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Background: Acquired perforating dermatoses (APDs) are characterized by transepidermal elimination of skin materials. Altered glycation of dermal components may be involved in pathogenesis., Aim: To assess whether patients affected by APDs have increased levels of cutaneous advanced glycation end-products (AGEs)., Methods: A cross-sectional controlled study involving a total of 109 patients was conducted, enrolling 29 patients consecutively diagnosed with primary APDs [reactive perforating collagenosis (RPC), elastosis perforans serpiginosa (EPS), perforating folliculitis (PF) and Kyrle disease (KD)], 40 age- and sex-matched healthy controls (HCs) and 40 patients with mild atopic dermatitis (AD). The levels of cutaneous AGEs were measured using a validated fluorescence technique., Results: The median skin autofluorescence value in patients with APDs was significantly higher [2.7 arbitrary units (AU), interquartile range (IQR) 1.9-3.9 AU] compared with HCs (1.8 AU, IQR 1.6-2.3 AU; P < 0.001) and patients with AD (2.1 AU, IQR 1.9-2.3 AU; P = 0.01). Median values were 3.5 AU (IQR 2.7-4.6 AU) for RPC, 1.83.5 AU (1.4-2.4 AU) for EPS, 3.1 AU (2.4-4.4 AU) for PF and 2.6 AU (2.3-3.1 AU) for KD., Conclusions: Our results may suggest a possible physiopathological role of AGEs in the transepidermal elimination mechanisms involved in certain APDs., (© 2021 British Association of Dermatologists.)

On 11 March 2020, the World Health Organization (WHO) has declared the novel coronavirus disease (COVID-19) a global pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus). A consistent number of case reports and clinical series have been already published describing a complex spectrum of skin manifestations associated with the SARS-CoV-2 infection. We carried out a review of the English-language literature up to 20 May 2020, reporting original cases or case series of the cutaneous manifestations of SARS-CoV-2 virus infection. The following databases were consulted: PubMed, Embase, Google Scholar and ResearchGate. The search of papers was conducted by using the key term 'COVID-19' or 'SARS-CoV-2' or 'coronavirus' combined with each of the following: 'skin', 'cutaneous', 'dermatologic' or 'dermatology', 'manifestation', 'lesions', or 'rash'. The patterns of dermatological manifestations associated with SARS-CoV-2 infection could be classified into four categories: exanthema (varicella-like, papulo-vesicular and morbilliform rash), vascular (chilblain-like, purpuric/petechial and livedoid lesions), urticarial and acro-papular eruption. Lastly, other skin manifestations to be considered are the cutaneous adverse reactions to the drugs prescribed for the treatment of COVID-19. Whether SARS-CoV-2 infection can directly cause a worsening of chronic inflammatory diseases such as psoriasis or atopic dermatitis remains to be determined. Dermatology's outlook in the COVID-19 pandemic is multidimensional., (© 2020 European Academy of Dermatology and Venereology.)

Background and Objectives: Treatment of severe dermatological autoimmune diseases and toxic epidermal necrolysis (TEN) with high-dose intravenous immunoglobulin (IVIg) is a well-established procedure in dermatology. As treatment with IVIg is usually considered for rare clinical entities or severe cases, the use of immunoglobulin is not generally based on data from randomized controlled trials usually required for evidence-based medicine. Since the indications for the use of IVIg are rare, it is unlikely that such studies will be available in the foreseeable future. Because first-line use is limited by the high costs of IVIg, the first clinical guidelines on the use of IVIg in dermatological conditions were established in 2008 and renewed in 2011., Methods: The European guidelines presented here were prepared by a panel of experts nominated by the European Dermatology Forum (EDF) and European Academy of Dermatology and Venereology (EADV). The guidelines were developed to update the indications for treatment currently considered effective and to summarize the evidence for the use of IVIg in dermatological autoimmune diseases and TEN., Results and Conclusion: The current guidelines represent consensual expert opinions and definitions on the use of IVIg reflecting current published evidence and are intended to serve as a decision-making tool for the use of IVIg in dermatological diseases.

