Factors associated with pruritic papular eruption of human immunodeficiency virus infection in the antiretroviral therapy era.

BACKGROUND: Pruritic papular eruption (PPE) of HIV is common in HIV-infected populations living in the tropics. Its aetiology has been attributed to insect bite reactions and it is reported to improve with antiretroviral therapy (ART). Its presence after at least 6 months of ART has been proposed as one of several markers of treatment failure. OBJECTIVES: To determine factors associated with PPE in HIV-infected persons receiving ART. METHODS: A case-control study nested within a 500-person cohort from a teaching hospital in Mbarara, Uganda. Forty-five cases and 90 controls were enrolled. Cases had received ART for ≥ 15 months and had an itchy papular rash for at least 1 month with microscopic correlation by skin biopsy. Each case was individually matched with two controls for age, sex and ART duration. RESULTS: Twenty-five of 45 cases (56%) had microscopic findings consistent with PPE. At skin examination and biopsy (study enrolment), a similar proportion of PPE cases and matched controls had plasma HIV RNA < 400 copies mL(-1) (96% vs. 85%, P = 0·31). The odds of having PPE increased fourfold with every log increase in viral load at ART initiation (P = 0·02) but not at study enrolment. CD4 counts at ART initiation and study enrolment, and CD4 gains and CD8(+) T-cell activation measured 6 and 12 months after ART commencement were not associated with PPE. Study participants who reported daily insect bites had greater odds of being cases [odds ratio (OR) 8·3, P < 0·001] or PPE cases (OR 8·6, P = 0·01). CONCLUSIONS: Pruritic papular eruption in HIV-infected persons receiving ART for ≥ 15 months was associated with greater HIV viraemia at ART commencement, independent of CD4 count. Skin biopsies are important to distinguish between PPE and other itchy papular eruptions.

Two-year results from an open-label, multicentre, phase III study evaluating the safety and efficacy of canakinumab in patients with cryopyrin-associated periodic syndrome across different severity phenotypes.

OBJECTIVE: Longer-term effects of prolonged selective interleukin-1ß blockade with canakinumab were evaluated in the largest cohort of cryopyrin-associated periodic syndrome (CAPS) patients studied to date. METHODS: Adult and paediatric CAPS patients (n=166, including canakinumab-naive and pretreated patients from previous studies) received canakinumab subcutaneously 150 mg or 2 mg/kg (≤40 kg) every 8 weeks for up to 2 years. Response and relapse was assessed using scores for disease activity, skin rash and C-reactive protein (CRP) and/or serum amyloid A (SAA) levels. RESULTS: Complete response was achieved in 85 of 109 canakinumab-naive patients (78%; 79/85 patients within 8 days, and five patients between days 10 and 21). Of 141 patients with an available relapse assessment, 90% did not relapse, their CRP/SAA levels normalised (<10 mg/l) by day 8, and remained in the normal range thereafter. Median treatment duration was 414 days (29-687 days). Upward adjustments of dose or frequency were needed in 24.1% patients; mostly children and those with severe CAPS. Predominant adverse events (AE) were infections (65.7%) of mostly mild-to-moderate severity. Serious AE reported in 18 patients (10.8%) were mainly infections and were responsive to standard treatment. The majority of patients (92%) reported having no injection-site reactions and only 8% patients reported mild-to-moderate reactions. Patients receiving vaccination (15%) showed normal immune response. CONCLUSIONS: Subcutaneous canakinumab 150 mg every 8 weeks was well tolerated and provided substantial disease control in children and adults across all CAPS phenotypes. Higher canakinumab doses in younger patients and more severe CAPS disease were efficacious in achieving complete responses without evidence of increased AE. TRIAL REGISTRATION NUMBER: NCT00685373 (clinicaltrials.gov).

Topical salicylic acid gel as a treatment for molluscum contagiosum in children.

OBJECTIVE: To determine if the application of salicylic acid gel or phenol solution affected resolution of molluscum contagiosum (MC) lesions in children. PATIENTS AND METHODS: This was a randomized, prospective controlled trial with two treatment arms and one vehicle arm for treatment of MC in children. The trial was set in the dermatology outpatient clinics of a teaching hospital and a district general hospital. A total of 114 children were enrolled in the study (age range 1-15 years) over a 4-year period; 83 of the children completed the study. Patients were randomized to receive one of three possible treatments: monthly vehicle application of 70% alcohol, monthly application of 10% phenol in 70% alcohol once or twice weekly 12% salicylic acid gel. All patients also received treatment with daily aqueous cream to reduce eczema. They returned monthly to the clinic for treatment and counting of MC lesions. They were reviewed either until complete resolution or up to 6 months, whichever occurred sooner. The main outcome measure was the time taken for complete resolution of MC lesions. RESULTS: In the intention-to-treat analysis there was no difference between treatment arms when the 31 non-completers were analysed as failures (log-rank test: p = 0.38). In an 'as treated' analysis, 16 of 27 children (59.2%: 95% confidence interval 30.2-88.3) had cleared with vehicle, 18 of 32 (56.3%, 30.3-82.2) with phenol solution and 21 of 24 (87.5%, 50.1-124.9) with salicylic acid gel (log-rank test: p = 0.03). On an as treated basis, salicylic acid was significantly better at clearing MC than dilute phenol (p = 0.006). The treatment in all groups was very well tolerated or acceptable in 93% of children. CONCLUSION: Our results suggest that topical salicylic acid may be beneficial in speeding resolution of MC in children. Dilute phenol application does not appear to affect the disease course.

