Cutaneous manifestations in patients with COVID-19: a preliminary review of an emerging issue

BACKGROUND

The infection caused by the recently identified SARS-CoV-2, called coronavirus disease-19 (COVID-19), has rapidly spread throughout the world. With the exponential increase of patients worldwide, the clinical spectrum of COVID-19 is being better defined and new symptoms are emerging. Numerous reports are documenting the occurrence of different cutaneous manifestations in patients with COVID-19.

OBJECTIVES

To provide a brief overview of cutaneous lesions associated with COVID-19.

METHODS

A literature search was performed in the PubMed, Scopus and Web of Science databases up to 30 April 2020. This narrative review summarizes the available data regarding the clinical and histological features of COVID-19-associated skin manifestations.

RESULTS

The literature reports showed a great heterogeneity in COVID-19-associated cutaneous manifestations, as well as in their latency periods and associated extracutaneous symptoms. Pathogenic mechanisms are unknown, although the roles of a hyperactive immune response, complement activation and microvascular injury have been hypothesized. Based on our experience and the literature data, we subdivided the reported cutaneous lesions into six main clinical patterns: (i) urticarial rash; (ii) confluent erythematous-maculopapular-morbilliform rash; (iii) papulovesicular exanthem; (iv) chilblain-like acral pattern; (v) livedo reticularis-livedo racemosa-like pattern; and (vi) purpuric 'vasculitic' pattern. These six patterns can be merged into two main groups: the first - inflammatory and exanthematous - includes the first three groups listed above, and the second includes the vasculopathic and vasculitic lesions of the last three groups.

CONCLUSIONS

The possible presence of cutaneous findings leading to suspect COVID-19 puts dermatologists in a relevant position. Further studies are needed to delineate the diagnostic and prognostic values of such cutaneous manifestations.

Once-Weekly Administration of High-Dosage Etanercept in Patients with Plaque Psoriasis: Results of a Pilot Experience (Power Study)

Etanercept is a soluble tumour necrosis factor receptor fusion protein which is approved for the treatment of plaque psoriasis at the dose of either 25mg twice weekly (BIW) or, for the initial 12 weeks, 50mg BIW. Alternative dosing regimens have not been evaluated in psoriasis. In this study, we compare the efficacy and tolerability of two etanercept dosing regimens - 50mg BIW and 100mg once weekly (OW) - for 12 weeks in 108 patients with moderate-to-severe recalcitrant psoriasis. Efficacy measures included Psoriasis Area and Severity Index (PASI), severity of pruritus recorded on a visual analogue scale (VAS) and the influence on quality of life assessed by means of Dermatology Life Quality Index (DLQI). Both etanercept regimens caused a significant change in all the efficacy parameters after 4 weeks and 12 weeks, at a comparable rate. At week 12, a PASI improvement of at least 50% from baseline (PASI 50) was achieved by 74% of patients treated with 50mg BIW and 78% of patients treated with 100mg OW. A PASI 75 response was obtained in 54% and 50% of patients treated with 50mg BIW and 100mg OW, respectively. Treatment was well tolerated with similar type and frequency of adverse events between the two groups.

Treatment of Mild to Moderate Plaque Psoriasis with Calcitriol Ointment Applied with or without a Dosing Device

Results of topical treatments can be influenced by several factors, including accurate dosing based on the affected skin area. The aim of this open-labelled multicenter study is to evaluate if correct dosing of calcitriol ointment has an impact on the clinical response of plaque psoriasis. For this purpose, patients with plaque psoriasis eligible to be treated with calcitriol ointment were randomized to treatment with a ‘standardized dose’ method, using a dosing device (N. 100), or treatment without the device (N. 101), for 12 weeks. Regardless of the use of the dosing device, calcitriol ointment caused a significant reduction of both the severity of signs and symptoms and the extent of body surface area affected after both 4 weeks and 12 weeks. Clinical response was not significantly different between the two groups. Local adverse events occurred in 12 subjects (of whom five treated with the device) and were mild and transient in most cases.

Topical Vitamin E Acetate for the Treatment of Cheilitis: A Multicentre Experience

Treatment of cheilitis is usually difficult and often disappointing. We evaluated the effects of a topical preparation containing vitamin E acetate (VEA® lipogel) in 254 patients (mean age, 29.5) with cheilitis of various nature and etiology, involving the vermilion region and/or the perioral skin. The most frequent form of cheilitis was that induced by oral isotretinoin; other forms were irritant contact dermatitis, atopic cheilitis, and contact allergy. Patients were instructed to apply VEA® lipogel daily; the number of daily applications was modulated on the basis of the severity of symptoms (two or three times a day in the majority of cases). After 4 weeks of treatment, clinical examination showed that the severity of symptoms and signs significantly improved (P<0.001). The response to treatment was reported as particularly rapid by 32% of patients. Patient's assessment of overall effectiveness and acceptability was positive in the majority of cases. Treatment was well tolerated; local adverse reactions were observed in 2.75% of patients and were mostly transient and mild. Our experience suggests that VEA® lipogel is an effective and safe approach to cheilitis. The safety of this preparation is also due to the presence of only a few excipients and the absence of fragrances, preservatives and colouring agents.

Treatment of Inflammatory Acne with a Combination Therapy with Lymecycline and Adapalene Followed by Maintenance Treatment with Adapalene

Oral antibiotics, especially tetracyclines, are commonly used to treat moderate to moderately severe acne vulgaris. There are hints suggesting that a combination treatment with oral tetracyclines and topical retinoids can cause a greater and prompter improvement of acne than monotherapy with tetracyclines. We evaluated the clinical activity of a 12-week combined therapy with oral lymecycline (300mg/day for 2 weeks and then 150mg/day) and topical adapalene (gel or cream) in 419 patients with inflammatory acne. A significant reduction in the number of acne lesions was noted at 4 and 12 weeks (P<0.0001). Thereafter, 400 patients underwent a maintenance treatment with adapalene alone for 12 weeks. At week 24 a relevant improvement of acne lesions still persisted (P<0.0001) in most patients. Only 16 patients relapsed and required additional use of oral lymecycline which proved again successful. No substantial differences were noted in the magnitude of clinical response between patients treated with adapalene gel and those treated with cream formulation. Treatment was well tolerated. Local adverse reactions occurred in 11.7 % of patients and resulted in premature discontinuation of treatment in 1.4 %. Systemic (gastrointestinal) untoward effects developed in 1.2 % of patients and caused treatment interruption in 0.7 % of cases. No serious adverse events occurred.