Background: Mid-dermal elastolysis (MDE) is a rare skin condition, characterized by selective loss of elastic fibres in the mid dermis. The pathogenesis of MDE is still unclear., Aim: To investigate expression of lysyl oxidase-like 2 (LOXL2) in a reasonable sample of patients with MDE and to search for mutations in LOXL2., Methods: We investigated archived lesional tissue of 13 patients with MDE and skin tissue samples of 10 sex- and age-matched healthy controls (HCs). Gene and protein expression of LOXL2 was investigated using real-time reverse-transcription PCR and immunohistochemistry. Mutation analysis was performed using the Sanger method., Results: We observed decreased LOXL2 mRNA expression in lesional skin of patients with MDE (0.48 ± 0.16) compared with healthy skin of the same patients (1.5 ± 0.51) and normal skin of HCs (1.9 ± 0.13). Compared with healthy patient skin (epidermis 2.38 ± 1.6, dermis 1.2 ± 1), LOXL2 protein expression in lesional patient skin (epidermis 1.1 ± 0.7, dermis 0.3 ± 0.45) was significantly decreased (P < 0.04 and P = 0.02, respectively). Mutation analysis of the entire LOXL2 gene could be performed for five patients, all of whom were found to have at least one mutation in the LOXL2 gene. Three of these had a mutation in the promoter region (c.967 G>C, c.1022 C>T, and c.1025 G>A, respectively), and one of them also had a mutation in the splice region of intron 11/exon 12 (IVS11-1 G>A). Of the remaining two patients, one had a mutation in exon 3 (T1391), and the other had a mutation in exon 11 (C663Y)., Conclusions: Our present data suggest that decreased elastin renewal due to LOXL2 mutations and consecutive reduced LOXL2 expression contribute to the pathogenesis of MDE., (© 2018 British Association of Dermatologists.)

Introduction: The public perception of dermatology and dermatologists may be very relevant in guiding strategies for improving dermatologic care but it has been poorly investigated in Europe., Objective: To investigate the public's perception of dermatology and dermatologists in Italy., Methods: A representative sampling of Italian adults (n = 1500, aged 18-70 years), residing throughout the national territory was interviewed through a population-based telephone survey using a structured questionnaire., Results: The majority of interviewed aged between 35 and 54 years (45%) and had an intermediate educational level (57%), were employed (56%), and had at least one child in the family (68%). 70% of the interviewed knew at least one skin disease, particularly psoriasis, dermatitis, urticaria, skin tumours and nevi. The general practitioner resulted to be the first healthcare provider to consult in the case of skin problems for 73% of surveyed, with only 27% referring directly the private dermatologist. The dermatologist was the main referral specialist for psoriasis, pruritus and skin tumours by 66%, 54% and 53% of the sample, respectively. The most common reason for dermatological consultation was the control of nevi. In the case of childhood dermatitis, 52% indicated the paediatrician and 38% the dermatologist as the reference specialist. Almost half of the surveyed turned out to have a trusted dermatologist to consult in the case of skin problems. Finally, among those visited at least one time by a dermatologist, 46% were promoters, that is, they would recommend their dermatologist to a friend (net promoter score, 27)., Conclusions: The general population has a wide-ranging understanding of skin diseases and the central role of dermatologists in skin care. Patients are looking for technical competence and loyalty, because this lead to more trusted and satisfactory physician-patient relationship. Public campaigns may be relevant in increasing awareness on curability of common skin diseases., (© 2017 European Academy of Dermatology and Venereology.)

Background: Primary cutaneous CD4 + small/medium T-cell lymphoproliferative disorder (CD4 + PCSM-LPD) is defined by a predominance of small- to medium-sized CD4 + pleomorphic T cells and a favorable clinical course., Objective: We performed a retrospective analysis of 6 patients with CD4 + PCSM-LPD and reviewed the literature to address questions about its diagnosis, treatment, and prognosis., Methods: Patients were 3 men and 3 women with a median age of 50 years. All patients presented with a single erythematous nodule, localised on the head in 4 patients and the upper trunk in 2 cases. No patients showed extracutaneous disease at any evaluation. Histopathologic features were characterised by nodular, diffuse, or, in 1 case, a superficial dense infiltrate of small/medium-sized pleomorphic CD4 + /PD1 + T lymphocytes. T-cell receptor clonality was demonstrated in 5 cases. Treatment was surgical excision in 5 cases and radiotherapy in 1 case., Results: All patients achieved complete resolution without relapses, during a median follow-up of 3 years. A review of the literature confirmed that CD4 + PCSM-LPD presents predominantly with a solitary nodular lesion on the face, neck, or upper trunk in adult patients. Surgical excision is the preferred treatment. Spontaneous resolution after biopsy may occur., Conclusions: CD4 + PCSM-LPD is a rare disorder with a favorable course.

