Showing papers in "Journal of The European Academy of Dermatology and Venereology in 2012"

Guidelines for treatment of atopic eczema (atopic dermatitis) part I.

Abstract: The existing evidence for treatment of atopic eczema (atopic dermatitis, AE) is evaluated using the national standard Appraisal of Guidelines Research and Evaluation. The consensus process consisted of a nominal group process and a DELPHI procedure. Management of AE must consider the individual symptomatic variability of the disease. Basic therapy is focused on hydrating topical treatment, and avoidance of specific and unspecific provocation factors. Anti-inflammatory treatment based on topical glucocorticosteroids and topical calcineurin inhibitors (TCI) is used for exacerbation management and more recently for proactive therapy in selected cases. Topical corticosteroids remain the mainstay of therapy, but the TCI tacrolimus and pimecrolimus are preferred in certain locations. Systemic immune-suppressive treatment is an option for severe refractory cases. Microbial colonization and superinfection may induce disease exacerbation and can justify additional antimicrobial treatment. Adjuvant therapy includes UV irradiation preferably with UVA1 wavelength or UVB 311 nm. Dietary recommendations should be specific and given only in diagnosed individual food allergy. Allergen-specific immunotherapy to aeroallergens may be useful in selected cases. Stress-induced exacerbations may make psychosomatic counselling recommendable. 'Eczema school' educational programs have been proven to be helpful. Pruritus is targeted with the majority of the recommended therapies, but some patients need additional antipruritic therapies.

European Evidence‐based (S3) Guidelines for the Treatment of Acne

Abstract: Subcommittee Members: Dr. Alexander Nast, Berlin (Germany) Dr. Cristina Oprica, Stockholm (Sweden) Prof. Dr. Brigitte Dreno, Nantes (France) Mrs. Stefanie Rosumeck, Berlin (Germany) Dr. Vincenzo Bettoli, Ferrara (Italy) Prof. Dr. Berthold Rzany, Berlin (Germany) Prof. Dr. Klaus Degitz, Munich (Germany) Dr. Adel Sammain, Berlin (Germany) Mr. Ricardo Erdmann, Berlin (Germany) Dr. Thierry Simonart, Brussels (Belgium) Prof. Dr. Andrew Finlay, Cardiff (United Kingdom) Dr. Niels Kren Veien, Aalborg (Denmark) Prof. Dr. Ruta Ganceviciene, Vilnius (Lithuania) Dr. Maja Vurnek fivkovi , Zagreb (Croatia) Dr. Alison Layton, Harrogate (United Kingdom) Prof. Dr. Christos Zouboulis, Dessau (Germany) Dr. Jose Luis Lopez Estebaranz, Madrid (Spain) Prof. Dr. Falk Ochsendorf, Frankfurt (Germany) Prof. Dr. med. Harald Gollnick, Magdeburg (Germany)

Cytokines, chemokines and growth factors in wound healing

Abstract: In wound healing, a variety of mediators have been identified throughout the years. The mediators discussed here comprise growth factors, cytokines and chemokines. These mediators act via multiple (specific) receptors to facilitate wound closure. As research in the last years has led to many new findings, there is a need to give an overview on what is known, and on what might possibly play a role as a molecular target for future wound therapy. This review aims to keep the reader up to date with selected important and novel findings regarding growth factors, cytokines and chemokines in wound healing.

The concept of psoriasis as a systemic inflammation: implications for disease management

Abstract: Psoriasis is a systemic, immune-mediated disorder, characterized by inflammatory skin and joint manifestations. A range of co-morbidities is associated with psoriasis, including metabolic diseases, such as diabetes, and psychological disorders. Although the systemic nature of psoriasis often remains unrecognized, the inflammatory processes involved may be associated with the development of co-morbidities, which, themselves, have a significant impact on the patient's health and quality of life. The relative risks of myocardial infarction (MI) and stroke are increased in patients with psoriasis compared with the general population. These are especially seen in younger patients with more severe disease, and are believed to contribute to the 3- to 4-year reduction in life expectancy among patients with severe psoriasis. The recent results of large studies indicate that the increased cardiovascular (CV) risk is at least partially attributable to psoriasis and independent of the presence of metabolic co-morbidities. The possible interplay between psoriasis and CV disease is complex. Metabolic diseases such as obesity and diabetes have overlapping genetic predispositions with psoriasis. Both conditions are likely to also interact at a functional level because obesity and the up-regulation of pro-inflammatory mediators in psoriasis appear to influence adipocyte homoeostasis, inducing non-professional immune functions. This may perpetuate psoriatic inflammation, displaying similarities to the immunopathogenesis of atherosclerosis. Finally, the disturbed adipokine profile and inflammation associated with psoriasis enhances insulin resistance, causing subsequent endothelial dysfunction, atherosclerosis and eventual coronary events. The differential contribution of psoriasis and uncontrolled classical CV risk factors to the increased CV risk seen in psoriasis patients is not clear. Successful treatment with methotrexate appears to lower the rates of MI in patients with psoriasis. Tumour necrosis factor-α (TNF-α) inhibitors are known to counteract insulin resistance and emerging studies demonstrate an even higher protective effect of TNF-α antagonist therapy against the development of diabetes or CV co-morbidities in patients. The recent data reviewed here indicate a role for earlier and more appropriate treatment of psoriasis with drugs such as TNF-α antagonists. Such an approach has the potential to significantly improve patient outcomes through the treatment of psoriasis itself and possibly also in protection against co-morbidities.

