Long-term proactive management of psoriasis with calcipotriol and betamethasone dipropionate foam: an Italian consensus through a combined nominal group technique and Delphi approach.

BACKGROUND: Although long-term management of psoriasis is paramount, this approach is challenging in clinical practice. In the recent PSO-LONG trial, a fixed-dose combination of betamethasone dipropionate (BD) and calcipotriol (Cal) foam applied twice a week on non-consecutive days for 52 weeks (proactive treatment) reduced the risk of relapse. However, the role of Cal/BD foam in the long-term management of psoriasis needs further clarifications. The ProActive Management (PAM) program, a nationwide Italian project, aims at reaching a consensus on the role of proactive management of psoriasis. METHODS: A steering committee generated some statements through the nominal group technique (NGT). The statements were voted by an expert panel in an adapted Delphi voting process. RESULTS: Eighteen statements were proposed, and the majority of them (14/18) reached a consensus during the Delphi voting. The need to provide long-term proactive topical treatment to reduce the risk of relapse for the treatment of challenging diseases sites or in patients where phototherapy or systemic therapies are contraindicated/ineffective was widely recognized. A consensus was reached about the possibility to associate the proactive treatment with systemic and biological therapies, without the need for dose intensification, thus favoring a prolonged remission. Moreover, the proactive treatment was recognized as more effective than weekend therapy in increasing time free from relapses. Approaches to improve adherence, on the other hand, need further investigation. CONCLUSIONS: The inclusion in guidelines of a proactive strategy among the effective treatment options will be a fundamental step in the evolution of a mild-moderate psoriasis therapeutic approach.

Seven years-experience of adalimumab therapy for Hidradenitis Suppurativa in a real-life dermatologic setting.

INTRODUCTION: Hidradenitis Suppurativa (HS) often causes severe impairment of the quality of life of patients affected, as it is characterized by recurrent relapses of inflammation and predisposes to retractive scars, with severe alteration of anatomy of the affected regions. Adalimumab is currently the only approved long-term biological therapy for this disease. MATERIAL AND METHOD: We retrospectively review the data of HS patients treated with Adalimumab at the 'Hidradenitis Suppurativa Clinic', University of Ferrara, Italy since the drug was first available to October 2020. The aim is to describe our real-life experience in a clinical outpatient service. We assessed the main demographic features, therapy duration, reasons of suspension and efficacy (evaluated by HiSCR - Hidradenitis Score) in relation to surgical procedures, hospitalization, number of areas involved by the disease and BMI > 30. We also assessed the aspects related to the use of adalimumab's biosimilar. RESULTS: Data on 76 patients, with a mean age of 38.26 ± 14.74 years and mean BMI 28.10 ± 5.92 were collected. Most of the treated patients had Hurley stage III (58/76); mean Sartorius score was 115.5 ± 55.86, mean IHS4 was 76.1 ± 44.3. A statistically significant correlation between hospitalization and cessation of adalimumab, the loss of the achievement of the HiSCR, and surgery was found. No need to do surgery was a protective factor against the failure of adalimumab treatment, meaning that the most severe cases are more likely to fail the biological therapy. CONCLUSION: New scenarios are opening up in clinical practice: the arrival of biosimilars allow greater sustainability of expenditure, while the anti-IL17 allow the patient who has failed therapy with adalimumab a valid and safe therapeutic option to be undertaken. A comprehensive care including hospitalization, a specific antibiotic therapy and surgical treatment is often mandatory to achieve a satisfactory control of the disease.

The Association among Pyoderma Gangrenosum, Ulcerative Colitis, and Hidradenitis Suppurativa and the Syndromic Hidradenitis Suppurativa Network: A Case Report.

Hidradenitis suppurativa (HS), together with other inflammatory diseases, is involved in a syndromic network where different combinations of signs and symptoms characterize the definition. The observation of the concurrent occurrence of HS, pyoderma gangrenosum (PG), and inflammatory bowel disease (IBD), in detail ulcerative colitis (UC), led the authors to describe a new association. The patient, a 36-year-old woman, who saw IBD as the first appearing condition, shortly followed by HS and PG, was referred because of a clinical situation quickly worsening. A severe aggravation of both GI symptoms and general systemic situation total led to total colectomy. Surprisingly, shortly after the radical surgical treatment of UC, the cutaneous manifestations of HS and PG with no specific treatment almost completely disappeared suggesting the existence of a common etiopathogenetic mechanism and possibly an inductor role of UC on the other disorders. The presentation of this case offers the opportunity to deal with the fact that the resolution of one of the associated conditions may lead to the clearance of one or more of the others. It confirms a pathogenetic link between them and the pivotal role of one of them, in this case colitis.

The link between hidradenitis suppurativa and phylloid hypomelanosis in partial trisomy-13 mosaicism: New evidences and further genetic/pathogenetic insights.

Partial trisomy-13 mosaicism (PT13M) is a rare condition. Among its possible associated cutaneous features, phylloid hypomelanosis (PH), characterized by leaf-like macules reminiscent of floral ornaments in the form of round or oval spots and patches and oblong lesions, is typical. Two cases of PH associated with hidradenitis suppurativa (HS) have been already reported in the literature. We report a third child with PH due to PT13M associated with HS-like lesions limited to hypomelanotic regions. We hypothesize that follicular occlusion genes may be located in the duplicated part of chromosome 13.