Background: The treatment of severe dermatological autoimmune diseases and toxic epidermal necrolysis (TEN) with high-dose intravenous immunoglobulin (IVIg) is a well-established procedure in dermatology. As treatment with IVIg is usually considered for rare clinical entities or severe clinical cases, the use of immunoglobulin is not generally based on data from randomized controlled trials that are usually required for the practice of evidence-based medicine. Owing to the rarity of the indications for the use of IVIg, it is also unlikely that such studies will be available in the foreseeable future. Because the high costs of IVIg treatment also limit its first-line use, the first clinical guidelines on its use in dermatological conditions were established in 2008 and renewed in 2011., Materials and Methods: The European guidelines presented here were prepared by a panel of experts nominated by the EDF and the EADV. The guidelines were developed to update the indications for treatment currently considered as effective and to summarize the evidence base for the use of IVIg in dermatological autoimmune diseases and TEN., Results and Conclusion: The current guidelines represent consensual expert opinions and definitions on the use of IVIg reflecting current published evidence and are intended to serve as a decision-making tool for the use of IVIg in dermatological diseases., (© 2016 European Academy of Dermatology and Venereology.)

Cyclosporine A (CsA) efficacy and safety have been proven in various dermatoses both in adults and in children even as long-term treatment. Over the last 25 years, Italian dermatologists have gathered relevant experience about CsA treatment for psoriasis and atopic dermatitis. This paper has been developed by an Italian Consensus Conference and it is aimed at providing recommendations based on real-world clinical experience in adult patients, consistent with efficacy and safety data arising from the scientific literature. The paper is mainly focused on the analysis of the optimal therapeutic schemes for psoriasis and atopic dermatitis, in terms of doses and treatment duration, according to individual characteristics and to the severity of the disease. Moreover, it overviews ideal management, taking into account pharmacological interactions, influence of comorbidities, and the most common adverse events related to CsA treatment.

Biological agents are widely used in rheumatology, dermatology and inflammatory bowel disease. Evidence about their efficacy and safety has been strengthened for all those therapeutic indications over the last decade. Biosimilar agents are monoclonal antibodies similar to previously approved biologics. In the European Union, they have been approved for all the indications in the management of immune-mediated inflammatory diseases (IMIDs), although data only in rheumatoid arthritis and ankylosing spondylitis are currently available. Direct evidence on efficacy, safety, and immunogenicity of biosimilars is mandatory in psoriasis, psoriatic arthritis, and inflammatory bowel disease, as well as in children. Based on the current evidence in the literature, we present the joint official position of the Italian Societies of Rheumatology, Dermatology and Inflammatory Bowel Disease on the use of biosimilars in IMIDs., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Aim of the study was to investigate the impact of TNF-α antagonists on health-related quality of life (HRQoL) in selected skin diseases, i.e. chronic plaque psoriasis, Behçet's disease (BD), hidradenitis suppurativa (HS) and pyoderma gangrenosum (PG). We have carried out a systematic literature search of Medline (2000 to April 2013) using the Cochrane highly sensitive and specific search strategy. Citations were screened for randomized, controlled trials of TNF-α antagonists (adalimumab, etanercept and infliximab) versus placebo in adults with psoriasis, BD, HS or PG. From the literature it is evident that skin diseases can affect physical, psychological, social and occupational aspects of everyday life. TNF-α antagonists induced consistent benefits across health outcomes in psoriasis, but only monoclonal antibodies, infliximab and adalimumab were effective in improving QoL in patients with BD, HS and PG. Dermatology Life Quality Index was the most common used tool for investigating HRQoL. For the majority of patients with skin diseases, the most important negative impacts on QoL were appearance related. Generally, the burden on QoL was correlated to the severity of skin disease and the improvement in QoL achieved by TNF-α blockers was proportional to the degree of disease remission. HRQoL issues are becoming even more important in evaluating medical care, including treatment of skin diseases. In general, achieving the highest clearing of skin disease with anti-TNF-α agents is required for optimal improvement in QoL.

Sarcoidosis is a multisystemic disease with cutaneous lesions present in about one fourth of patients. Cutaneous lesions may be specific or nonspecific based on the presence or the absence of sarcoidal granulomas. Subcutaneos sarcoidosis is the less frequent of the specific cutaneous lesions of sarcoidosis. We report here 2 new cases and review 83 cases reported in literature of subcutaneous sarcoidosis. Subcutaneous sarcoidosis present usually with asymptomatic firm nodules covered by normal-appearing skin, mostly on the forearms and legs. Diagnosis may require a high index of suspicion. In the vast majority of patients, subcutaneous nodules were the manifestation that allowed the diagnosis of systemic sarcoidosis. There is a strong association between subcutaneous sarcoidosis and bilateral hilar lymphadenopathy (72.7%). About 15% of patients have in order of frequency uveitis, parotitis, arthritis, mucositis, dactylitis, neurological and renal involvement, hepatosplenomegaly.