Comparison of Two Different Dosing Regimens with Lymecycline, in Association with Adapalene, in Inflammatory Acne

Combined treatment with oral lymecycline and topical adapalene has been shown to induce greater and faster improvement of acne than monotherapy with lymecycline. We wanted to evaluate the effects of combined therapy with topical adapalene (cream or gel) plus oral lymecycline used at different dosages (group A: 300mg/day for 2 weeks and then 150mg/day for 14 weeks; group B: 300mg/day for 16 weeks) in 242 patients with inflammatory acne. Both dosage regimens were well tolerated in the majority of patients and significantly improved both the acne lesion count and seborrhoea. There was a trend towards a greater reduction of seborrhoea and nodules in patients of group B. After the initial 16-week phase, patients entered an 8-week follow-up phase, consisting of the use of adapalene monotherapy. The results obtained after this phase confirm the therapeutic value and the favourable tolerability of adapalene as maintenance treatment after successful treatment of inflammatory acne. At the same time, a significantly reduced count of comedones was observed in patients of group B as compared with group A, suggesting that prolonged use of high-dose lymecycline may have a more pronounced influence on comedogenesis.

Treatment of Psoriasis Vulgaris with Calcipotriol Betamethasone Dipropionate Combination Followed by Calcipotriol and Assessment of the Adjuvant Basic Use of Urea-Based Emollients

A new combination product containing betamethasone dipropionate and calcipotriol (Dovobet® ointment) has been proven very effective and well tolerated in patients with psoriasis vulgaris. Emollients are adjunctive modalities commonly used in psoriasis; however, their actual role in combination with topical drugs as well as well as their compatibility with these drugs have not been well elucidated. In 313 adult patients with psoriasis vulgaris, we studied the efficacy and tolerability of treatment with Dovobet® ointment combined with urea-based emollients (Excipial U®) for 4 weeks, followed by treatment with calcipotriol (Daivonex®) either alone (group A) or combined with urea-containing emollients (Excipial U®, group B) for 8 weeks. Clinical evaluations were performed at baseline, at 4 and 12 weeks, assessing the clinical score for erythema, scaling, infiltration and pruritus, graded on the basis of a 5-point scale. After the initial 4-week treatment, a significant improvement of all clinical parameters was observed (p<0.05). Overall, clinical results improved further during the maintenance treatment phase; significant changes (p<0.05) were observed in each group. Most patients considered treatment efficacy positively at both 4 weeks and 12 weeks. Interestingly, at the end of the study, a greater percentage of patients in group B than in group A judged the efficacy as excellent. Treatment was very well tolerated. Only two patients complained of mild and transient burning sensation during the first days of treatment. The results of this study confirm the great efficacy and tolerability of sequential treatment with Dovobet®, and Daivonex® in psoriasis vulgaris and show the enhanced acceptability of this treatment associated with urea-based emollients.

Risk Factors for Sensitization to Anisakis Simplex: A Multivariate Statistical Evaluation

Anisakis simplex is a nematode belonging to the Anisakidae family. The ingestion of third stage larvae in uncooked or undercooked seafood may cause human diseases known as anisakiasis and anisakidosis. A total of 400 (159 atopic and 241 non-atopic) subjects living in an area of southern Italy (Bari district) were consecutively evaluated to identify the association of some factors (sex, age, atopy, consumption of uncooked seafood and sensitization to dust mites) with the risk of Anisakis simplex sensitization. Patients were investigated on history of atopy and allergic diseases and were skin prick tested with commercial allergen extracts of Anisakis simplex, Acarus siro, Lepidoglyphus destructor, Tyrophagus putrescentiae, Glycyphagus domesticus, Euroglyphus maynei, Dermatophagoides pteronyssinus and Dermatophagoides faunae. Our results suggest that atopic subjects have a lower risk of Anisakis allergy than non-atopic subjects and show the association of Anisakis simplex sensitization with the consumption of uncooked seafood (anchovies and squid), increasing age and sensitization to Glycyphagus domesticus.

Oral Terbinafine in the Treatment of Multi-Site Seborrheic Dermatitis: A Multicenter, Double-Blind Placebo-Controlled Study

Seborrheic dermatitis (SD) is a common disorder for which no satisfactory curative treatment exists. Preliminary studies suggest that terbinafine may be effective. The efficacy and tolerability of oral terbinafine was evaluated in multi-site SD in a randomized, double-blind, placebo-controlled study. For this purpose, 174 adult patients with SD lesions involving ≥3 skin areas, each causing ≥2 moderate/severe symptoms according to a pre-defined clinical score, were classified according to the localization of lesions: patients with lesions predominantly involving non-exposed skin areas, such as scalp and hairline and sternum and/or interscapular area (Population A, n=83) or patients with lesions in exposed sites, mainly the face (Population B, n=91). Patients were randomized to oral terbinafine (250 mg/day) (n=86) or matching placebo (n=88), each given for 6 weeks. Primary efficacy variable was the response rate, defined as ≥50% decrease in baseline total clinical score without rescue medication intake after 6 weeks of treatment. The main secondary assessments were: subject's global assessment of relief and proportion of patients satisfied with treatment. Recurrence rate was assessed in responder patients during a 4-week treatment-free period. In Population A the response rate after 6 weeks of treatment was significantly higher with terbinafine (70% vs 45.4%; p=0.03) and so was the proportion of patients who reported relief (75% vs 41%; p=0.007) and who were satisfied (66% vs 40%; p=0.02). No significant differences were recorded in Population B. Adverse events occurred in 11.5% of terbinafine patients and 8% of placebo patients. One patient discontinued treatment with terbinafine because of adverse events (mild tachycardia and insomnia). In conclusion, our results show that terbinafine is significantly more effective than placebo in reducing the severity of SD lesions in non-exposed sites. Clinical trials comparing terbinafine to standard treatment regimens in different types of patients with SD are warranted.