Carcinogenic risks of Psoralen UV‐A therapy and Narrowband UV‐B therapy in chronic plaque psoriasis: a systematic literature review

Abstract: BACKGROUND: Oral 8-methoxypsoralen-UV-A (PUVA) and narrowband UV-B (NB-UVB or UVB TL-01) are effective and widely used treatments for chronic plaque psoriasis. Although the role of PUVA therapy in skin carcinogenesis in humans with psoriasis has been clearly demonstrated, there is still controversy regarding the risk of skin cancer with NB-UVB. Furthermore, there is no clear evidence about the maximum cumulative number of sessions not to be exceeded in a lifetime. OBJECTIVES: To assess the respective cutaneous carcinogenic risks of PUVA or NB-UVB in psoriasis; to estimate the respective dose-relationship between skin cancers and PUVA or NB-UVB; to estimate a maximum number of sessions for PUVA or NB-UVB not to be exceeded in a lifetime. METHODS: A systematic literature search was carried out in Medline, Embase and Cochrane Library databases from1980 to December 2010 in English and French, with the keywords 'Psoriasis' AND 'UVB therapy' AND 'UVA therapy' AND 'cancer' AND 'skin' OR 'neoplasm' OR 'cutaneous carcinoma' OR 'melanoma'. RESULTS: Of 243 identified references, 49 published studies were included. Most of them (45/49) concerned PUVA therapy, with 41 assessing the risk of non-melanoma skin cancers (NMSC) following PUVA. All publications referring to the US prospective PUVA follow-up study revealed an increased risk of NMSC with the following characteristics: risk most pronounced for squamous cell carcinomas developing even with low exposures and increasing linearly with the number of sessions, tumors occurring also on non-exposed skin including invasive penile tumors, risk persisting after cessation of treatment. An increased risk of basal cell carcinomas was observed in patients receiving more than hundred PUVA sessions. The four prospective European studies selected in our review and most of the pre-1990 European and US retrospective studies failed to find a link between exposure to PUVA and skin cancer. Only the most recent cohorts, including three large long-term retrospective European studies comparing records with their respective national cancer registries reported on an independent increased risk of NMSC with PUVA, The risk was lower as compared to the US prospective PUVA follow-up study. Six studies assessed the risk of melanoma following PUVA therapy: two of the three US publications coming from the same PUVA prospective follow-up study revealed an increased risk with more than doubled incidence of both invasive and in situ melanoma among patients exposed to at least 200 PUVA treatments compared with patients exposed to lower doses, whereas the three retrospectives European studies, comparing the incidence of melanoma in PUVA users with national cancer registers, did not find any increased risk of melanoma. No increased risk of skin cancer was evidenced in the four studies specifically assessing the potential carcinogenic risk of NB-UVB. CONCLUSION: There is an increased risk of skin cancer following PUVA, shown by both US and European studies. The greater risk measured by the US studies may be at least partly explained by high UVA dose exposure and the lighter phototypes of the treated patients. The lack of prospective studies in psoriasis patients treated with NB-UVB constitutes a barrier to the robust assessment of carcinogenic risk of this phototherapy technique.

Daylight photodynamic therapy for actinic keratosis: an international consensus: International Society for Photodynamic Therapy in Dermatology.

Abstract: Photodynamic therapy (PDT) is an attractive therapy for non-melanoma skin cancers including actinic keratoses (AKs) because it allows treatment of large areas; it has a high response rate and results in an excellent cosmesis. However, conventional PDT for AKs is associated with inconveniently long clinic visits and discomfort during therapy. In this article, we critically review daylight-mediated PDT, which is a simpler and more tolerable treatment procedure for PDT. We review the effective light dose, efficacy and safety, the need for prior application of sunscreen, and potential clinical scope of daylight-PDT. Three randomized controlled studies have shown that daylight-mediated PDT is an effective treatment of thin AKs. Daylight-mediated PDT is nearly pain-free and more convenient for both the clinics and patients. Daylight-mediated PDT is especially suited for patients with large field-cancerized areas, which can easily be exposed to daylight. Further investigations are necessary to determine at which time of the year and in which weather conditions daylight-mediated PDT will be possible in different geographical locations.