The skin is a frequent site of pathological immune responses that can take place in the dermal and/or the epidermal compartments.These immunopathological reactions often occur towards innocuous antigens and may be the result of T cell-dependent and/or autoantibody dependent mechanisms. Defective immune regulation is increasingly recognized as very relevant in many skin and systemic immune-mediated disorders. In some instances (e.g., psoriasis and atopic dermatitis) genetic predisposition can affect also the capacity of keratinocytes to initiate or perpetuate inflammatory responses. A more precise understanding of the molecular and cellular mechanisms underlying each disorder may allow the identification of novel targets for more effective therapeutic strategies.

In view of the central pathogenic importance of leukocyte extravasation in inflammatory skin diseases, therapeutic interference with this - surprisingly complex - process is clearly a promising new approach for treating these dermatoses. Despite some disappointments during the clinical use of these agents and despite their crippling price tag, the recent incorporation of biologicals that target defined molecular controls of leukocyte extravasation into dermatological and rheumatological practise, consequently, has greatly enriched our therapeutic options for battling major, chronic, inflammatory dermatoses such as psoriasis. However, the - as yet unresolved and still rather controversially discussed - critical question is: Which of the multiple steps that control leukocyte extravasation in the human system really offer the most promising, most pragmatic, and safest molecular targets for therapeutic intervention for which disease entity? The current debate intends to stimulate public and rational debate of this crucial issue, beyond the evident commercial interests that are touched by whatever stand one takes.

The superfamily of chemokines comprises numerous small, cytokine-like chemotactic proteins, which have a fundamental role in the regulation of leukocyte trafficking. The chemokine-chemokine receptor system is highly redundant and promiscuous, and forms a complex network relevantly involved in the expression of chronic inflammatory skin diseases, including allergic contact dermatitis, atopic dermatitis and psoriasis. The pattern of chemokine expression shows overlapping features but also important differences in these diseases due to distinct sources and types of pro-inflammatory signals involved in chemokine induction, and the inherent capacity of resident skin cells to produce chemokines. Chemokine receptors (G-protein coupled receptors) rather than chemokines appear the appropriate therapeutic targets as they are more chemically tractable and play less redundant functions.

Graft-versus-host disease (GVHD) is an immunologically mediated disease occurring most frequently after allogeneic bone marrow transplantation. The aim of this study was to evaluate the contribution of immunohistochemistry in the diagnosis of cutaneous GVHD. Patients transplanted for either leukemia or beta-thalassemia were included in the study. Skin lesions of acute and chronic GVHD were examined both by direct immunofluorescence to detect immunoglobulin deposits and by an avidin-biotin-peroxidase complex technique to evaluate the inflammatory cell infiltrate. Epidermal and dermal fluorescent bodies (IgG and IgM) were frequently found in both acute and chronic GVHD. Most of the infiltrating cells were CD3+ T lymphocytes, with CD8+ cells representing the major cell population invading the epidermis both in acute GVHD and in chronic lichenoid GVHD. A small proportion of the dermal cells were CD14+ macrophages; no B cells were detected. HLA-DR, but not HLA-DQ antigens, were variably expressed by keratinocytes in all cases of acute GVHD and in chronic lichenoid GVHD. KL-1, a monoclonal antikeratin antibody specific for the 56.5 KD acidic polypeptide usually present in suprabasal keratinocytes, stained all epidermal layers, including the basal layer. Langerhans cells were dramatically reduced in number in the epidermis of both acute and chronic lichenoid GVHD. It is concluded that immunohistologic analysis may be supportive in the diagnosis of acute and early chronic lichenoid cutaneous GVHD.

Pityriasis lichenoides (PL) represents a spectrum of inflammatory skin diseases comprising pityriasis lichenoides et varioliformis acuta (PLEVA) and pityriasis lichenoides chronica (PLC). This study aimed to provide a summary of effective treatments for PL. A systematic review was performed according to PRISMA guidelines for studies investigating PL treatment including ≥3 subjects and published in English between 1 January 1970 and 15 April 2019. A total of 441 papers were screened, and 37 original manuscripts meeting the inclusion and exclusion criteria were found, including 12 case series, 18 reviews, four prospective studies, two comparative studies and a single randomized controlled study. In most studies, ultraviolet (UV) phototherapy (narrow‐band UVB, broadband UVB, UVA1 or PUVA) was used. Clearance rates with the different modalities are hardly comparable between different studies, ranging approximately between 70% and 100%. Narrow‐band UVB showed an efficacy similar to PUVA as such as the combination of UVA and UVB vs. PUVA. Oral erythromycin showed clearance rates ranging between 66% and 83%, whereas methotrexate up to 100% but in small and dated studies. Evidence for other treatments is scarce. There is a lack of high level of evidence studies on PL treatment. The interpretation of the results is biased by the possible auto‐resolution of the disease, the sample heterogeneity between children and adults and the short follow‐up period of the studies. Only some studies investigated how results were durable after cessation of therapy. Quality of life and the impact of treatment were never assessed. According to the results of this review, we suggest narrow‐band UVB phototherapy as first‐line treatment. Oral erythromycin with or without topical corticosteroids and low‐dose methotrexate as second‐line therapies. High‐powered studies and randomized controlled trials are needed to establish the optimal treatment for PL. [ABSTRACT FROM AUTHOR]