Re-Induction as a Possible Alternative Modality of Dose Escalation of Infliximab: A Prospective Evaluation in a Small Series of Psoriatic Patients

Infliximab is an anti-tumour necrosis factor-alpha chimeric monoclonal antibody which is highly effective in psoriasis, as well as in other indications. In clinical practice, some patients may require dose escalation to overcome a reduction of the extent and/or duration of response during regular maintenance treatment, possibly due to the loss of stable serum concentrations of the drug. Common strategies of dose escalation are the increase of dose per infusion and the decrease of interval between infusions. Here we report the results of re-induction therapy with infliximab used as a dose escalation strategy in 9 patients whose psoriasis relapsed during maintenance treatment with infliximab 5 mg/kg every 8 weeks. Re-induction was well tolerated and capable of restoring response in 8 of these patients.

Infliximab Monotherapy for Refractory Psoriasis: Preliminary Results

Tumour necrosis factor (TNF)-alpha plays an important role in the pathogenesis of psoriasis. Infliximab is an anti-TNF-alpha chimeric monoclonal antibody, which is licensed for the treatment of rheumatoid arthritis and Crohn's disease. Some reports have shown the efficacy of infliximab, either in monotherapy or in combination with methotrexate, for the treatment of psoriatic arthropathy and psoriasis.

The efficacy and tolerability of infliximab monotherapy was evaluated in 29 patients with moderate to severe psoriasis, unresponsive to conventional treatments. Fourteen patients suffered from concomitant arthropathy. Patients received intravenous infliximab, 5mg/kg, at weeks 0, 2, and 6. After this 3-dose-induction regimen, patients were followed-up at monthly intervals and retreated with a single-dose infusion in case of relapse of signs and symptoms. Clinical assessment was performed using the psoriasis area and severity index (PASI) to monitor psoriasis activity; pruritus and joint pain were assessed on a scale of 0 to 3. A marked improvement of skin lesions and subjective symptoms was noted in the majority of patients; an excellent reduction of PASI score (⩾75%) was observed in 13.8% of cases at week 2, 71.4% at week 6 and 78.6% at week 10. During the follow-up period, some patients maintained satisfactory clinical results without requiring any additional infusions. In general, skin lesions showed a trend towards a more prolonged and sustained improvement as compared with subjective symptoms. Treatment was well tolerated and no serious adverse events occurred.

Treatment of Seborrhoeic Dermatitis of the Scalp with Desonide 0.05% Solution

Topical corticosteroids are commonly used for the short-term management of seborrhoeic dermatitis (SD) of the scalp. The aim of this study was to evaluate the effectiveness, tolerance and cosmetic acceptability of desonide 0.05% solution, whose alcohol-free formulation is innovative with respect to traditional corticosteroid lotions, in the treatment of SD of the scalp.

For this purpose, 155 adult subjects applied on scalp lesions desonide once daily for 1 week, on alternate days for 3 weeks, and two times a week for 4 weeks. A significant reduction of the severity of erythema, scaling and pruritus was observed (P<0.001). Interestingly, during the phase of gradual reduction of weekly applications, results were frequently maintained or improved further. Twenty patients (13%) at 4 weeks and 85 patients (58%) at 8 weeks had their scalp SD cleared. Most patients regarded the overall effectiveness, tolerability and acceptability as satisfactory; patients who had previously used common steroid lotions expressed a positive judgment on desonide solution compared to the other lotions in terms of efficacy, acceptability, rapidity of action, tolerability and persistence of effects.

In conclusion, our preliminary findings indicate that desonide 0.05% solution is suitable for the short-term management of scalp SD.

Epidemiology of chronic spontaneous urticaria: results from a nationwide, population-based study in Italy

BACKGROUND

Chronic spontaneous urticaria (CSU) is a common skin disease, but there is a paucity of precise epidemiological data on this disease.

OBJECTIVES

To obtain information on the epidemiology of CSU in Italy.

METHODS

The data source was the Health Search IMS Health Longitudinal Patient Database. The study population was formed by patients aged ≥ 15 years, registered with a total of 700 general practitioners, homogeneously distributed across Italy. An algorithm based on the International Classification of Diseases, ninth revision, Clinical Modification was used for the identification of patients with CSU. The annual prevalence and incidence rates of CSU over a 12-year period (2002-2013) were estimated, along with demographic and clinical determinants.

RESULTS

The annual prevalence of CSU ranged from 0·02% in 2002 to 0·38% in 2013. The incidence was 0·10-1·50 per 1000 person-years. For both prevalence and incidence rates, female patients outnumbered male. The risk of CSU was statistically significantly higher in the presence of the following variables: obesity; anxiety, dissociative and somatoform disorders; malignancies; use of immunosuppressive drugs; and chronic use of systemic corticosteroids. History of autoimmune thyroiditis showed a trend towards an increased risk of CSU, though it was not statistically significant. Smoking was associated with a significantly reduced risk of CSU.

CONCLUSIONS

Our findings on CSU prevalence are consistent with those obtained in previous studies. Furthermore, this large population-based study provides important information regarding the association of CSU with demographic and clinical determinants, which have been examined in the primary-care setting.

Hair disorders associated with autoimmune connective tissue diseases

Hair disorders are frequently observed in various systemic diseases, including autoimmune connective tissue diseases (CTDs), with predilection of lupus erythematosus (LE), followed by dermatomyositis (DM) and scleroderma. Hair disorders in CTDs may manifest as various clinical patterns, such as telogen hair loss, diffuse thinning or fragility of hair, and scarring alopecia. Less common hair disorders include anagen effluvium, alopecia areata, and trichomegaly. Some drugs used to treat CTDs may cause hair loss in a drug-related manner or hyperthrichosis. In the assessment of common hair loss patterns, such as telogen effluvium, the possible association with CTDs must be borne in mind and should not be overlooked. Alopecia appears to be a significant sign in the course of LE and especially systemic LE. In DM, the involvement of the scalp is common, and is often characterized by a diffuse, violaceous, scaly, non-scarring and symptomatic hair loss. Linear scleroderma en coup de sabre is an uncommon localized form of morphea with involvement of the paramedian forehead and frontal scalp, where it is associated with cicatricial alopecia. The most important variant of scarring alopecia in the context of CTDs is that associated with discoid lupus erythematosus (DLE). In the diagnostic work-up of DLE-related cicatrical alopecia, histopathological and immunopathological studies are useful, and a relevant role has been attributed to dermatoscopy (trichoscopy) over the last years. Hair loss has been reported in several other CTDs, including mixed and undifferentiated CTDs, and primary Sjögren's syndrome, although it is likely to be underestimated in such diseases.