Adherence to topical treatment in psoriasis: a systematic literature review

Abstract: Background Treatment adherence has been recognized as an important issue in the management of chronic diseases such as psoriasis. Objective The aim of this work was to analyse data about topical treatment adherence in psoriasis. Methods Systematic literature review (62 references) between 1980 and 2011 (database: PubMed, Embase and Cochrane; Mesh keywords: Patient Compliance [Mesh] OR Medication Adherence [Mesh] AND Psoriasis [Mesh]; limits: date of publication >1980, humans subjects, written in French or English, aged ≥19 years). Two parameters were evaluated: (i) the ratio of number of product applications performed vs. number of applications expected according to physician recommendations, (ii) the ratio of amount of product used vs. amount of product prescribed. Results A total of 22 studies were selected. Nine studies reported on the frequency of topical treatment application in a real world setting. Five studies showed a frequency of applications varying between 50% and 60% of those expected. Because of the high variability in medication adherence assessment methods, the data could not be combined. Twelve articles reported on the frequency of topical treatment application in randomized controlled trials with adherence varying between 55% and 100%. Concerning the amount of product use, four studies showed patients applied between 35% and 72% of the recommended dose during a treatment period of 14 days to 8 weeks. The most frequently mentioned reasons for non-adherence to topical treatment were low efficacy, time consumption and poor cosmetic characteristics of topical agents. Patients experiencing adherence issues were significant younger, were men, had younger age at onset of psoriasis and had a higher self-assessed severity. To improve adherence, the following strategies were suggested: to give patients information about psoriasis, to recognize social impact, to give written instructions for use such as a care plan, to explain side effects of topical therapies, to choose treatment and its cosmetic properties in agreement with the patient. Conclusions Literature data about topical treatment adherence are heterogeneous and scarce. They confirm the limited topical treatment adherence in psoriasis in real life, much lower than what is reported in randomized controlled trials. Therapeutic education and clear instructions on the use of topical agents are necessary to improve adherence. Studies are needed to identify predictors of limited adherence and to identify interventions improving adherence to topical medications in psoriasis.

Extracellular matrix molecules implicated in hypertrophic and keloid scarring

Abstract: Tissue regeneration repairs the fabric of the skin to maintain homeostasis after injury. The expression and proliferation of extracellular matrix (ECM) molecules in the dermis, mediated by a range of growth factors and cytokines, is a fundamental element of wound repair. Previous work focused on how these complex molecular mechanisms relate to the formation of raised dermal scars, including keloid and hypertrophic scars, characterized by excessive deposition of ECM molecules. However, the mechanisms in the wound repair pathway which lead to the differential expression and organization of ECM molecules observed in different types of scar tissue are not fully understood. To summarize what is known about the expression and composition of ECM molecules in abnormal scarring, an extensive search of the literature was conducted, focusing on keywords connected to skin scarring, hypertrophic scars and keloid disease. The transcription and translation of collagen I and III, fibronectin, laminin, periostin and tenascin are all increased in raised dermal scar tissue. However, hyaluronic acid, dermatopontin and decorin are decreased, and the expression and localisation of fibrillin and elastin fibres in the dermis are altered compared with normal skin and scars. Recent whole genome profiling and proteomic studies have led to the identification of regulatory elements with different expression profiles in hypertrophic and keloid tissue. If the mechanisms of raised dermal scar formation are to be elucidated and effective therapeutic treatments developed, an integrated approach to research is required, focussing on the interactions between ECM molecules, regulatory elements and pathways.

Clinical parameters in male genital lichen sclerosus: a case series of 329 patients

Abstract: Background The dermatological aspects of male genital lichen sclerosus (MGLSc) have not received much prominence in the literature. Sexual morbidity appears under-appreciated, the role of histology is unclear, the relative places of topical medical treatment and circumcision are not established, the prognosis for sexual function, urinary function and penis cancer is uncertain and the pathogenesis has not been specifically studied although autoimmunity (as in women) and HPV infection have been mooted. Objective To illuminate the above by analysing the clinical parameters of a large series of patients with MGLSc. Methods A total of 329 patients with a clinical diagnosis of MGLSc were identified retrospectively from a dermatology-centred multidisciplinary setting. Their clinical and histopathological features and outcomes have been abstracted from the records and analysed by simple descriptive statistics. Results The collation and analysis of clinical data derived from the largest series of men with MGLSc ever studied from a dermatological perspective has been achieved. These data allow the conclusions below to be drawn. Conclusions MGLSc is unequivocally a disease of the uncircumcised male; the adult peak is late in the fourth decade; dyspareunia is a common presenting complaint; non-specific histology requires careful interpretation; most men are either cured by topical treatment with ultrapotent steroid (50–60%) or by circumcision (>75%); effective and definitive management appears to abrogate the risk of developing penile squamous cell carcinoma; urinary contact is implicated in the pathogenesis of MGLSc; HPV infection and autoimmunity seem unimportant.

Papulopustular rosacea, skin immunity and Demodex: pityriasis folliculorum as a missing link.

Abstract: Papulopustular rosacea (PPR) is a common facial skin disease, characterized by erythema, telangiectasia, papules and pustules. Its physiopathology is still being discussed, but recently several molecular features of its inflammatory process have been identified: an overproduction of Toll-Like receptors 2, of a serine protease, and of abnormal forms of cathelicidin. The two factors which stimulate the Toll-like receptors to induce cathelicidin expression are skin infection and cutaneous barrier disruption: these two conditions are, at least theoretically, fulfilled by Demodex, which is present in high density in PPR and creates epithelial breaches by eating cells. So, the major pathogenic mechanisms of Demodex and its role in PPR are reviewed here in the context of these recent discoveries. In this review, the inflammatory process of PPR appears to be a consequence of the proliferation of Demodex, and strongly supports the hypothesis that: (1) in the first stage a specific (innate or acquired) immune defect against Demodex allows the proliferation of the mite; (2) in the second stage, probably when some mites penetrate into the dermis, the immune system is suddenly stimulated and gives rise to an exaggerated immune response against the Demodex, resulting in the papules and the pustules of the rosacea. In this context, it would be very interesting to study the immune molecular features of this first stage, named "pityriasis folliculorum", where the Demodex proliferate profusely with no, or a low immune reaction from the host: this entity appears to be a missing link in the understanding of rosacea.