Background TRANSIT ( NCT01059773) compared immediate and gradual transition from methotrexate to ustekinumab in psoriasis patients via multiple measures, including patient-reported outcomes. Objective To evaluate patient perception of treatment benefits in TRANSIT. Methods A total of 489 psoriasis patients received ustekinumab, with immediate cessation of methotrexate (Arm 1) or 4 weeks' overlap with decreasing methotrexate dose (Arm 2). Ustekinumab was administered at weeks 0, 4, 16, 28 and 40. Dermatology Life Quality Index ( DLQI), EuroQol 5-item ( EQ-5D), visual analogue scale ( VAS) valuation technique and patient benefit index ( PBI) were employed. Mean global PBI and sub-scores were calculated from the sum of the benefit items weighted by their respective relevance at baseline. Patient-relevant benefit was defined as PBI ≥1 (scale: 0 [no benefit] to 4 [maximum benefit]). Correlations of global PBI with Psoriasis Area and Severity Index ( PASI) and DLQI were examined. Results Relationships between PBI and clinical data were evaluable in 340 patients. The most important treatment goals at baseline included: 'be healed of all skin defects', 'have confidence in therapy', 'get better skin quickly' and 'regain control of the disease'. Benefit in PBI global score was achieved at week 4 by 93% of patients in Arm 1 and 91% in Arm 2. Global PBI scores increased in both Arms between weeks 4 and 52. Global PBI correlated weakly with PASI change from baseline (correlation coefficient range: −0.22 to −0.40), and moderately with DLQI (−0.29 to −0.54). Overall DLQI score was lower than baseline at all times; and the percentage of patients with an overall score of 0 or 1 increased with time. Correspondingly, EQ VAS scores increased with time. DLQI and EQ VAS results were similar between arms. Conclusions Regardless of the strategy for transitioning from methotrexate, ustekinumab was associated with rapid and sustained improvement in patient-reported outcomes. PBI appears a suitable tool for assessing patient-relevant treatment benefits in psoriasis patients. [ABSTRACT FROM AUTHOR]

Heat urticaria ( HU) is a rare type of physical inducible urticaria, characterized by itchy erythema and well-demarcated weals appearing soon after heat exposure. Most cases occur in female patients aged 20-45 years. Both localized and generalized forms exist, depending on the limitation of the reaction to the skin area directly exposed to the physical stimulus or the involvement of distant sites, respectively. In most cases, HU is an immediate reaction, but delayed forms (mostly familial) have been described. HU is a long-lasting disease with overall duration at diagnosis of approximately 2 years. In about half of cases it is associated with systemic symptoms such as weakness, wheezing, headache, flushing, nausea, vomiting, diarrhoea, tachycardia, even dyspnoea or syncope. The main differential diagnosis includes cholinergic urticaria, exercise-induced anaphylaxis and solar urticaria. The diagnosis of HU is established by provocation testing, which is also helpful to evaluate the critical temperature threshold. The mean threshold temperature is about 44 °C. A heat desensitization programme can be an effective treatment. Nonsedating H1 antihistamines administered at licensed doses are the mainstay of symptomatic therapy in nearly 60% of patients, but full symptom relief is achieved in only a minority of them. Omalizumab has proven effective in recent case reports. [ABSTRACT FROM AUTHOR]

The chronic nature of psoriasis means that patients often require lifetime treatment. Over this time, treatment frequently has to be adapted to meet variable demands resulting from changes in life course and life events. Biological drugs used to treat psoriasis vary in their dosing regimens, convenience and flexibility. Dermatologists need to understand which biologic agent is best suited for each individual patient. A wealth of evidence supports the safe and effective use of etanercept, which offers a rapid and sustained response, flexibility of dosing, maintenance of response after dose reduction or interruption, and efficacy against non-skin manifestations such as psoriatic arthritis. An expert panel met to agree the typical patient profile of a psoriasis patient treated with etanercept, the main benefits of etanercept in psoriasis, and the patient group most likely to benefit from its use. They agreed that flexibility of dosing, the potential to individualize therapy by stopping and starting treatment while maintaining efficacy, and the possibility of cost saving through the use of flexible treatment regimens were important benefits supporting the use of etanercept in many patients with psoriasis. [ABSTRACT FROM AUTHOR]