Survival rate of antitumour necrosis factor-α treatments for psoriasis in routine dermatological practice: a multicentre observational study

BACKGROUND

Adherence is an overall marker of treatment success, and it depends on multiple factors including efficacy and safety. Despite the wide use of tumour necrosis factor (TNF)-α blockers in the treatment of plaque-type psoriasis, few data regarding treatment adherence in routine clinical practice are available.

OBJECTIVES

To estimate the long-term survival rate of anti-TNF-α therapy in a cohort of patients with psoriasis in routine clinical practice; to evaluate the reasons for and predictors of treatment discontinuation.

METHODS

The Outcome and Survival rate Concerning Anti-TNF Routine treatment (OSCAR) study was based on a retrospective analysis to estimate the long-term survival rate of the first anti-TNF-α treatment in patients with psoriasis, from three Italian academic referral centres. Adult patients (n = 650) with plaque psoriasis treated with a first course of adalimumab, etanercept or infliximab for ≥ 3 months were included.

RESULTS

Global adherence to anti-TNF-α treatments after 28·9 ± 15·4 months (867 ± 462 days) of observation was 72·6%. Etanercept showed a longer survival (mean 51·4 months, 1565 days; P < 0·001) compared with infliximab (36·8 months, 1120 days) and adalimumab (34·7 months, 1056 days). Treatment discontinuation due to primary and secondary inefficacy was observed in 5·2% and 14·5% of patients, respectively, whereas discontinuation due to adverse events was reported in 29 subjects (4·5%). Independent predictors of treatment withdrawal were female gender [hazards ratio (HR) 1·3], treatment with adalimumab or infliximab compared with etanercept (HR 2·7 and 1·7, respectively), and the concomitant use of traditional systemic treatment, as a rescue therapy, compared with monotherapy (HR 1·9).

CONCLUSIONS

Overall survival of anti-TNF-α agents in psoriasis is elevated, with drug discontinuation mostly due to inefficacy. Etanercept showed a longer adherence compared with adalimumab and infliximab.

Janus kinase inhibition as a potential strategy for the treatment of psoriasis: state of the art and future perspectives

Research is focusing the attention on drugs acting on intracellular signaling as a possible strategy for various malignancies and autoimmune disorders, as well as prevention of transplant rejection. In such a context, an intriguing therapeutic target appears to be the signaling pathway mediated by Janus kinases (JAK)/signal transducers and activators of transcription (STAT) protein family. Several companies are developing and evaluating JAK inhibitors for immune-mediated disorders, including psoriasis. Among these drugs, ruxolitinib and especially tofacitinib have reached more advanced phases of clinical and experimental development. This review discusses the potential role of JAK inhibition in the treatment of psoriasis and presents the preliminary data regarding the clinical development of JAK inhibitors in this disease.

Methyl-aminolevulinate photodynamic therapy for the treatment of actinic cheilitis: a retrospective evaluation of 29 patients

AIM

Multiple treatment modalities have been proposed for actinic cheilitis (AC), and topical photodynamic therapy (PDT) has recently been included among these modalities. We report our experience with PDT using methyl-aminolevulinate (MAL) in AC.

METHODS

We performed a retrospective analysis of 29 patients who had undergone MAL-PDT for treatment of AC: 4 patients received one single session and 25 patients two consecutive weekly sessions.

RESULTS

At 3 months, 21 patients (72%) obtained a complete clinical response, which was sustained over a follow-up period of 6-36 months (mean, 20 months) in 20 patients. Cosmetic outcome was generally rated as good or very good. Transient local adverse events related to the procedure were common and mild to moderate in the majority of cases.

CONCLUSION

Our preliminary experience suggests that MAL-PDT may be considered a valid modality for the treatment of AC, although long-term follow-up studies in large patient series are required to obtain precise data about clinical and histological recurrences.

Anti-tumor necrosis factor treatment in occult hepatitis B virus infection: a retrospective analysis of 62 patients with psoriatic disease

One of the problems possibly related to the use of biological agents targeting tumor necrosis factor (TNF)-alpha is the increased risk of infections, including the activation of hepatitis B virus (HBV). HBV activation can occur in carriers of hepatitis B surface antigen (HBsAg), but the risk may also involve the HBsAg-negative (anti-HBc ± anti-HBs) occult carriers. Precise data on the safety of anti-TNF and/or other immunosuppressive drugs in HBV occult carriers are not available. We performed a retrospective analysis of 62 psoriatic patients with occult HBV infection treated with anti-TNF biological agents over a period of approximately 4 years: 44 subjects were treated with etanercept, 8 with infliximab and 10 with adalimumab. During the observational treatment period, no signs of HBV activation were observed. Only in one patient the reappearance of HBsAg, without detectable HBV-DNA, was noted before retreatment with etanercept and after 10 months from discontinuation of the previous course. In this patient etanercept was re-administered in association with lamivudine without any adverse event. Our results suggest the overall safety of treatment with anti-TNF drugs in HBV occult carriers, although a careful and constant monitoring of virological markers is required in such patients during treatment with anti-TNF drugs in order to have an early recognition of viral reactivation.

Psodisk, a new visual method for assessing the burden of psoriasis on patients

BACKGROUND

The last decades have witnessed an increasing interest for the psychosocial aspects of chronic skin diseases, such as psoriasis. Nonetheless, systematic assessments of the impact of psoriasis on patients' lives are rarely done in daily clinical practice. The existing instruments are mostly meant to be completed by patients alone, and rarely comprise a graphical representation of the results.

OBJECTIVE

To develop a questionnaire allowing both a quick assessment of the impact of psoriasis on patients and, at the same time, an intuitive graphic visualization of the outcome of the test.

METHODS

A preliminary version of an Italian questionnaire aimed to assess the global impact of psoriasis on patients, meant to be filled in together by the patient and the dermatologist and to produce visual, intuitive results, was developed through focus groups. The instrument was then the object of a Delphi survey addressed to a panel of experts, to assess both the need of possible improvements of the questionnaire (in terms of the formulations of the questions and of the domains to be explored) and the usefulness of the questionnaire.