Drug-induced bullous pemphigoid in diabetes mellitus patients receiving dipeptidyl peptidase-IV inhibitors plus metformin.

Abstract: Background Preclinical data and reports of adverse skin reactions in patients treated with dipeptidyl peptidase-IV inhibitors (gliptins) have increased awareness towards skin-targeting side-effects of these anti-hyperglycaemic drugs Bullous pemphigoid (BP), sometimes drug-induced, is the most commonly acquired autoimmune blistering dermatosis in western countries, typically a disease of the elderly people with significant morbidity and excess mortality Objective To report the development of BP in five diabetics under gliptin (4 vildagliptin, 1 sitagliptin) plus metformin in fixed-dose drug combinations Case reports From March to August 2010 six out of nine newly diagnosed BP patients in our Department were type 2 diabetics Five of them were on gliptin plus metformin (three different trade preparations) for 2–13 months prior to BP onset In all cases BP was controlled after withdrawal of the suspected medication and relatively mild therapeutic interventions In two cases the eliciting role of the preceding treatment is supported by evidence at the level ‘probable/likely’ according to the WHO-UMC algorithm Conclusions This is the first report of drug-induced BP as a group adverse event of the gliptins plus metformin combination therapy for glycaemia control in type 2 diabetes mellitus patients

Experience with ustekinumab for the treatment of moderate to severe Hidradenitis suppurativa

Abstract: Background Hidradenitis suppurativa (HS) is a severe chronic inflammatory follicular disease characterized by nodules and abscesses affecting apocrine gland-bearing regions. HS is not well-controlled with conventional medical therapies such as topical therapy, oral antibiotics and retinoids, however, abrogation of tumour necrosis factor-α (TNF-α) function has proven effective in some patients. Objective To assess the safety and efficacy of the interleukin-12/23 inhibitor, ustekinumab for treatment of HS in three patients with moderate-severe disease. Methods The subjects received 3–45 mg subcutaneous injections of ustekinumab at 0, 1 and 4 months. Improvement was assessed by the dermatology life quality index (DLQI), visual analogue scale of pain (VAS) and physician’s global assessment (PGA) at each monthly visit. Results Prior to treatment, subjects had moderate-severe HS (Hurley stage II-III) with a DLQI score between 8 and 12. At 6 months, one patient showed complete disease remission, while a 25–49% improvement was seen in a second patient and no change in a third. A moderate but statistically significant relationship was observed between VAS and DLQI scores (r = 0.75; P < 0.01). Conclusion Ustekinumab may provide a safe and effective new treatment strategy for HS in some patients. Interleukin 12/23 inhibition is a potential therapeutic option for patients in which other therapies prove ineffective.

Ultrasound detection and identification of cosmetic fillers in the skin

Abstract: Background While the incidence of cosmetic filler injections is rising world-wide, neither exact details of the procedure nor the agent used are always reported or remembered by the patients. Thus, although complications are reportedly rare, availability of a precise diagnostic tool to detect cutaneous filler deposits could help clarify the association between the procedure and the underlying pathology. Objectives The aim of this study was to evaluate cutaneous sonography in the detection and identification of cosmetic fillers deposits and, describe dermatological abnormalities found associated with the presence of those agents. Methods We used ultrasound in a porcine skin model to determine the sonographic characteristics of commonly available filler agents, and subsequently applied the analysis to detect and identify cosmetic fillers among patients referred for skin disorders. Results Fillers are recognizable on ultrasound and generate different patterns of echogenicity and posterior acoustic artefacts. Cosmetic fillers were identified in 118 dermatological patients; most commonly hyaluronic acid among degradable agents and silicone oil among non-degradable. Fillers deposits were loosely scattered throughout the subcutaneous tissue, with occasional infiltration of local muscles and loco-regional lymph nodes. Accompanying dermatopathies were represented by highly localized inflammatory processes unresponsive to conventional treatment, morphea-like reactions, necrosis of fatty tissue and epidermal cysts; in the case of non-degradable agents, the associated dermatopathies were transient, resolving upon disappearance of the filler. Conclusions Cosmetic filler agents may be detected and identified during routine ultrasound of dermatological lesions; the latter appear to be pathologically related to the cosmetic procedure.

Porokeratosis: present concepts.

Abstract: Porokeratosis represents a group of disorders of epidermal keratinization which are characterized by the histopathological feature of the cornoid lamella, a column of tightly fitted parakeratotic cells. The aetiology of porokeratosis is still unclear. This review summarizes the currently available data on the pathophysiology of this condition and discusses the clinical variants and the currently available therapies.

Primary focal hyperhidrosis: current treatment options and a step-by-step approach.

Abstract: Primary focal hyperhidrosis is a common disorder for which treatment is often a therapeutic challenge. A systematic review of current literature on the various treatment modalities for primary focal hyperhidrosis was performed and a step-by-step approach for the different types of primary focal hyperhidrosis (axillary, palmar, plantar and craniofacial) was established. Non-surgical treatments (aluminium salts, local and systemic anticholinergics, botulinum toxin A (BTX-A) injections and iontophoresis) are adequately supported by the current literature. More invasive surgical procedures (suction curettage and sympathetic denervation) have also been extensively investigated, and can offer a more definitive solution for cases of hyperhidrosis that are unresponsive to non-surgical treatments. There is no consensus on specific techniques for sympathetic denervation, and this issue should be further examined by meta-analysis. There are numerous treatment options available to improve the quality of life (QOL) of the hyperhidrosis patient. In practice, however, the challenge for the dermatologist remains to evaluate the severity of hyperhidrosis to achieve the best therapeutic outcome, this can be done most effectively using the Hyperhidrosis Disease Severity Scale (HDSS).

