deep urticarial swelling. Recurrent histaminergic angioedema led to the diagnosis of chronic urticaria, even when there are no superficial associated hives. Chronic urticaria is a benign disease, and autoimmune in 40 % of cases. The occurrence of angioedema in chronic urticaria is not a sign of severity. The occurrence of angioedema in chronic urticaria is associated with a longer duration of urticarial disease. NSAIDs and/or systemic corticotherapy are classic triggers of angioedema in chronic urticaria. In the absence of clinical endpoints, there is no need to make further assessment in chronic urticaria good responders to antihistamines.

[Heart failure and stasis ulcer: A significant association (prospective study of 100 cases)]

BACKGROUND

Risk factors for stasis ulcers have been poorly studied. We conducted a three-year controlled prospective study of the usual risk factors [venous insufficiency (VI), obesity, phlebitis] and of other factors suggested by our experience, such as heart failure (HF).

PATIENTS AND METHODS

Both in-patients and out-patients referred for stasis ulcers were included. The diagnosis of stasis ulcer was based on clinical criteria: venous insufficiency, cutaneous signs and/or severe leg oedema. Doppler ultrasound was performed systematically if the lesions showed no dramatic improvement within two months of treatment to eliminate arterial ulcers. VI, liver cirrhosis, heart failure, deep venous thrombosis, obesity, after-effects of leg injury, homolateral artificial hip and knee joints, and consumption of anti-leukaemia or leg-oedema-eliciting drugs were the criteria analysed by clinical examination or by consulting the information in the hospital records. Data were analyzed using SPSS/PCv12 software. Chi(2) and Fischer's exact tests were to compare cases and controls, who were identical in age, gender, and department of initial contact for reasons other than leg ulcers, stasis eczema or lipodermatosclerosis.

RESULTS

We included 100 cases and 200 control subjects. Most were out-patients and only 4% were hospitalized in cardiology. Univariate analysis showed that stasis ulcer was significantly associated (p < 10(-4)) with VI (71% of cases versus 32.5% of control subjects), HF (44% versus 11%), obesity (44% versus 21.5%), after-effects of injury (17% versus 0%), and to a lesser extent, with artificial knee joints (7% versus 2.5%; p = 0.04). Multivariate analysis showed that stasis ulcer was strongly associated with VI (OR=5.5; 3-9.9) and HF (OR=4.7; 2.1-10.4). HF (right 16%, left 11%, global 57%, unspecified 16%) was also significantly associated with bilateral localization of leg ulcers (p = 10(-4)) but not with delayed healing (> 6 months).

DISCUSSION

This study highlights two risk factors for stasis ulcer: artificial knee joints (in the univariate analysis only) and HF. An increase in leg oedemas is probably an important mechanism but we suggest the role of hypoxaemia in patients with isolated left HF. We advise an internist approach in the management of venous leg ulcers, which we prefer to name stasis ulcers, before having ruled out a general disease. In particular, we recommend a consultation with a cardiologist in the event of doubt.

Influence of measles vaccination on the progression of atopic dermatitis in infants

Atopic dermatitis (AD) is a chronic inflammatory skin disease, affecting 10-20% of children. Measles vaccination has been reported to have contradictory effects on incidence of AD in children. Therefore, we performed the first prospective, double-blind, placebo-controlled study to analyze the evolution of AD in infants after measles vaccination. The study included 12 infants (10-14 months old) with AD, randomly assigned to two groups: while the first group received a single dose of a standard measles vaccine ROUVAX, the second was treated with placebo (vehicle). Infants were followed-up for 6 months after administration of ROUVAX/placebo for the clinical signs associated with AD, by determination of SCORAD index. In addition, serum was taken before vaccination and 1 month later to determine the presence of seroconversion and to analyze the progression of serum levels of CCL18 (PARC) and E-selectin, known to be distinct serum markers that reflect clinical features of AD. In the vaccinated group, five of six children seroconverted 1 month after treatment and one infant showed a 50% improvement of SCORAD. Serum levels of CCL18 were significantly decreased in two treated infants (of four analyzed for this group) and E-selectin slightly decreased in one infant (of three analyzed by this test). In placebo-treated group the SCORAD improved in one patient and serum levels of CCL18 and E-selectin did not change. These data suggest that measles vaccination not only does not aggravate AD, but may also improve some of the immunological parameters of this allergic disease. Inclusion of a higher number of patients in a similar study should give a more comprehensive overview of the benefit of measles vaccination on the clinical evolution of AD patients, and potentially open new avenues to the clinical application of the anti-inflammatory effect of measles virus proteins.