KID Syndrome and Hidradenitis Suppurativa: A Rare Association Responding to Surgical Treatment.

BACKGROUND: Keratitis-ichthyosis-deafness (KID) syndrome is a rare genodermatosis characterized by keratitis, neurosensorial auditory impairment and ichthyosiform skin involvement. Frequent complications of the syndrome are chronic, opportunistic cutaneous infections, and the development of skin cancers. Several cases of association between KID syndrome and other conditions, including hidradenitis suppurativa (HS), are described in the literature. This correlation could be explained by the hyperproliferative state of the epidermis, which occurs in KID syndrome and may favor follicular plugging. OBJECTIVES: The aim of this study was to describe a very rare case of association between KID syndrome and HS and its complex therapeutic management. RESULTS: The failure of the drugs commonly used in HS and the excellent results of surgery, although difficult to achieve, were experienced. CONCLUSION: Despite the technical difficulties related to surgery, namely, cutaneous superinfections, frequent dehisce of the suture, and closure by secondary intention, the authors strongly recommend the surgical approach in these patients.

Eruptive Cherry Angiomas and Skin Melanoma: Further Insights into an Intriguing Association.

BACKGROUND: Some risk factors for malignant melanoma (MM) are recognized. OBJECTIVE: To compare the strength of association between MM and eruptive cherry angiomas (CAs) with that of other well-known associations. METHODS: This cross-sectional study included all subjects referred to the Outpatient Dermatology-Oncology and Dermoscopy Units of the Universities of Ferrara and Bologna, Italy, over a 5-month period and submitted to total body skin examination. We recorded: age, sex, cutaneous and non-cutaneous malignancies, presence of CAs, arbitrarily considered as "eruptive" when >10, >40 common melanocytic naevi or >2 clinically atypical naevi. The strength of association between the possible risk factors and MM was calculated by odds ratio in both the whole population and age quartiles. Variables associated with MM were included in multiple logistic regression analysis. RESULTS: 1,190 subjects were included; 615 had malignant skin tumours, 462 MM, 85 extracutaneous tumours. Five hundred and eighty-seven subjects had eruptive CAs, 485 subjects >40 melanocytic naevi and 368 more than 2 atypical melanocytic naevi. Eruptive CAs, especially in subjects younger than 70, and >2 atypical melanocytic naevi, mostly in subjects older than 50, were significantly associated with MM. The strength of these 2 associations was similar. The presence of >40 melanocytic naevi was not associated with MM. CONCLUSIONS: These findings confirmed an association between MM and eruptive CAs, which was as strong as the one between MM and >2 atypical melanocytic naevi. CAs seem an intriguing model of interaction between heterogeneous variables, like immunocompetence, stimuli inducing endothelial cell proliferation, and oncogenesis, which deserves further investigation.

Creatine Phosphokinase Values during Low Starting Dose Isotretinoin Therapy.

BACKGROUND: The value of creatine phosphokinase (CPK) monitoring during isotretinoin therapy is still a matter of debate because of the rarity of muscular and kidney damage in this setting. The aim of the study was to investigate the incidence of CPK elevation during a low starting dose isotretinoin regimen and to discuss the clinical approach to patients with increased CPK. METHODS: We reviewed the records of the acne patients from 2015 to 2018 at the University of Ferrara and at the University of Modena and Reggio Emilia. Routine clinical and laboratory follow-up was analyzed. RESULTS: The records of 328 patients were included in the study. Abnormal CPK levels were observed in 5.5% of cases. Revised Leeds acne scores and visual assessment scale (VAS) measurements decreased significantly after isotretinoin therapy. DISCUSSION: The adoption of the low starting dose isotretinoin regimen is associated with low incidence of CPK elevation. The finding of CPK over the conventional value of 5 times above the limit was rarely observed and was never associated with kidney damage. Therefore, it should be interpreted as a relatively benign phenomenon that does not require the interruption of isotretinoin therapy and that should be managed mainly through the reassurance of the patient.

Patch test reactions through the lens of dermoscopy: Further insights, particularly on weak allergic reactions.

BACKGROUND: Distinguishing weak allergic reactions from irritant patch test reactions may be difficult. OBJECTIVES: To describe the dermoscopic features of allergic reactions (especially weak allergic ones) and irritant patch test reactions, and to assess the suitability of dermoscopy in supporting differential diagnosis. METHODS: Eligible participants for this observational, cross-sectional study included consecutive adult outpatients patch tested during a 12-month period, who developed any skin reaction. Healthy volunteers were patch tested with sodium lauryl sulfate as irritant controls. At the 72-hour reading, patch test reactions were recorded both with a digital camera and a digital dermoscopic system. For each reaction, clinical and dermoscopic variables were separately assessed, scored, and then compared. RESULTS: Erythema, vessels, and vesiculation were constant dermoscopic features of allergic reactions (n = 173). In 46 weak (+) allergic reactions, dermoscopy showed (a) erythema (100%), (b) dense polymorphic vessels (100%), and (c) whitish vesicles (78.3%). Scores for vesicles and dotted vessels were significantly higher in weak allergic than in irritant reactions. Vesicles were identified as the chief dermoscopic parameter for correctly distinguishing weak allergic from irritant reactions. CONCLUSIONS: Dermoscopy can improve accuracy in the differential diagnosis between weak allergic and irritant patch test reactions.