RESULTS

A 10-item questionnaire in Italian, taking into account different aspects of the burden of psoriasis on the patient, was developed. The answers are given on a 10-point visual analogue scale and graphically represented on a disc as a polygon.

CONCLUSIONS

A formal validation of the questionnaire and a study to assess potential clinical and psychological benefits of a systematic implementation of the instrument in daily practice are planned.

Oral supplementation with a nutraceutical containing Echinacea, methionine and antioxidant/immunostimulating compounds in patients with cutaneous viral warts

AIM

The aim of thos paper was to determine the effect of oral supplementation (OS) with a nutraceutical, containing methionine, Echinacea, zinc, probiotics and other antioxidant and immunostimulating compounds, on the response of cutaneous warts to conventional standard therapy (CST).

METHODS

This was an open-label study in adults and adolescents aged 14 years or more and with a body weight ≥40 kg, who had at least one cutaneous viral wart. Eligible patients were consecutively allocated to CST (topical therapy with a preparation containing salicylic acid and lactic acid or liquid nitrogen cryotherapy) alone or CST combined with nutraceutical OS for 4 months.

RESULTS

A total of 172 patients were enrolled: 83 received CST alone and 89 CST+OS. During the 6-month observation period, a statistically significant reduction of the mean number of warts was obtained in each treatment group and subgroup. The addition of nutraceutical OS was associated with a significantly lower number of warts at 6 months as compared to CST alone. Complete remission was obtained in 54.5% and 86% of patients in the CST group and CST+OS arm, respectively (P<0.001). The influence of the nutraceutical on the response rate appeared to be more prominent in the subgroup of patients treated with topical therapy. The development of new warts during the study period occurred significantly less frequently with CST+OS compared to CST (9% versus 25%; P=0.004). No adverse events possibly related to the nutraceutical administration were observed.

CONCLUSION

Our pilot experience seems to suggest that nutraceutical OS is safe and beneficial in patients with cutaneous warts, and capable of enhancing the response to CST.

Molecular characterization of novel melanoma cell lines

We isolated two novel cell lines from different types of sporadic human malignant melanoma: the hmel1 line was obtained from a melanoma skin metastasis and the hmel9 cell line from a primary superficial spreading melanoma. The karyotype and pigmentation parameters were assessed in these cell lines. Cytogenetic analysis in early stages of culture revealed that both cell lines had chromosome instability and simultaneous growth of heteroploid subpopulations. The molecular analysis of some genes involved in melanoma showed that both cell lines harbor BRAF mutations. The unpigmented hmel1 and the pigmented hmel9 lines were found to express the tyrosinase gene. The tyrosine hydroxylase activity was detectable only in hmel9 cells and practically absent in the hmel1 cell line. This activity was found to be correlated with the relative tyrosinase protein amount in both melanoma cell lines. The biological behaviour in the two melanoma cell lines, derived from two different types of melanoma lesions displaying distinct clinical and histopathological features, confirms the heterogeneous characteristics of sporadic melanoma. Similarities and/or differences between cell lines extracted from different melanoma cases could be useful in the future for diagnostic, prognostic and therapeutic purposes.

Adjuvant role of a new emollient cream in patients with palmar and/or plantar psoriasis: a pilot randomized open-label study

Emollients are considered important adjunctive tools for the therapeutic management of psoriasis patients. In spite of the widespread use, the actual impact of emollients on psoriasis is far to be completely elucidated. The objective of this study was to evaluate the effect of a new emollient cream containing milk proteins and Glycyrrhiza glabra extracts in patients with palmar and/or plantar psoriasis treated with topical corticotherapy. This pilot open parallel-group trial was carried out in 40 patients with palmar and/or plantar psoriasis. Patients were randomized to receive monotherapy with mometasone furoate ointment, applied once daily to the palmoplantar lesions until remission and for a maximum of 4 weeks (N=20), or the same topical corticotherapy in combination with the emollient cream (N=20). The emollient was applied twice a day for 4 weeks. Clinical assessments were performed at baseline and 2 and 4 weeks after the start of treatment. All patients completed the study and showed a progressive improvement of their palmo-plantar psoriasis over the treatment period, achieving at week 4 a statistical significant reduction in the severity of all clinical signs (erythema, desquamation and infiltration) and in the surface area affected. The comparison between the two groups showed no differences in the mean average duration of corticosteroid therapy, whereas a significantly greater improvement of desquamation, surface area affected, and subjective symptoms was observed at week 4 in the group treated with the corticotherapy combined with the emollient as compared to patients who received the corticotherapy alone. This pilot experience suggests the importance of the adjuvant role of particular emollients in the management of psoriasis.

Psoriasis Relapse Evaluation with Week-End Cyclosporine a Treatment: Results of a Randomized, Double-Blind, Multicenter Study

Cyclosporine A (CsA) effectively controls psoriasis, however, its long-term continuous use is not recommended. This study aims to evaluate the efficacy and tolerability of week-end CsA microemulsion for the reduction of relapse rate in patients with chronic plaque psoriasis who had achieved clinical remission following continuous CsA therapy. The PREWENT (Psoriasis Relapse Evaluation with Week-End Neoral Treatment) study was a 24-week, randomized, double-blind, multicenter study, carried out in 22 Italian hospital or university Dermatology units. CsA was discontinued for 8 days previous to the patients being randomized to oral CsA 5 mg/kg/day or placebo for two consecutive days/week, for a total period of 24 weeks. The primary endpoint was clinical success rate at week 24, defined as the proportion of patients with no clinical worsening (no relapse or a Psoriasis Area and Severity Index [PASI] <75% of pre-treatment PASI). A total of 162 patients were randomized to CsA and 81 to placebo. Clinical success rates at 24 weeks were 66.9% and 53.2% with CsA and placebo, respectively (p = 0.072). Time to first relapse was significantly prolonged with CsA versus placebo (p = 0.023), and PASI was significantly lower from weeks 4 to 16 in CsA recipients. In patients with moderate-severe psoriasis, the clinical success rate was significantly increased with CsA compared to placebo (69.9% vs 46.3%; p = 0.011), and significantly lower increases in PASI were observed from week 4 to week 24 (p < 0.05 vs placebo). CsA was well tolerated, with no differences in mean blood creatinine or blood pressure between CsA and placebo recipients. However, the high withdrawal rate (22.2% of randomized patients), which was not related to side effects, may have led to an overestimation of efficacy, but the study had a good statistical power (88% greater than that observed in similar studies, i.e. 80%). Week-end CsA administration was shown to prolong safely and effectively the time to first relapse in psoriasis patients.