Female acne - a different subtype of teenager acne?

Abstract: Above all, acne is considered an adolescent affection. However, in literature as in daily life, female acne is becoming more and more common. According to the articles that cover this subject, the prevalence is estimated from 40% to 50%. The objective of our work was to make an overview of new data about female acne at the clinical and epidemiological level to be precise if female acne has to be considered as a subtype of acne different from teenager acne. This review shows that the most frequently recognized age when speaking about female acne is 25 years old. Most commonly it is a light to moderate acne that mainly affects the face. Two clinical forms can be identified: an inflammatory form, the most frequent, made up of papulo-pustules and nodules on the lower part of the face and a retentional form made up of blackheads and micro cysts with hyperseborrhoea. Concerning its evolution, it is characterized by three subtypes of which two are predominant: the most frequent form called 'continue acne' from adolescence to adult age and the less frequent form called 'late onset acne' that starts after 25 years of age. On a physiopathological level two main hypotheses can be proposed. Specific global assessment and therapeutic algorithm would be necessary for female acne, which in addition, in future would have to be considered separately from teenagers for the evaluation of a new drug.

Randomized controlled trial comparing treatment outcome of two compression bandaging systems and standard care without compression in patients with venous leg ulcers.

Abstract: Background In Hong Kong, at the time of the study, compression treatment was not considered usual care for venous leg ulcer patients Aim This randomized controlled trial compared quality of life (QOL) aspects in venous leg ulcer patients of over 55-years of age, of short-stretch compression (SSB), four-layer compression bandaging (4LB) and usual care (UC) (moist wound healing dressing, no compression) Method Study period was 24-weeks, the primary outcome was the patient functional status, disease-specific and generic health-related QOL measures and ulcer healing rates, comparing week 1 vs week 24 (end) results Assessments included photogrammetry, Brief Pain Inventory, SF-12 Health Survey, Charing Cross Venous Ulcer Questionnaire and Frenchay Activity Index Data analysis was performed using, where appropriate; Kaplan Meier and log rank chi-square and the repeated measures analysis of variance test Results A total of 321 patients participated in the study, 45 (14%) withdrew for various reasons Compression bandaging in both groups significantly reduced pain (P < 00001) and improved functional status and QOL Healing rate at 24 weeks for both compression groups was significant (P < 0001); for SSB this was 720% (77/107) vs 673% in the 4LB group (72/107) and 290% (31/107) with usual care The reduction in ulcer area from weeks 12 to 24 was significant only for SSB (P < 0047) Conclusion Compression was shown to be feasible for elderly community care patients in Hong Kong and is currently implemented as part of standard venous leg ulcer treatment

Assessment methods for the evaluation of vitiligo.

Abstract: There is no standardized method for assessing vitiligo. In this article, we review the literature from 1981 to 2011 on different vitiligo assessment methods. We aim to classify the techniques available for vitiligo assessment as subjective, semi-objective or objective; microscopic or macroscopic; and as based on morphometry or colorimetry. Macroscopic morphological measurements include visual assessment, photography in natural or ultraviolet light, photography with computerized image analysis and tristimulus colorimetry or spectrophotometry. Non-invasive micromorphological methods include confocal laser microscopy (CLM). Subjective methods include clinical evaluation by a dermatologist and a vitiligo disease activity score. Semi-objective methods include the Vitiligo Area Scoring Index (VASI) and point-counting methods. Objective methods include software-based image analysis, tristimulus colorimetry, spectrophotometry and CLM. Morphometry is the measurement of the vitiliginous surface area, whereas colorimetry quantitatively analyses skin colour changes caused by erythema or pigment. Most methods involve morphometry, except for the chromameter method, which assesses colorimetry. Some image analysis software programs can assess both morphometry and colorimetry. The details of these programs (Corel Draw, Image Pro Plus, AutoCad and Photoshop) are discussed in the review. Reflectance confocal microscopy provides real-time images and has great potential for the non-invasive assessment of pigmentary lesions. In conclusion, there is no single best method for assessing vitiligo. This review revealed that VASI, the rule of nine and Wood’s lamp are likely to be the best techniques available for assessing the degree of pigmentary lesions and measuring the extent and progression of vitiligo in the clinic and in clinical trials.

Photodynamic therapy for skin field cancerization: an international consensus. International Society for Photodynamic Therapy in Dermatology.

Abstract: Field cancerization is a term that describes the presence of genetic abnormalities in a tissue chronically exposed to a carcinogen. These abnormalities are responsible for the presence of multilocular clinical and sub-clinical cancerous lesions that explains the increased risks of multiple cancers in this area. With respect to the skin, this term is used to define the presence of multiple non-melanoma skin cancer, its precursors, actinic keratoses and dysplastic keratinocytes in sun exposed areas. The multiplicity of the lesions and the extent of the area influence the treatment decision. Providing at least equivalent efficacy and tolerability, field directed therapies are therefore often more worthwhile than lesion targeted approaches. Photodynamic therapy (PDT) with its selective sensitization and destruction of diseased tissue is one ideal form of therapy for this indication. In the following paper the use of PDT for the treatment of field cancerized skin is reviewed and recommendations are given for its use.