Cryopyrin-associated periodic syndromes and autoinflammation.

Autoinflammatory syndromes are a distinct class of inherited diseases of cytokine dysregulation with important cutaneous features. Several disorders, including familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome and neonatal onset multisystem inflammatory disorder (NOMID), are associated with mutations in a common gene, CIAS-1. These disorders are now believed to represent related conditions along a spectrum of disease severity, in which FCAS is the mildest and NOMID is the most severe phenotype. Patients typically present with lifelong atypical urticaria with systemic symptoms, with potential for developing end-organ damage due to chronic inflammation. Advances in the understanding of the genetic basis of these syndromes have also revealed cytokine signalling molecules that are critical to normal regulation of inflammatory pathways. The dramatic response of these syndromes to anakinra, an interleukin (IL)-1 antagonist, highlights the important role of IL-1 cytokine signalling in the pathogenesis of this rare but fascinating class of diseases.

A comparison of narrowband (TL-01) UVB-induced erythemal response at different body sites.

In most dermatology centres where phototesting is performed, the starting dose is calculated as a proportion of the minimal erythema dose (MED). Previous studies have found significant differences in MED readings between forearm and back skin with both broadband and narrowband (NB) UVB. Our objective was to compare MEDs obtained from three body sites, the forearm, back and abdomen, to see if there was a significant difference in individuals. We recruited 20 healthy volunteers who were exposed to our standard dose series for phototesting with NB-UVB to three body sites: forearm, back and abdomen. MEDs were assessed 24 h post exposure. The median MED for the abdomen was 0.79 J/cm2, the back 0.95 J/cm2 and the arm 1.11 J/cm2. Friedman's analysis of variance by ranks showed that these differences were significant (P = 0.003). There was no correlation between skin type and MED for any of the three anatomical sites. Our results support phototesting for all patients prior to treatment with NB-UVB. Furthermore, we have shown that the abdomen is the anatomical site of choice for phototesting, as this will result in a reduced risk of burning episodes.

Cutaneous findings in mummies from the British Museum.

This paper describes pathological abnormalities visible on the skin of mummies in the British Museum, London, and the photographic methods used to record their appearances. Although the mummification process limits the clinical information available, features compatible with eczema were identified for only the second time in mummified remains.

Sulphur and skin: from Satan to Saddam!

Since the dawn of time, Beelzebub has been showering fire and brimstone (sulphur) on tortured souls, but the cutaneous effects of this have been poorly described. Sulphur has also been used for centuries as a treatment for many skin conditions, such as fungal infections, scabies, psoriasis, eczema and acne. It has also been used extensively in cosmetic preparations and by cosmetic dermatologists treating conditions such as seborrhoeic eczema. Many natural bathing spas have high levels of sulphur; such balneology has been advocated by medical and cosmetic dermatologists as an effective treatment for cutaneous disorders for more than 500 years. Sulphur was often the active agent in many of the so-called 'patent medicines' that became popular in the mid-nineteenth century. Time has not withered medical practitioners' enthusiasm for sulphur. There are various reports in the medical literature of its current use. However sulphur treatment is not without its risks; a sulphur spring dermatitis has been described from a spa bath in Taiwan. With the satanic threat of bio-terrorism, some dermatologists may be treating the effects of contact with sulphur mustard all too soon.

A near fatal case of the dapsone hypersensitivity syndrome in a patient with urticarial vasculitis.

Dapsone (4,4'-diaminodiphenyl sulphone) is used for a variety of dermatological conditions including immunobullous diseases and urticarial vasculitis. Side-effects are common and include lethargy, headaches, methaemoglobinaemia and haemolysis. Severe adverse effects are rare but the dapsone hypersensitivity syndrome is well recognized. Symptoms include fever, haemolytic anaemia, lymphocytosis and hepatitis. We report a near fatal case of the dapsone hypersensitivity syndrome in a patient with urticarial vasculitis. This diagnosis should be remembered in any patient who becomes unwell whilst taking dapsone.