[Therapeutic failure in scabies: An observational study]. / Gales en échec de traitement : étude observationnelle.

BACKGROUND: Several sources suggest an escalation of scabies in France. AIM: To describe a population of patients continuing to present with scabies despite multiple treatments in order to identify factors associated with persistence of infection. PATIENTS AND METHODS: A descriptive cross-sectional study in adults and children consulting for persistent scabies despite at least one previous treatment. A standardized questionnaire explored potential sources of treatment failure. RESULTS: Thirty-one patients were analyzed. Initial symptoms were noted to have started between two and 52 weeks earlier (mean: 19 weeks). The mean number of prior consultations with a general practitioner was 3.1 (0-10) and 1.7 with a dermatologist (0-7). The mean number of patients per household was 3.5 (1-9). At least one dose of oral ivermectin (maximum of 6 doses per household) was prescribed for 84 % of patients (29 % of whom were not fasted at the time). Further, 74 % of patients received at least one local application of esdepallethrin and piperonyl butoxide (maximum: 5 courses), four received benzyl benzoate and two received permethrin; however, 58 % did not reapply the substance after hand washing. All households bought the prescribed treatments despite the costs. Close contacts of patients were treated in 58 % of households. Decontamination of bedding and clothing was carried out properly in 90 % of households. DISCUSSION: Persistence of infection appears to be linked to: (1) insufficient treatment of close contacts; (2) absence of a second treatment between days 7 and 14; (3) insufficient efficacy of the available treatments, doubtless due to multiple factors (intrinsic resistance of Sarcoptes, failure to repeat treatment, poor explanation of methods for dosing and application, and oral intake of treatments). Access to non-reimbursed treatments was not identified as a problem and decontamination of bedding and clothing was correctly performed in most cases. CONCLUSION: Though certain fundamental aspects of scabies treatment must be better known, longer consultations and provision of efficacious treatments are also a priority.

On demand Gamma-Knife strategy can be safely combined with BRAF inhibitors for the treatment of melanoma brain metastases.

BACKGROUND: Both Gamma-Knife radiosurgery (GKRS) and BRAF inhibitors (BRAF-I) have been shown to be useful in melanoma patients with brain metastases (BMs), thus suggesting that it could be interesting to combine their respective advantages. However, cases of radiosensitization following conventional radiation therapy in BRAF-I treated patients have raised serious concerns about the real feasibility and risk/benefit ratio of this combination. PATIENTS AND METHODS: Review by two independent observers of brain magnetic resonance imaging (MRI) follow-up pictures, and volume and edema quantifications, and survival assessment in all patients who had been treated by GKRS and BRAF-I at a single institution. RESULTS: Among 53 GKRS carried out in 30 patients who ever received BRAF-I and GKRS, 33 GKRS were carried out in 24 patients while under BRAF-I treatment, from which only 4 with an interruption of BRAF-I. The 20 other GKRS were carried out in 15 patients (including 9 of the 24) before initiation of BRAF-I treatment. No case of radiation-induced necrosis and no scalp radiation dermatitis occurred. A >20% increase in volume was observed in 35 of the 263 BM treated by GKRS (13.3%), but only 3 clear-cut edemas and 3 hemorrhages were detected within 2 months after GKRS, and 4 edemas and 7 hemorrhages later. Neither the MRI features nor the incidence of the volume changes, hemorrhage and edema were deemed unexpected for melanoma BM treated by GKRS. Median survival from first GKRS under BRAF-I and first dose of BRAF-I were 24.8 and 48.8 weeks, respectively. CONCLUSION: This series does not show immediate radiotoxicity nor radiation recall, in melanoma patients with BRAF-I whose BMs are treated by GKRS. Interrupting BRAF-I for stereotactic radiosurgery (SRS) of BM seems useless, although it is still advised for other radiation therapies. The potential benefit of combining SRS and BRAF-I can be safely tested.

[Telangiectasia during amlodipine therapy]. / Télangiectasies au cours d'un traitement par amlodipine.