Bacterial skin and soft tissue infections: review of the epidemiology, microbiology, aetiopathogenesis and treatment: a collaboration between dermatologists and infectivologists.

Abstract: Bacterial skin and soft tissues infections (SSTI) often determine acute disease and frequent emergency recovering, and they are one of the most common causes of infection among groups of different ages. Given the variable presentation of SSTI, a thorough assessment of their incidence and prevalence is difficult. The presence of patient-related (local or systemic) or environmental risk factors, along with the emergence of multi-drug resistant pathogens, can promote SSTI. These infections may present with a wide spectrum of clinical features and different severity, and can be classified according to various criteria. Many bacterial species can cause SSTI, but Gram-positive bacteria are the most frequently isolated, with a predominance of Staphylococcus aureus and Streptococcus pyogenes. The diagnosis of SSTI requires an extended clinical history, a thorough physical examination and a high index of suspicion. Early diagnosis is particularly important in complicated infections, which often require laboratory studies, diagnostic imaging and surgical exploration. SSTI management should conform to the epidemiology, the aetiology, the severity and the depth of the infection. Topical, oral or systemic antimicrobial therapy and drainage or debridement could be necessary, along with treatment of a significant underlying disease. This review discusses the epidemiology, the pathogenesis and the classification of bacterial SSTI, describes their associated risk factors and their clinical presentations. The authors provide a rational diagnostic and therapeutic approach to SSTI in respect of antibiotic resistance and currently available antimicrobial agents.

Dermoscopy guided scalp biopsy in cicatricial alopecia.

Abstract: Background Scalp biopsies are crucial for the diagnosis of cicatricial alopecia. However, the pathologic interpretation may not be diagnostic if biopsy is not obtained from the correct site. This is particularly relevant for cicatricial alopecia as the disease may be focal and disease activity difficult to appreciate by the naked eye. Objective To report a new simple technique to select the optimal biopsy site in cicatricial alopecia. Methods In the last 2 years we performed dermoscopy guided scalp biopsies using handled dermatoscopes in 80 patients with different forms of cicatricial alopecia. Biopsy site was selected based on presence of the following dermatoscopic features: perifollicular concentric white scales in lichen planopilaris, frontal fibrosing alopecia (FFA) and discoid lupus erythematosus (DLE); hair tufts in folliculitis decalvans, hairs surrounded by a peripilar grey-white halo in central centrifugal cicatricial alopecia and follicular red dots or keratotic plugs in DLE. Results The dermoscopy guided biopsies yielded a definitive pathological diagnosis in 95% of the cases. Comment The advantage of this method is that it is a fast, precise way to identify even individually affected follicles in early or focal cicatricial alopecia. It also allows for the morphologic characterization of particular follicular structures.

Skin signs in diabetes mellitus

Abstract: Diabetes mellitus is the most common endocrine disorder with continuously increasing prevalence. Blood vessels, nerves, eyes, kidneys and skin are affected, which causes both an enormous financial burden and a reduced quality of life of the affected patients. Long-standing diabetes may impair skin homeostasis resulting in skin manifestations in at least one third of all diabetics. The skin involvement may be the first presenting sign of diabetes, thus the respective skin signs should lead to diabetes focused diagnostic. Besides, the skin signs may be considered as a marker for the course of the disease or for the success of therapeutic interventions.

Efficacy of psoralen UV-A therapy vs. narrowband UV-B therapy in chronic plaque psoriasis: a systematic literature review.

Abstract: BACKGROUND: Oral 8-methoxypsoralen-UV-A (PUVA) and Narrowband UV-B (NB-UVB or UVB TL-01) are well established treatments for chronic plaque psoriasis but there is limited evidence regarding their respective efficacy. OBJECTIVES: To prepare for evidence-based recommendations concerning the practical use of oral 8-methoxypsoralen-UV-A and Narrowband UV-B in psoriasis, a systematic review to assess respective response rates, remission duration and predictive factors of efficacy was performed. METHODS: A systematic search was carried out in PubMed, Cochrane and Embase databases, using the key words 'Psoriasis', 'UVB therapy', 'UVA therapy' for the period from 1980 to December 2010. RESULTS: The initial literature search identified 773 articles. The final selection included 29 randomized controlled trials: 18 were about the efficacy of PUVA, eight about the efficacy of NB-UVB and three directly compared PUVA vs. NB-UVB. The response rate defined by 75% or more improvement in PASI was 80% with PUVA vs. 70% with NB-UVB. The meta-analysis of the three comparative studies found a higher probability of remission at 6 months with PUVA than with NB-UVB [OR = 2.73 (95% CI 1.19-6.27), P = 0.02]. The choice of initial dose, according to skin type, the minimal erythemal dose or minimal phototoxic dose, incremental regimen and periodicity of the sessions did not appear to be predictive factors of efficacy for PUVA or NB-UVB. Despite methodological limitations in trials, the number of sessions needed for psoriasis clearance appeared to be lower with PUVA than with NB-UVB (approx. 17 vs. 25, respectively). CONCLUSION: PUVA and NB-UVB are both effective therapies in treatment of psoriasis. Our results suggest that compared with NB-UVB, PUVA tends to clear psoriasis more reliably, with fewer sessions, and provides with longer lasting clearance. However, the long-term safety of PUVA, especially its cutaneous carcinogenic risk, and the easier administration procedure often lead dermatologists to prefer NB-UVB as first line phototherapy treatment in plaque type psoriasis.