Background The prognostic and therapeutic features of scleredema are poorly documented. Objectives To describe the characteristics of patients with scleredema regarding demographics, clinical characteristics, comorbidities, therapeutic interventions and course. Methods We conducted a retrospective multicentre study. Results We identified 44 patients (26 men).The mean age at diagnosis was 53.8 years. The most common associated disorders were endocrine/metabolic diseases including 30 patients suffering from diabetes, mostly type 2 diabetes. Monoclonal gammopathies were confirmed in five cases. A preceding respiratory tract infection was not a feature. Treatments with different combination or sequential modalities were used with variable results. Phototherapy (UVA1 or PUVA) was the treatment associated with higher, although partial response. Systemic corticosteroids and immunosuppressive drugs were reserved to patients with severe disease in whom phototherapy had failed or for patients with multiple myeloma. Forty-one patients were followed up (mean period: 32.2 months).Thirty-nine patients are alive, 30 with and 9 without skin disease. Two patients died of cardiovascular complications due to myeloma and severe diabetes. Conclusions Scleredema is a chronic debilitating disease associated with diabetes and metabolic syndrome, unresponsive to various treatments but not necessarily a life-threatening condition. Although there is no definitive treatment, phototherapy should be attempted first. Treatment of primary disease including strict glycaemic control combined with physical therapy should be also employed. [ABSTRACT FROM AUTHOR]

Background The nationwide prevalence of latent tuberculosis infection ( LTBI) in Italian patients with psoriasis has never been investigated. Objectives To estimate the nationwide prevalence of LTBI in Italian patients with psoriasis who are candidates for systemic treatment. Methods Data were obtained from the Psocare Registry on those patients ( n = 4946) with age > 18 years, systemic treatment at entry specified and tuberculin skin test ( TST) performed according to the Mantoux method. LTBI diagnosis was based on a positive TST result in the absence of any clinical, radiological or microbiological evidence of active tuberculosis. Results Latent tuberculosis infection was diagnosed in 8·3% of patients with psoriasis (409 of 4946). The prevalence of LTBI was lower in patients on biologics than in those on conventional systemic treatments, ranging from 4·3% (19 of 444) of patients on adalimumab to 31% (eight of 26) of those on psoralen-ultraviolet A ( P < 0·05). Independent factors associated with LTBI were male sex [odds ratio ( OR) 1·30, 95% confidence interval ( CI) 1·04-1·62; P = 0·02], age over 55 years ( OR 2·93, 95% CI 2·18-3·93; P < 0·001) and being entered into a conventional treatment ( OR 3·83, 95% CI 3·10-4·74; P < 0·001). Positive history of tuberculosis was seen in 1% of patients ( n = 49). Conclusions The nationwide prevalence of LTBI in Italian patients with psoriasis candidate to systemic treatment is high, and screening is recommended prior to biological treatment. [ABSTRACT FROM AUTHOR]

Skin and joint manifestations are part of the clinical spectrum of many disorders. Well-known associations include psoriatic arthritis and arthritis associated with autoimmune connective tissue diseases. This review focuses on less common associations where skin lesions can provide easily accessible and valuable diagnostic clues, and directly lead to the specific diagnosis or limit the list of possibilities. This may also affect health care resources as diagnostic tests are often low-specific, highly expensive and poorly available. This group of diseases can be divided into two subsets, based on the presence/absence of fever, and then further classified according to elementary skin lesions (macular, urticarial, maculo-papular, vesico-bullous, pustular, petechial and nodular). In most instances joint involvement occurs as peripheral migrating polyarthritis. Erythematosus macular or urticarial rashes occur in most febrile disorders such as monogenic autoinflammatory syndromes, Schnitzler's syndrome, Still's disease and rheumatic fever and afebrile diseases as urticarial vasculitis. Pustular rash may be observed in chronic recurrent multifocal osteomyelitis ( CRMO) and pyogenic arthritis with pyoderma gangrenosum and acne ( PAPA) syndrome (both febrile) as well as in Behcet's disease and Synovitis, acne, pustulosis, hyperostosis and osteitis syndrome (both non-febrile). Papular lesions are typical of secondary syphilis, sarcoidosis, interstitial granulomatous dermatitis, papular petechial of cutaneous small-vessel vasculitis and nodular lesions of polyarteritis nodosa and multicentric reticulohistiocytosis all of which are afebrile. Differential diagnosis includes infections and drug reactions which may mimic several of these conditions. To biopsy the right skin lesion at the right time it is essential to obtain relevant histological information. [ABSTRACT FROM AUTHOR]