Generalized pustular psoriasis (Zumbusch): a French epidemiological survey

A retrospective epidemiological survey of generalized pustular psoriasis (GPP) was carried out in France in 2005. 121 dermatological wards received a questionnaire concerning the patients treated in 2004. It related to demographic data, morbidity, mortality, failures and the therapeutic practices of each ward. CNAMTS, the main French health insurance, was also questioned about its registry concerning GPP.112 wards (92.5%) answered the questionnaire, totalling 99 cases (sex ratio male/female: 0.77, mean age 52.5 years +/- 18), which were handled by 46 wards. Incidence and prevalence were estimated in 2004 at a minimum of 0.64 and 1.76/million respectively. Incidence deduced from the CNAMTS data in 1998 and 2001 was similar. The treatment habits were the same in the 46 wards, which used acitretin as first line treatment (89%), followed by methotrexate (8%). High potency dermatocorticosteroids (DC) were most often used (87%). Complications and death were noted in 17% and 2% of the cases respectively, recalcitrant GPP in 42%. Immunobiologics were required in 13% of patients. Univariate analysis showed that treatment failure was related to: i) management in a university ward (OR: 2.9, p = 0.03) probably reflecting the management of the more severe cases ii) prescription of high or very high potency DC as first line local therapy (OR: 7.6, p = 0.05) iii) therapies other than retinoids as first line systemic therapy (OR: 5.5, p = 0.04). The systemic treatment is well codified but future studies will have to confirm the usefulness of DC in the management of GPP.

Generalized pustular psoriasis (von Zumbusch) following iatrogenic hypocortisolism

Generalized pustular psoriasis can be triggered by hypocalcemia, pregnancy, stress and drugs but frequently has no obvious cause. We report a case which was only cured after treatment of iatrogenic adrenal axis suppression. A 41 year old woman had been suffering for nine months from a generalized pustular psoriasis which had occurred after a three week topical corticosteroid therapy of plaque psoriasis with 90 g of betamethasone dipropionate + 2% salicylic acid. Successive systemic treatments failed but topical corticosteroids brought relief to the patient. Cortisol level was found to be very low. Further investigations showed iatrogenic adrenal axis suppression. Hydrocortisone supplementation brought spectacular improvement and complete healing in a few months.We suggest that our patient was extremely sensitive to corticosteroids because the first pustules appeared after a conventional topical treatment. Adrenal axis suppression has never been involved in the aggravation of inflammatory dermatoses except in two cases of severe atopic dermatitis. Endogen corticosteroids inhibit proinflammatory cytokines by a feed-back mechanism and might have a great importance in the immune regulation loop. Cortisol level measurement should be considered in corticodependent inflammatory dermatoses.

Giant foot schwannoma

Schwannoma of the foot is rare; only 12 cases have been reported. A schwannoma is a benign neurogenic tumour derived from Schwann cells. The diagnosis is often delayed because the symptoms are mainly those of compression disorders. We describe a 7cm schwannoma of the heel in a 30-year-old man. Ten years earlier a schwannoma was removed from the same site. The recurrent lesion was widely excised and a medial plantar flap was used to repair the heel.

[Imputable cutaneous eruption caused by ticlopidine after implantation of a coronary endoprosthesis: why not continue treatment?]

BACKGROUND

The decision to interrupt a ticlopidine regimen in a patient who develops an adverse effect can be particularly difficult when discontinuing the drug could lead to a high risk situation.

CASE REPORT

A 64-year old patient developed a skin rash after taking ticlopidine for coronary artery stenting. Stopping ticlopidine could have led to stent occlusion and no alternative therapy seemed to be suitable. We therefore decided to carry on the treatment under close clinical surveillance. The skin signs rapidly resolved.

DISCUSSION

This cases shows that ticlopidine may be continued in patients who develop an adverse skin reaction. The rapid involution of the cutaneous signs in our patient demonstrated that the risk of discontinuing treatment can be greater than that of continuing.

[Pyoderma gangrenosum]

Pyoderma gangrenosum is a very strange disease usually diagnosed on clinical grounds only and without any characteristic biological disturbance. It must be neither missed nor diagnosed too easily at the expense of vascular or infective ulcerations which are much more frequent. Its physiopathology remains shrouded in mystery since the abnormalities that have been found were extremely varied and sometimes conflicting, and were observed in short series. Thus, pyoderma gangrenosum appears as a syndrome which if often causeless or due to multiple diseases and might well be split into different entities in the forthcoming years. Despite its obscure pathogenesis, most patients can be cured by systemic corticosteroid therapy, sulfones or clofazimine. The main point of interest of that disease is that in almost 50 percent of the cases it is associated with a severe underlying pathology.

Porphyria cutanea tarda after allogeneic bone marrow transplantation for chronic myelogenous leukemia

A case of porphyria cutanea tarda (PCT) occurring after bone marrow transplantation (BMT) is reported. A 43-year-old male with chronic myelogenous leukemia received an human leukocyte antigen (HLA)-identical allogeneic transplantation with T-cell depleted marrow. Because of graft rejection, a second transplant was performed 4 months later. A grade II acute graft- vs.-host disease and a cytomegalovirus (CMV) infection were subsequently observed. Two years after the second transplant, cutaneous symptoms of PCT with typical biochemical abnormalities developed. Liver biopsy revealed signs of hepatitis with iron overload. CMV was isolated from liver tissue. The possible roles of underlying disease, BMT, and CMV liver disease are discussed in view of the recently reported cases of PCT in patients with AIDS or hematological disorders.