Treatment of Psoriasis with Different Dosage Regimens of Etanercept: Preliminary Results from the TαRanta Plastic Study Group

This pilot open-label study is aimed to assess clinical response in psoriasis patients receiving diverse dose regimens of etanercept, consisting of the same global cumulative dose of etanercept administered over different treatment periods. Eligible patients were assigned sequentially in a 1:1 ratio to receive: etanercept 50 mg once weekly (QW) or 50 mg twice weekly (BIW) for 12 weeks. The final analysis included a total of 72 patients. At week 12 the Psoriasis Area and Severity Index (PASI) and Skindex-29 scores notably improved in both treatment arms, without significant differences between the two groups. The rate of patients attaining a PASI improvement ≥ 50% (PASI 50) at week 12 was 92% in the high-dose group. In these patients, etanercept dosage was decreased to 50 mg QW from week 13, with persistence of the PASI 50 response at week 24 in all cases. Thereafter, treatment was discontinued up to week 36 and almost 30% of patients experienced a gradual relapse of their psoriasis within this period. In the low-dose group, the PASI 50 response was observed in 75% of patients. These responders continued to be treated with etanercept 50 mg QW up to week 36 with persistence of the PASI 50 in 100% of cases at week 24 and 93% at week 36. In the low-dose regimen, 8 patients who did not respond at week 12 underwent dose escalation to 50 mg BIW for a further 12 weeks. At week 24, six of these patients gained the PASI 50 response, 4 of whom maintained the response up to week 36, after treatment discontinuation from week 24. Our results confirm that etanercept is very effective and well-tolerated in psoriasis and that the drug dosages and treatment duration may be modulated and adapted to clinical needs in a flexible way.

Photoallergic contact dermatitis

Photoallergic contact dermatitis (PCD) is a delayed-type hypersensitivity cutaneous reaction in response to a photoantigen applied to the skin in subjects previously sensitized to the same substance. For the development of PCD, irradiation with ultraviolet (UV) radiations, usually UVA, is required to create a complete antigen, and the culprit substance needs to be within the skin at the time of UVA exposure. The incidence of PCD in the general population is unknown and is considered uncommon. Epidemiological data have been obtained from studies performed using photo-patch tests in patients with suspected photodermatoses in tertiary care outpatient units. Prevalence of PCD over time has been also dependent on prescription and/or usage patterns of potential photosensitizers, and was particularly high in the past, causing mini-epidemics in some countries because of the widespread use of halogenated salicylanilides and other photosensitizing compounds. Many topical substances with photosensitizing properties are currently available, with the most important ones being sunscreen agents and nonsteroidal antiinflammatory drugs. The diagnosis of PCD, in patients with a history of photosensitivity and especially with an eczematous form of photodermatosis, should be confirmed by photo-patch testing.

Pemphigus vulgaris with circulating anti-desmoglein 3 and anti-BP180 antibodies: a case report and brief review of cases with coexistence of pemphigus vulgaris and bullous pemphigoid

Pemphigus vulgaris (PV) and bullous pemphigoid (BP) are two autoimmune blistering diseases involving the skin and the mucous membranes characterized by circulating autoantibodies directed against desmosomal cadherins or antigens expressed in the basement membrane zone, respectively. The simultaneous presence of clinical and/or immunopathological features of PV and BP in the same patient has been reported in very few cases in the literature to date. Most of these cases had exclusive cutaneous involvement, while a minority showed concomitant oral lesions. We describe the case of a 59-year-old female patient with a 10-year history of refractory PV lesions limited to mucous membranes (conjunctiva, oral cavity and genital mucosa), which were controlled by the addition of mycophenolate sodium to oral prednisone. Immunofluorescence studies revealed findings consistent with PV, whereas enzyme-linked immunosorbent assay revealed circulating anti-BP180 antibodies in association with anti-desmoglein 3 antibodies. The significance and relevance of this finding are briefly discussed, in light of the literature data.

Methyl-aminolevulinate photodynamic therapy for the treatment of actinic keratoses and non-melanoma skin cancers: a retrospective analysis of response in 462 patients

AIM

Topical photodynamic therapy (PDT) with methyl-aminolevulinate (MAL) is widely used for the management of actinic keratoses (AK) and non-melanoma skin cancers (NMSCs). The authors report the results of a retrospective chart review showing the cumulative four-year experience with MAL-PDT in a hospital outpatient setting.

METHODS

The medical records selected concerned all patients who completed the MAL-PDT regimen (one single session for AK and two sessions one week apart for NMSCs) and who underwent post-treatment assessments over a follow-up period of at least 12 months.

RESULTS

Present case series included a total of 462 patients: 210 patients with AK, 228 subjects with 348 basal cell carcinomas (BCCs), 213 of nodular type (nBCC) and 135 of superficial type (sBCC), 17 patients with Bowen's disease and seven with squamous cell carcinoma. On the whole, following a single session, complete clearance of AK was achieved in 79% of patients at three months and in 68.1% at 12 months. As concerns BCCs, regardless of the clinical type, a complete response was observed in 71% of lesions at three months, with a rate of recurrence at 12 months of 15%. The risk of both initial treatment failure and recurrence was higher for nBCCs than sBCCs. Our results, even if obtained in very few cases, indicate that Bowen's disease is very responsive to MAL-PDT, unlike microinvasive or invasive SCC. Treatment was generally well tolerated.

CONCLUSIONS

Our experience confirms that MAL-PDT is a valid approach to patients with AK, BCC and Bowen's disease, with an acceptable tolerability profile and a very low risk of complications.