Background Existing tools for nail psoriasis are complex and may not adequately measure outcomes that are important to patients. Objectives We have developed and validated a new tool, the Nail Assessment in Psoriasis and Psoriatic Arthritis ( NAPPA), with three components: a questionnaire assessing quality of life ( NAPPA-QoL), a two-part questionnaire assessing patient-relevant treatment benefits (the Patient Benefit Index, NAPPA- PBI) and a psoriasis Clinical Assessment of Severity ( NAPPA- CLIN). Methods Development of the questionnaires involved multiple steps: (i) collection of items about nail psoriasis-related impairments and treatment goals; (ii) selection of 48 items by an expert panel, including patients; (iii) translation into eight languages; (iv) feasibility testing and (v) longitudinal validation in six countries. Results Patients found the questionnaires clear (84%) and comprehensible (95%). NAPPA- Qo L and NAPPA- PBI scores correlated moderately with clinical outcomes [e.g. Nail Psoriasis Severity Index ( NAPSI)] and markedly with other quality-of-life questionnaires (e.g. EQ- 5D™). Both questionnaires were sensitive to change. Internal consistency was good (Cronbach α ≥ 0·88 for all scales). The NAPPA- CLIN, a brief version of NAPSI that involves assessment of only four digits rather than all 20, was found to correlate highly with total NAPSI score ( r = 0·97, P < 0·001). Conclusions Overall, the three-component NAPPA tool is a valid, reliable and practical instrument to assess patient-relevant nail psoriasis outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented regarding the investigation of the clinical course and features of the skin disease cutaneous mastocytosis (CM).

The article presents the October 2009 issue of the "Journal of the European Academy of Dermatology and Venereology," which offers information on the European S3-Guidelines for treating psoriasis vulgaris. It notes that the guidelines are intended for dermatologists and for medical specialists involved treating the disease. The guidelines are also meant to aid the activity of contributing to the fulfilment of a need or purpose to health insurance organizations and political decision-makers.

Our understanding of the pathogenesis of psoriasis is changing rapidly and the traditional view that it is a disease limited to the skin continues to be challenged. Indeed, there is convincing evidence that psoriasis patients have a higher prevalence of comorbid disease, particularly cardio-metabolic disorders and psoriatic arthritis (PsA). The results of recent investigations into psoriasis and cardiovascular or metabolic comorbidities provide increasing evidence for a possible shared pathogenic mechanism for these disorders, linked by an underlying chronic systemic inflammatory state. This highlights the importance of investigating associated comorbidities beyond skin manifestations. Psoriatic arthritis is a chronic inflammatory arthropathy that can occur in association with psoriasis and most commonly affects the distal joints in the hands and feet. Skin lesions precede arthritic symptoms in approximately 75% of cases; typically, the cutaneous manifestations of the disease develop 10 years prior to the onset of joint symptoms. This disease course, therefore, provides a potential window of opportunity to initiate effective and aggressive therapies to prevent long-term damage, if symptoms of PsA can be detected early. One of the major features of PsA is enthesitis, yet clinically asymptomatic cases of entheseal abnormalities are likely to go undiagnosed. This concept was evaluated in a prospective study in which entheseal changes in clinically asymptomatic psoriasis patients were compared with findings from a control group. Ultrasonography detected a significantly higher incidence of entheseal abnormalities in patients with psoriasis, despite the absence of clinical symptoms of arthropathy. Ongoing monitoring of these patients has also revealed that a higher baseline score for enthesitis may be associated with a more severe psoriasis outcome. These findings demonstrate that detecting early signs of PsA in asymptomatic patients with psoriasis may have the potential to positively influence disease prognosis and ultimately clinical outcome. Dermatologists can, therefore, play a key role in the early detection and management of PsA. Conflicts of interest None declared. [ABSTRACT FROM AUTHOR]

