Two Cases of Hidradenitis Suppurativa Treated with Adalimumab at the Department of Dermatology and Venereology, Clinical Hospital Mostar.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease primarily affecting apocrine gland-rich areas of the body and presenting with painful nodules, abscesses, sinus tracts, and scarring (1). HS is a defect of the follicular epithelium; some have therefore called for the naming the disease acne inversa instead of hidradenitis suppurativa. The term acne inversa links the pathogenesis to acne and reflects the fact that it is an expression of follicular occlusion in localizations inverse to acne vulgaris (2). HS typically occurs after puberty. Studies have shown that the average onset is in the second or third decades of life (3). One of the most frequently cited risk factors for HS is cigarette smoking. Another significant risk factor for HS is obesity. About one-third of patients with HS have reported a family history of the disease (4). A clinically relevant staging and disease severity assessment is essential for the development of evidence-based treatments. There are several scoring systems for the assessment of disease severity of HS, including Hurley staging, HS Physician's Global Assessment (PGA), the modified Sartorius score (MSS), and the HS Severity Index (HSSI). Each of these assessments has both advantages and limitations in daily practice; there is currently no gold standard (5-8). The Hurley staging system is the simplest and most widely used instrument for HS classification in routine clinical practice. It classifies HS into three stages. HS-PGA is relatively easy to apply and is frequently used to measure clinical improvement in clinical trials of medical treatments (5). The system describes six disease stages, increasing in severity on a scale from 1 to 6 (9). MSS is a more detailed and dynamic classification system based on the counting of individual nodules and fistulas within seven anatomical regions. The system, which was developed by Sartorius et al. and later modified, is the first disease-specific instrument for dynamically measuring clinical severity of HS (10). The treatment of HS includes topical clindamycin, triamcinolone acetonide, clobetasol, topical resorcinol, oral antibiotics, hormonal therapy, oral retinoids, and biologic therapies (11). Biologic therapies are increasingly used in patients who fail to sufficiently respond to antibiotic and hormonal treatments. Adalimumab, infliximab, and etanercept have all been tested in the treatment of HS but vary in effectiveness and in how well they have been studied. Subcutaneous weekly adalimumab (160 mg at week 0, 80 mg at week 2, and 40 mg each week thereafter) is the only biologic agent approved by the US Food and Drug Administration (FDA) and the European Medicine Agency (EMA) for the treatment of HS, and it is recommended as first-line therapy for patients with moderate-to-severe disease who are intolerant or unresponsive to oral antibiotics (12). The first male patient aged 59 years was referred to our Department with very long history of HS. The first symptoms had been unrecognized and presented as a pilonidal cyst 25 years ago as well as cysts on the intergluteal region treated with multiple surgical interventions and systemic antibiotics. The first hospitalization at our Department was in 2016. In addition to HS, the patient had diabetes mellitus (DM) type II and hypertension. A physical examination showed multiple abscesses, fistulas, and nodules in the axillary, inguinal, perianal, gluteal, and intergluteal regions; Hurley staging: stage II, PGA staging: IV, DLQI: 24 (Figure 1, Figure 2). Microbiological repeated swabs showed numerous bacteria such as Esch.coli, S.aureus, Serratia.spp, Enterococcus spp, St.epidermidis, and Proteus mirabilis. Laboratory tests which included complete blood cell count, biochemistry, serology for syphilis, HIV, and hepatitis B and C infection together with chest X-rays were all within normal limits. Abdominal ultrasound examination found no abnormalities. Quantiferon test was positive. After the monotherapy with isoniazid, a repeated Quantiferon test two months later was negative. The patient was treated with betadine solution and pus drainage until 2018, when at the Department of Dermatology and Venerology prescribed adalimumab in doses of 80 mg initially, 40 mg ×2 on the first day and the day after that, then 80 mg after fifteen days followed by 40 mg every ten days. After 16 weeks of treatment with adalimumab, Hurley staging was II, PGA IV, DLQI 3. The second male patient aged 28 years was referred to our Department with a shorter history: the first symptoms were presented as pilonidal sinus in 2012, after that in 2015 as inflamed nodules and fistulas in the axillary and inguinal regions. In 2018, physical examination showed the same nodules with a more intense character as well as furuncles on the scalp and skin of the back, with Hurley staging stage II, PGA staging III, DLQI 14 (Figure 3, Figure 4). Until the disease was diagnosed, the patient was treated several times with peroral antibiotics, while laboratory tests which included complete blood cell count, biochemistry, serology for syphilis, HIV, and hepatitis B and C infection together with chest X-rays were all within normal limits with the exception of elevated cholesterol (6.1). Abdominal ultrasound examination found no abnormalities. Quantiferon test was negative. The following therapy was administered during hospitalization: Humira (adalimumab) initial dose 160 mg, a dose of 80 mg after 14 days, and after 7 days 40 mg, in addition to local therapy with 10% resorcinol solution at the location of the skin changes. After 16 weeks of treatment with adalimumab, Hurley staging was II, PGA staging was III, and DLQI index was 3. Hidradenitis suppurativa is a chronic, recurrent inflammatory and debilitating skin disease of the terminal hair follicle that usually presents after puberty with painful, deep seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillary, inguinal, and anogenital region (3). Biological therapies have been increasingly used for patients who failed to sufficiently respond to antibiotics and hormonal treatments. Adalimumab, infliximab, and etanercept have all been tested in the treatment of hidradenitis suppurativa but vary in effectiveness and in how well they have been studied. Subcutaneous weekly adalimumab (160 mg at week, 80 mg at week 2, and 40 mg each week thereafter) is the only biologic agent approved by the US Food and Drug Administration (FDA) and the European Medicine Agency (EMA) for the treatment of HS and is recommended as first-line therapy for patients who moderate-to-severe disease and who are intolerant or unresponsive to oral antibiotics (5,12). Treatment of hidradenitis suppurativa remains a considerable challenge and should be individualized according to the state and extent of the disease. Therapeutic options for hidradenitis suppurativa were long restricted to the use of local disinfectants and systemic antibiotics as well as repeated incisions and drainage, which produce only short-term benefits. Our patients showed regression of lesions after sixteen weeks of biological therapy.