Italian position paper on urticaria. Italian Board on Urticaria

The Italian Board on Urticaria has prepared a document focusing on the definition and classification of urticaria, taking into account the recent progress in identifying the causes, eliciting factors, and pathomechanisms of this disease. As urticaria has a profound impact on the quality of life, effective treatment is important. Therefore, specific treatment options for the management of urticaria are evaluated on the basis of the recent literature. Non-sedating H(1) antihistamines are recommended as the first-line treatment as they have proven effective in several randomized double-blind controlled studies. Dosages higher than those recommended may be necessary in some cases. However, additional or alternative therapies may be required for different urticaria subtypes and in view of individual variations in the course of the disease and response to treatment. Immunosuppressive drugs such as corticosteroids are not recommended for long-term treatment due to unavoidable, severe adverse effects.

Antiinflammatory effects of H1-antihistamines: clinical and immunological relevance

Signs supporting antiinflammatory effects of H1-antihistamines were first reported long ago, but their clinical relevance remains controversial, especially with respect to their ability to inhibit the release of histamine and other preformed mediators. Experimental studies have documented that H1-antihistamines may affect several inflammatory events, including chemotaxis and the survival of eosinophils, the expression of adhesion molecules, and the release of chemokines and cytokines from different sources, thus highlighting the potential for a modulation of chronic inflammation and immune responses. Interestingly, a specific inhibitory effect on Th2-type cytokine secretion has been demonstrated for some new generation antihistamines. The mechanisms responsible for the antiinflammatory activity of H1-antihistamines are still unclear, but are presumed to be both receptor-dependent and receptor-independent. Recent findings have indicated the ability of these drugs to down-regulate intracellular signaling pathways, i.e., NF-kappaB. In this article, the current knowledge and novel findings about the antiinflammatory action and mechanisms of H1-antihistamines are briefly reviewed and critically analyzed, from the standpoint of possible clinical implications with special reference to skin disorders.

A Multicenter Open-Label Experience on the Response of Psoriasis to Adalimumab and Effect of Dose Escalation in Non-Responders: The Aphrodite Project

There is much evidence to show the efficacy of adalimumab, a human monoclonal antibody targeting tumour necrosis factor-alpha, in the treatment of plaque psoriasis. In this open-label experience, 147 high-need patients suffering from plaque psoriasis, with a mean Psoriasis Area and Severity Index (PASI) of 18.8, and concomitant psoriatic arthritis (PsA) received subcutaneous injections of 40 mg of adalimumab every other week (EOW). This was actually the dosage regimen recommended for PsA, as the drug had not then been approved for psoriasis at the time of the patients' enrolment. At week 12, an improvement of at least 50% of the PASI (PASI-50) was observed in 111 (77%) patients. Continuation of treatment in responders with adalimumab 40 mg EOW led to a sustained response, with the PASI-50 achieved by 97% of patients in the as-treated analysis at week 24 (PASI-75 in 82% and PASI-90 in 45% out of 109 patients who received EOW injections up to week 24). Thirty subjects who failed to attain the PASI-50 response at week 12 were treated with adalimumab 40 mg every week for a further 12 weeks. At week 24, 80% of these patients obtained a PASI-50 response after dose escalation. Tolerability was good in the majority of patients. Only two patients discontinued treatment because of an adverse event (repeated flu-like episodes and a pleuropericarditis of unknown origin, respectively).

Influence of body mass index, comorbidities and prior systemic therapies on the response of psoriasis to adalimumab: an exploratory analysis from the APHRODITE data

Adalimumab is a fully human monoclonal antibody directed against tumor necrosis factor (TNF)-alpha, which is effective for the treatment of psoriasis and psoriatic arthritis (PsA). The aim of this study is to determine whether the response of psoriasis to adalimumab treatment might be influenced by certain particular factors, such as body mass index (BMI), history of biologic therapy, blood hypertension and metabolic comorbidities. For this reason, an exploratory analysis was conducted on 144 patients with psoriasis and concomitant PsA treated with adalimumab 40 mg every other week, evaluating the influence of such factors on the Psoriasis Area and Severity Index (PASI) response rate at week 12. Our preliminary results suggest that the response rate at week 12, in terms of both PASI-50 and PASI-75, appeared to be independent of the presence of hypertension and/or metabolic comorbidities. The PASI-50 response was observed more frequently in patients with BMI less than 30 as compared to obese patients (79% vs 58%, p = 0.02). Previous use of anti-TNF biologics did not appear to affect per se the rate of responders, although it was associated with a lower PASI-75 rate among responders.

Is there an association between antiphospholipid antibodies and psoriasis?

Ever increasing evidence supports the association between psoriasis and cardiovascular risk. Antiphospholipid antibodies (APAs), which can occur in many autoimmune diseases, are considered prothrombotic and have been associated with atherosclerosis. The aim of this study is to evaluate the prevalence and levels of APAs in psoriasis patients. Fifty patients with moderate to severe plaque psoriasis and 48 healthy subjects were investigated for lupus anticoagulant (LAC) by screening and confirmatory coagulation tests, as well as for antibodies against cardiolipin or beta2-glycoprotein I. Levels of APAs and LAC-related parameters were similar for patients with psoriasis and normal controls (p>0.05). APAs were found in only one psoriatic patient (2%) and in none of the controls. LAC was detected in 2 patients (4%) and in one subject of the control group (2.1%). These results suggest that the prevalence of APAs is not increased in plaque psoriasis as compared to the control group. The increased cardiovascular risk observed in psoriatic patients is therefore likely to be correlated to factors different from APAs.

Efalizumab in moderate-to-severe plaque psoriasis: a retrospective case series analysis from clinical practice

Efalizumab is an anti-CD11a humanized monoclonal antibody which is safe and effective for the treatment of plaque psoriasis. We performed a retrospective analysis on -high-need- patients with moderate-to-severe psoriasis treated with Efalizumab monotherapy for more than 2 years. Chart review of patient records also concerned information about rebound, relapse, and retreatment after temporary interruption, as well as transitioning from Efalizumab to alternative treatments. Of the 52 patients who completed the initial 12 weeks of treatment, 65% attained the PASI-50 response at week 12. A notable improvement of skin lesions on critical sites, such as palmoplantar surfaces or genitals, was also observed. Continuous treatment resulted in a sustained response in the majority of patients, with a PASI-75 response in nearly 88% of those Efalizumab-treated in the long term (week 72 onwards) and a PASI-90 in 77% of patients by weeks 120-132. In general, the treatment was well tolerated, with mild-to-moderate flu-like symptoms as the most frequent adverse events, particularly after the first two doses. Increase of leukocyte and/or lymphocyte counts was the most common laboratory test alteration during treatment, also in the long term. In our case series, Efalizumab was safe and well-tolerated even in patients with relevant comorbidities, including one patient with HBsAg carriage and five patients with latent TB.