Background Psoriasis is a chronic inflammatory disease associated with an increased cardiovascular risk. Metabolic syndrome is a significant predictor of cardiovascular events. Objective To investigate the prevalence of metabolic syndrome in patients with psoriasis. Methods We performed a hospital-based case–control study on 338 adult patients with chronic plaque psoriasis and 334 patients with skin diseases other than psoriasis. Results Metabolic syndrome was significantly more common in psoriatic patients than in controls (30·1% vs. 20·6%, odds ratio 1·65, 95% confidence interval 1·16–2·35; P = 0·005) after the age of 40 years. Psoriatic patients also had a higher prevalence of hypertriglyceridaemia and abdominal obesity, whereas hyperglycaemia, arterial hypertension and high-density lipoprotein cholesterol plasma levels were similar. Although psoriasis patients were more frequently smokers, the association of psoriasis with metabolic syndrome was independent from smoking. There was no correlation between severity of psoriasis and prevalence of metabolic syndrome. Psoriatic patients with metabolic syndrome were older and had a longer disease duration compared with psoriatic patients without metabolic syndrome. Conclusion Psoriatic patients have a higher prevalence of metabolic syndrome, which can favour cardiovascular events. We suggest psoriatic patients should be encouraged to correct aggressively their modifiable cardiovascular risk factors. [ABSTRACT FROM AUTHOR]

The main dermatology textbooks describe only in passing pruritus in psoriasis and rarely mention other symptoms. A quantification of the presence of symptoms is not available for clinical subgroups of psoriasis.To investigate the prevalence of symptoms experienced by patients with different clinical types of psoriasis.The study was carried out in patients hospitalized for psoriasis between February 2000 and February 2002 at the inpatient wards of the Istituto Dermopatico dell'Immacolata, Rome, Italy. Symptoms were evaluated using the symptoms scale of Skindex-29. Clinical severity was assessed by the dermatologists using the Psoriasis Area and Severity Index (PASI), and by the patients completing the self-administered PASI. Psychiatric morbidity was evaluated using the 12-item General Health Questionnaire.In total, 936 eligible patients were analysed. The proportions of patients experiencing symptoms often or always in the 4 weeks before hospitalization were: 63·8% itching, 59·7% irritation, 46·1% burning/stinging, 39% sensitivity, 26% pain (from 10% in guttate psoriasis to 50% in arthropathic), 25·4% bleeding (17% pustular, 19% localized plaque, 36% palmoplantar), and 23·9% bothered by water (from 8·5% in the guttate form to 68% in palmoplantar). The prevalence of all symptoms was significantly higher in women and tended to increase with clinical severity.Our study provides evidence of the high frequency of a number of symptoms in different subgroups of psoriasis patients determined by their sociodemographic characteristics, clinical type and disease severity. Symptoms represent a serious disabling factor in patients affected by psoriasis, including those with low levels of psychological distress. Dermatologists should include symptoms in the evaluation of disease severity both in clinical practice and in clinical trials. [ABSTRACT FROM AUTHOR]

Epidermodysplasia verruciformis (EV) is characterized by abnormal genetically-determined susceptibility to widespread and persistent infection of the skin with human papillomaviruses (HPV). The infection results in disseminated pityriasis versicolor-like lesions and flat warts. Skin malignant changes are very common and occur on sun-exposed areas. Several treatments have been used but without consistent benefit. Recently, retinoids and alpha-interferon, alone or in combination, have been reported to be of value in the therapy of EV lesions. We present the case of a 43-year-old white female affected by EV who developed multiple squamous cell carcinomas in the oral and genital mucosae during the previous four years. Both wart and cancer lesions harbored HPV24 along with the novel putative HPV type FA51.The patient was treated with a combination of acitretin (0.2 mg/kg per day) and peginterferon alfa-2b (1 μg/kg per week s.c.) for one year, with marked improvement of verrucous lesions and no recurrence of mucosal cancer. Thereafter, interferon was stopped whereas acitretin therapy was continued, but a new Bowen's disease developed in the perianal region, and the acitretin dose was increased at 0.5 mg/kg per day. At six-month follow-up, only a low number of flat warts persisted, and no clinical signs of cutaneous or mucosal carcinoma were evident. [ABSTRACT FROM AUTHOR]

We report a 60-year-old man with familial scleroatrophic syndrome of Huriez who developed squamous cell carcinomas on the affected skin of the right palm. Immunohistochemical analysis showed a marked reduction in the number of CD1a+, Lag+ and S100+ epidermal Langerhans cells, but not of CD1b+ and factor XIIIa+ dermal dendritic cells, limited to palmoplantar skin. The Langerhans cell depletion was not associated with an abnormal skin content of mRNA for factors involved in Langerhans cell development or recruitment in the epidermis, including granulocyte/macrophage colony-stimulating factor, transforming growth factor-β1 and macrophage inflammatory protein-3α. The results indicate that other as yet unknown mechanisms may account for the reduced number of Langerhans cells in the affected skin of such patients. [ABSTRACT FROM AUTHOR]