Treatment of plaque-type psoriasis with oral CF101: data from an exploratory randomized phase 2 clinical trial

Abstract: Aims CF101 demonstrated a marked anti-inflammatory effect in Phase 2 studies conducted in patients with rheumatoid arthritis and dry eye syndrome. The aim of this study was to evaluate the safety and efficacy of CF101 for the treatment of patients with moderate to severe plaque-type psoriasis. Materials and methods This was a phase 2, multicentre, randomized, double-blind, dose-ranging, placebocontrolled study. Seventy five patients with moderate to severe plaque-type psoriasis were enrolled, randomized and treated with CF101 (1, 2, or 4 mg) or placebo administered orally twice daily for 12 weeks. Safety and change from base line of Psoriasis Area and Severity Index (PASI) score and physician’s global assessment (PGA) score over 12 weeks. Results In the 2 mg CF101-treated group, a progressive improvement in the mean change from baseline in the PASI score vs. placebo throughout the study period was observed, with a statistically significant difference on weeks 8 and 12 (P = 0.047; P = 0.031, respectively). In this group, 35.3% of the patients achieved PASI ‡50 response, and 23.5% of the patients achieved a PGA score of 0 or 1. CF101 was safe and well tolerated. Conclusions CF101 was well tolerated and demonstrated clear evidence of efficacy in patients with moderate to severe plaque psoriasis.

Nail lichen planus: epidemiological, clinical, pathological, therapeutic and prognosis study of 67 cases.

Abstract: Background Lichen planus limited to the nail is uncommon, and information about its long-term prognosis is lacking. Objectives We attempted to review the epidemiological, clinical and histological features, the response to treatment and the follow-up of a large series of patients with nail lichen planus (NLP). Methods We searched for the records of all patients with a clinical and histopathological diagnosis of isolated NLP apart from January 1997 to December 2008. The patients presented during this period and followed until December 2009 in the consultation for nail disorder were reviewed in detail. Results Data on 67 patients were collected, with an average age of 47 years (6–78 years). A male preponderance was observed (64%). The mean duration of the disease was about 38 months. Fingernails were the site of involvement in 94% of cases. Matrix involvement was observed in 91% of cases. A total of 120 specimen’s biopsy were taken and was contributory in 90% of cases. Two specimens biopsy were practiced in 70.15% of patients. Systemic corticosteroids were used in 46 patients, and associated in 20 cases to intralesional corticosteroids. Conclusions Our findings indicate that if NLP is correctly diagnosed and appropriately treated. Nail biopsy is proven to be a relatively simple, safe and useful procedure with a minimal scarring risk. Long-term observation indicates that the prognosis of NLP is poor with high rate of relapses, with permanent damage to the nail unit.

Evidence-based recommendations on topical treatment and phototherapy of psoriasis: systematic review and expert opinion of a panel of dermatologists

Abstract: Background Although topical treatments and phototherapy are available for more than 40 years, there is a paucity of evidence-based recommendations regarding their use. Objectives The aim of this work was to develop evidence-based recommendations on topical treatments and phototherapy in psoriasis for daily clinical use. Methods A scientific committee selected clinically relevant questions on efficacy and safety of topical agents and phototherapy in psoriasis. This selection was made using the Delphi method. A systematic literature search was performed in Medline, Embase and the Cochrane Library. The articles selected for analysis were reviewed and the level of evidence was appraised according to the Oxford Levels of Evidence. An Expert consensus meeting took place in June 2011, including 42 dermatologists. Recommendations for use of topical treatments and phototherapy were made during interactive workshops where the evidence was presented and discussed. Agreement among participants was assessed on a 10-point scale. The participants systematically assessed the impact of the recommendations on clinical practice. Results A total of 3555 references were identified, among which 312 articles were included in the systematic reviews. Three recommendations were issued on phototherapy including both PUVA and narrow-band UVB. The recommendations related to administration schedule, clearance rate and risk of side-effects. The mean agreement between participants was good varying from 8.5 to 9.5. Six recommendations were issued on topical treatments focusing on administration schedule, clearance rate, risk of side-effects, cost-effectiveness and measures to improve treatment adherence. The mean agreement between participants varied from 7.3 to 9.9. Conclusions These recommendations for the use of topical agents and phototherapy in psoriasis are evidence-based and supported by a panel of dermatologists. The next step will be to disseminate these recommendations and assess the opinion of physicians who were not involved in generating the recommendations.

Prevalence, severity and clinical features of psoriasis in fingernails and toenails in adult patients: Italian experience.