Narrow-band UVB phototherapy combined with tacrolimus ointment in vitiligo: a review of 110 patients

BACKGROUND

Narrow-band ultraviolet B (NB-UVB) phototherapy and topical tacrolimus are included among the most innovative approaches to vitiligo.

OBJECTIVE

To evaluate the efficacy and tolerability of combined treatment with NB-UVB and topical tacrolimus in vitiligo.

METHODS

After informed consent, adult patients with chronic (> 1-year duration) stable vitiligo refractory to conventional treatments were enrolled in an open-labelled prospective study. Treatment regimen consists of once-daily application, in the evening, of tacrolimus 0.03% ointment to the lesions of the face, or tacrolimus 0.1% ointment to the vitiligous patches located on other areas. Concomitant NB-UVB phototherapy was performed twice weekly for 16 weeks.

RESULTS

Study population included 110 patients (mean age, 42) with a total of 403 lesions. Within the treatment period, variable repigmentation was evident on more than 70% of lesions. Clinical response (repigmentation more than 50%) was observed in 42% of lesions. Response was strictly dependent on the site, being more frequent for face lesions (73%), followed by limbs (68%) and trunk (53.5%). The therapeutic effect on the extremities and genital areas was quite disappointing. Treatment was well tolerated.

CONCLUSIONS

Our preliminary data suggest that the combination of topical tacrolimus with NB-UVB phototherapy can represent an alternative highly effective approach to refractory vitiligo located on the face, trunk and limbs. Long-term safety data and randomized controlled trials on a large number of patients are required.

Infliximab in recalcitrant severe atopic eczema associated with contact allergy

Infliximab is an anti-tumour necrosis factor (TNF)-alpha chimeric monoclonal antibody which is effective in diseases associated with a T-helper (Th) 1 response, such as rheumatoid arthritis, Crohn's disease and psoriasis. There are sporadic case reports of atopic dermatitis (AD) induced or precipitated by anti-TNF-alpha therapy, which have been attributed to the switch towards Th2-mediated reactions. We report the case of a 30-year-old man with long-standing severe AD associated with contact allergy and poorly responding to conventional treatments. The use of infliximab resulted in a dramatic amelioration of AD lesions and pruritus, persisting at follow-up examinations over a 3-year period. Probably, the unexpected response to infliximab therapy in this case might be due to some peculiar features of AD in our patient (i.e. chronic-continuous course and concomitant contact allergy) which could have been responsible for a more preponderant recruitment of Th1 cells as compared to common forms of AD.

Once-weekly administration of high-dosage Etanercept in patients with plaque psoriasis: results of a pilot experience (power study)

Etanercept is a soluble tumour necrosis factor receptor fusion protein which is approved for the treatment of plaque psoriasis at the dose of either 25mg twice weekly (BIW) or, for the initial 12 weeks, 50mg BIW. Alternative dosing regimens have not been evaluated in psoriasis. In this study, we compare the efficacy and tolerability of two etanercept dosing regimens--50mg BIW and 100mg once weekly (OW)--for 12 weeks in 108 patients with moderate-to-severe recalcitrant psoriasis. Efficacy measures included Psoriasis Area and Severity Index (PASI), severity of pruritus recorded on a visual analogue scale (VAS) and the influence on quality of life assessed by means of Dermatology Life Quality Index (DLQI). Both etanercept regimens caused a significant change in all the efficacy parameters after 4 weeks and 12 weeks, at a comparable rate. At week 12, a PASI improvement of at least 50% from baseline (PASI 50) was achieved by 74% of patients treated with 50mg BIW and 78% of patients treated with 100mg OW. A PASI 75 response was obtained in 54% and 50% of patients treated with 50mg BIW and 100mg OW, respectively. Treatment was well tolerated with similar type and frequency of adverse events between the two groups.

Clobetasol propionate 0·05% in a novel foam formulation is safe and effective in the short-term treatment of patients with delayed pressure urticaria: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Delayed pressure urticaria (DPU) is characterized by the appearance of typical painful skin lesions (weals) after pressure stimulus. Oral corticosteroids are effective treatments but long-term therapy is problematic. A new topical formulation of clobetasol propionate 0.05% in thermophobic foam (CF) (Olux) has recently become available. The foam is easy to apply, with low skin residues.

OBJECTIVES

To evaluate in a double-blind placebo-controlled trial the efficacy, tolerability and safety of CF in the topical treatment of DPU.

METHODS

Twenty-six subjects with a positive history of DPU (13 men, mean age 44 years) were enrolled in a 4-week trial. CF or the corresponding placebo were applied twice daily. Drug application was performed in the most affected areas and in a target area where a standardized pressure challenge test was performed at baseline and at week 4. Efficacy was evaluated by scoring skin lesions regarding erythema, oedema and itching (0, no sign; 4, severe signs) and by calculating the area of the pressure challenge-induced lesion. Safety was evaluated by measuring plasma levels of adrenocorticotropic hormone (ACTH) and cortisol.

RESULTS

CF significantly (P = 0.0001) reduced lesion area by 84% in comparison with baseline values and by 97% in comparison with the placebo group values. Lesion area in the CF group was reduced from 144 cm(2) to 21 cm(2) at the end of the study. No significant differences in lesion area and clinical lesion scores were observed in the placebo group (lesion area 201 cm(2) at baseline; 216 cm(2) after 4 weeks). A significant clinical improvement was observed in all treated skin areas in the CF group. Mean +/- SD erythema score was reduced by CF from 1.8 +/- 0.6 at baseline to 0.6 +/- 0.5 at the end of the treatment (P = 0.001). Similar modifications were observed also for oedema (from 1.6 +/- 0.6 to 0.2 +/- 0.5) and itching score. Nonsignificant modifications of plasma levels of ACTH, cortisol and glucose were observed in both study groups, in comparison with baseline values. No adverse events were recorded during the trial in either treatment group.

CONCLUSIONS

CF is effective, safe, convenient and well tolerated in the short-term treatment of DPU.