Knowledge, Attitudes, and Behaviors of Mostar University Students on the Harmful Effects of Ultraviolet Radiation Exposure - A KAB Study.

Various reports suggest that adolescents seem to be obsessed with tanning. Existing evidence on attitudes demonstrate that young adults focus on improving appearance through a tan, with protective behaviors often being absent. The popularity of tanning, primarily among the young adult population, further promotes unsafe sun-related behaviors. The aim of this study was to determine the knowledge level of Mostar University students on the harmful effects of ultraviolet radiation (UVR), their attitudes and sun-related behaviors, and whether medical students are more likely to apply preventive measures against UVR in comparison with students from other faculties. The survey included a total of 140 undergraduate Mostar University students: 70 medical students and 70 non-healthcare-related faculty students. The data were collected by completing the personal design questionnaire created for this study. This study shows that Mostar University students have a high level of knowledge about UVR and skin cancer, but their behavior is not sufficiently preventive and appropriate to their knowledge. Medical students often use UV protection measures and employ more preventive behavior than that of other faculty students, but it is still at a low level of prevention. Findings concurred with existing evidence that the knowledge of associated risks from UVR was not sufficient to motivate safer sun-related practices.

The Usage of Hypoallergenic Cosmetics in Patients with Atopic Dermatitis.

The aim of this study was to investigate how many patients with atopic dermatitis applied hypoallergenic cosmetics compared with topical corticosteroids. The study included 41 patients with atopic dermatitis (AD) who were treated from June 1 to July 1, 2017 at the Department of Dermatology and Venerology, Clinical Hospital Mostar. According to the data analyzed, 46.34% of patients used hypoallergenic cosmetics while 24.39% used them periodically. 32.7% patients used topical corticosteroids and 17.07 % used them periodically. 19.51 % of the patients with atopic dermatitis used alternative products, while 17.07% used them periodically. Out of the total number of patients, most of the patients used neutral products. 78.05% used neutral cosmetic products, and 19.51 % used them periodically. 65.85 % patients used sunscreens and 24.40 % used them periodically. The majority of patients used neutral cosmetic products and sunscreens. There was no statistically significant difference in the frequency of the use hypoallergenic cosmetics compared with topical corticosteroids (χ2 = 1.802; df = 2; P=0.405). Women used sunscreens more often (χ2 = 16,02; df = 1; p = <0,05).

Cutis Verticis Gyrata - A Case Report.

Cutis verticis gyrata (CVG) is a skin condition characterized by excessive growth of the skin of the scalp, resulting in furrows and folds which are similar to the gyri of the brain cortex. CVG can be classified into two forms: primary (essential and non-essential) and secondary. We report the case of a 53-year-old male patient with the primary type of CVG. The patient did not present with any cutaneous complication. His main complaint was the unaesthetic aspect of his scalp related to a psychological inferiority complex.