Abstract: Background Psoriasis is a chronic inflammatory skin disease affecting 2.0–6.5% of the European population. Although the most striking clinical features of psoriasis involve the skin, other organs including nails and joints may be affected in a substantial proportion of patients. Literature reports nail involvement in 10–56% of psoriatic patients, with common physical and social impairment. However, the precise prevalence of specific clinical features of nail psoriasis is somewhat under-reported. Objectives Our cross-sectional study aimed at describing the prevalence and the clinical features of nail involvement in adult psoriatic patients in a psoriasis referral centre in northern Italy. Methods A total of 178 (124 men, 54 women) consecutive adult patients (≥18 years old) with psoriasis were included. Psoriasis Area and Severity Index (PASI) and Nail Psoriasis Severity Index (NAPSI) scores were calculated for each patient. Relevant medical history was recorded. Results Nail involvement was present in 137 (99 men, 38 women) patients (76.9%). The most common nail abnormality was onycholysis, followed by crumbling, subungual hyperkeratosis, pitting and discoloration. Pitting and onycholysis were the most prevalent patterns observed in fingernails, whereas onycholysis and crumbling were the most frequent changes detected in toenails. The most frequently and severely affected nails were the fourth fingernail and the first toenail. The average PASI score was higher in individuals with nail involvement (12.0 vs. 8.7, P = 0.06). Nail changes were present in 85.7% of patients with psoriatic arthritis. Conclusions Our study confirms that nail involvement may be overlooked in psoriasis patients. Different psoriatic patterns in the nail affect specific digits more frequently.

Psoriasis and hypertension: a case-control study

Abstract: Background Several studies stated that patient with psoriasis carried an increased risk of psoriasis but some studies did not demonstrate this association. Objectives The aim of this study was to evaluate the prevalence of hypertension in psoriasis based on a sample of Spanish population. Methods This was a hospital-based case-control study involving 661 psoriatic patients (cases) and 661 control matched by gender and age. Meta-analysis of the previous studies was made. Results The prevalence of hypertension was significantly higher in psoriasis patients than controls (30.3%, 21.3%, respectively, P < 0.001). In a multivariate analysis, hypertension was associated with psoriasis after controlling for age, gender, diabetes, obesity and smoking (OR = 1.44, 95% confidence interval: 1.07–1.94). Conclusion The results of this study support the association between psoriasis and hypertension.

Safety results from a pooled analysis of randomized, controlled phase II and III clinical trials and interim data from an open‐label extension trial of the interleukin‐12/23 monoclonal antibody, briakinumab, in moderate to severe psoriasis

Abstract: Background Anti-interleukin-12/23 treatment (anti-IL-12/23) has recently demonstrated significant efficacy for moderate to severe psoriasis, yet potential safety signals warrant further investigation. Objectives Expand safety findings for the anti-IL-12/23, briakinumab, beyond individual phase II and III clinical trials. Methods Safety data pooled from five phase II and III clinical trials (parent studies) and an open-label extension study (OLE), through 22 October 2010; patients with ≥1 dose of briakinumab in a parent study or the OLE are included. All parent study briakinumab treatment groups were combined with the OLE population, which received 100-mg briakinumab every 4 weeks. Adverse events (AEs) were collected from the first dose of briakinumab, whether in a parent study or the OLE, through 45 days post-last dose. Results Two thousand five hundred and twenty patients (4704 patient-years drug exposure) received ≥1 dose of briakinumab during the interim period: 5.6% withdrew due to AEs. Serious infections occurred in 1.3% and malignancies in 2.6% (including 1.0% basal cell carcinoma, 0.8% squamous cell carcinoma). Twenty-seven major adverse cardiovascular events (MACE) occurred, seven in one parent study and 20 in the OLE (incidence = 0.57 events/100 PY). Four cardiovascular risk factors were retrospectively found to be significant predictors for MACE during briakinumab exposure: history of cardiovascular disease, diabetes, body mass index (≥30) and baseline blood pressure (systolic ≥140 or diastolic ≥90). Conclusions Pooled briakinumab safety results from five parent studies and an OLE suggest increased rates of infections, malignancies and MACE, and that patients receiving anti-IL-12/23 treatment for moderate to severe psoriasis should be monitored for these potential safety signals.

Acute-phase response in chronic urticaria

Abstract: The patterns of acute-phase response (APR) biomarkers differ upon various inflammatory conditions. Little information is available on the systemic inflammatory response in urticaria/angio-oedema. It has been shown that concentrations of circulating APR biomarkers, IL-6 and C-reactive protein (CRP), are elevated more in severe chronic urticaria (CU) than in patients showing milder urticarial symptoms. It is not clear whether the increase of IL-6 and CRP is merely an epiphenomenon or may contribute to the pathogenesis of CU. It is tempting to speculate that mediators of APR may enhance urticarial inflammation. In addition, there is some association between APR and activation of coagulation/fibrinolysis in CU. It is well known that even slight elevation in CRP baseline concentration is enough to produce significant increase in cardiovascular risk. In this light, one should ask whether CU patients, in particular those showing stronger systemic inflammatory response and long-lasting course are more vulnerable to the cardiovascular events. Apart from highly troublesome symptoms and low quality of life, CU may then involve some remote, serious systemic consequences. Taken together, CU can be identified as a mast cell- and basophil-dependent inflammatory disorder of the skin, which is accompanied by APR. Characterization of APR in CU may appear essential for an insight into the activity of this disease and for assessment of the inflammation degree. Moreover, measurement of these biomarkers might be particularly relevant while assessing CU patients demanding an anti-inflammatory or immunosuppressive therapy. This review summarizes information regarding APR in the course of urticaria/angio-oedema.