Aplasia Cutis Congenita in a Newborn Child Associated with Two Fetus Papyraceous.

Aplasia cutis congenita (ACC) is a rare inborn lesion, presenting with absence of skin. The etiology is unknown and is probably not attributable to a single cause but to a combination of genetic factors. Multiple causes have been suggested for ACC: syndromes and teratogens, intrauterine infection--varicella zoster virus, herpes simplex virus--fetal exposure to cocaine, heroin, alcohol, or antithyroid drugs. The most common site is the scalp. We report a case with multiple lesions on the trunk, resembling an instance with ACC group 5. This form of ACC occurs in association with the in utero death of a twin or more (in this case triple) fetus. Histological findings are available in very few reports. Therapy options depend on the characteristics of the lesion, but conservative treatment is usually chosen.

Analysis of psychopathological traits in psoriatic patients.

Psoriasis vulgaris is a multifactorial, heterogeneous disease that is associated with problems in skin image and feelings of shame and stigmatization. The aim of this study was to analyze psychopathological traits in patients with psoriasis and a comparative group. A total of 254 dermatological patients participated in the study: 124 patients with confirmed diagnoses of psoriasis vulgaris and 130 patients with melanocytic and non-melanocytic nevi on covered parts of the body. Psychometrically mensural and standardized instruments were used in the study: list of general data, appendix of disease data, Beck Depression Inventory test, State-Trait Anxiety Inventory, Measure of psychological stress and Eysenck's Personal Questionnaire. There is a significant statistical difference in the result of psychometric tests between the study groups. Patients with psoriasis have more severe symptoms of depression, more physical symptoms of anxiety and higher results on the anxiety scale as a state and as a trait p=0.000. Eysenck's personal questionnaire showed higher results on the psychoticism scale p=0.000 and lower results on the extraversion scale p=0.035 among psoriatic patients.

Knowledge and attitudes towards sun protection in Croatia.

Skin cancer is the most common form of cancer; the World Health Organization estimates that more than 2 million cases of skin cancer are being diagnosed each year worldwide. Excessive sun exposure and ultraviolet (UV) radiation are the major avoidable risk factors for skin cancer, including melanoma. Sun protection can be achieved through behavioral modification, social changes and environmental changes: regular use of sunscreen, wearing hats and protective clothes, staying in the shade, creating shade by planting trees or constructing canopies, practicing work and sport activities during the time of the day when the sun is not the strongest and many others. The aim of this paper was to investigate the knowledge and attitudes about sun protection and sun behavior patterns in Croatia, as well as the perception of melanoma among general population. Our results indicate relatively good sun behavior patterns among our participants and their mostly correct perception of melanoma.

Risk factors associated with the occurrence of basal cell carcinoma.

Basal cell carcinoma (BCC) is the most frequent malignant skin tumor, which is associated with both genetic factors and environmental influences. The objective of this study was to investigate the risk factors associated with the occurrence of BCC in the inhabitants of the Western Herzegovina area. The study took place during 1997-2003. We examined the risk factors which are presumably associated with the occurrence of BCC: skin type, exposure to UV rays and family occurrence of BCC, supplemented by the examination of the skin type, UV rays and existence of malignant tumors amongst the family members. We recorded a high correlation between the type of skin and the risk of occurrence of BCC. Long term and frequent skin exposure to UV rays were also associated with BCC. We also recorded increased risk for BCC in persons whose family members suffered from malignant skin tumors. Avoiding exposure to the sun as well as protection from UV rays may decrease the risk of BCC.

Quality of life in psoriatic patients and the relationship between type I and type II psoriasis.

Psoriatic patients, along with skin changes, frequently show various psychological changes such as depression, anxiety and have overall lower quality of life. The aim of this study was to evaluate the quality of life in patients with psoriasis compared to other dermatological patients, as well as to investigate the differences between the two subgroups--type I and type II psoriasis. A total of 94 dermatological patients were included. The patients were divided into two groups, the first group made of psoriatic patients which was further divided into two subgroups, and the second, control group made of patients with other skin diseases. DSQL quality of life questionnaire was used. The study showed that among psoriatic patients there was no significant difference in the quality of life, but there was a significant difference between the psoriasis type I and the control group, which could be explained by the strong influence of the disease on the quality of life in psoriatic patients.