BACKGROUND: Calcium inhibitors are recommended as first-line treatment in hypertension. We report the development of telangiectasia on the trunk and upper limbs in a female patient on amlodipine (Amlor(®)) that subsided on treatment discontinuation. PATIENTS AND METHODS: A 63-year-old woman consulted for numerous asymptomatic stellate telangiectasias on her upper trunk and shoulders, with sparing of the face. No Darier's sign was seen and clinical examination was otherwise normal. The patient had been treated with amlodipine (Amlor(®)) and a combination of bisoprolol and hydrochlorothiazide (Lodoz(®)) for 5years for essential hypertension. Laboratory tests, which included serum tryptase assay, were normal. Histological analysis showed a normal epidermis with dilated superficial dermal capillaries and no inflammatory infiltrate or dermal elastosis. Amlodipine was discontinued and replaced with ramipril (an ACE inhibitor). The other treatments were changed over and the telangiectasias regressed spontaneously within several months, with no relapse being seen at one year of follow-up. COMMENTS: Reports of telangiectasia associated with calcium inhibitors most commonly involve the dihydropyridine family, of which amlodipine is a member. Inhibition of muscular contraction induced by this treatment results in vasodilatation, accounting for the associated antihypertensive properties, and this could play a role in telangiectasia formation. The literature contains reports of cases of photo-distributed telangiectasia, suggesting that as well as vasodilatation, calcium inhibitors may in certain cases cause abnormal sensitivity of blood vessels to ultraviolet radiation. The absence of facial lesions rules out the hypothesis of photo-induced lesions in our patient.

[Granulomas induced by injections of leuprorelin acetate (Enantone®)]. / Granulomes induits par des injections de leuproréline acétate (Enantone ®).

BACKGROUND: Gonadorelin analogues (LHRH) are used for the endocrine treatment of prostatic cancer, central early puberty and various gynaecological conditions. Cutaneous adverse events seldom occur. We report a case of injection-site granulomas induced by leuprorelin acetate (Enantone®). CASE REPORT: A 76-year-old man presented with several subcutaneous nodules on his left arm. The nodules were hard but painless. He had received subcutaneous injections of Enantone® for prostatic cancer. Histological examination of a skin biopsy specimen demonstrated granulomatous inflammation with a necrotic centre; screening for an infectious aetiology was negative. Serial sections showed giant cells containing translucent round microspheres in the subcutaneous tissue. Limitation to the leuprorelin acetate injection sites in the arm and detection at histological analysis of microspheres probably bound to an injected product militated in favour of granulomas caused by injections of Enantone®. DISCUSSION: Injection-site granulomas caused by Enantone® are rare. Their formation may depend on the mode of administration: the more superficial the injection, the higher the risk of developing granulomas. The formation of these lesions is probably a foreign body reaction to the excipient.

[Fever with skin rash and polyarthralgia in a genetically black-skinned woman]. / Eruption cutanée et polyarthralgie fébrile chez une femme génétiquement pigmentée.

Adult onset Still's disease (AOSD) is a systemic disorder characterized by intermittent fever, evanescent rash, polyarthralgia or arthritis, and neutrophilic leucocytoclasis. Appearance of skin rash during fever episodes is the characteristic feature. An atypical form of AOSD with a fixed pigmented skin rash was described in 1994. Prognosis of the atypical form is thought to be more severe than that of the classic form. The purpose of this report is to describe the first case of atypical AOSD in a genetically black-skinned woman. Treatment required administration of high-dose systemic corticosteroids.

Survival of melanoma patients treated with targeted therapy and immunotherapy after systematic upfront control of brain metastases by radiosurgery.

BACKGROUND: Targeted therapy (TT) and immunotherapies (ITs) have dramatically improved survival in metastatic melanoma (MM). However, their efficacy on brain metastasis (BM) remains limited and poorly documented. PATIENTS AND METHODS: Retrospective cohort of consecutive MM patients (pts) with BMs, all systematically upfront treated by Gamma-Knife (GK) at first BM and retreated in case of new BMs, from 2010 to 2015 at the time when ipilimumab BRAF ± MEK inhibitors and anti-PD1 were introduced in practice. Survival after 1st GK (OSGK1) according to prognostic factors and treatment. RESULTS: Among 179 consecutive pts treated by GK, 109 received IT and/or TT after the 1st GK. Median OSGK1 was 10.95 months and 1- and 2-year survival rates were 49.5% and 27.4%, respectively, versus a median overall survival (OS) of 2.29 months (p < .001) in those who did not receive IT or TT. In pts who initially had a single BM, median OS and 1- and 2-year survival rates were 14.46 months, 66.7% and 43.4%, respectively; in pts with 2-3 BMs: 8.85 months, 46.4% and 31%, respectively; in pts with >3 BMs: 7.25 months, 37.2% and 11.9%, respectively. Multivariate analysis for OSGK1 confirmed that IT and TT were significantly and highly protective. Best OSGK1 was observed in BRAF-wild-type pts receiving anti-PD1 or in BRAF-mutated pts receiving BRAF-inhibitors and anti-PD1 (12.26 and 14.82 months, respectively). CONCLUSION: In real-life MM pts with BMs, a strategy aiming at controlling BM with GK together with TT and/or TT seems to achieve unprecedented survival rates.

[Treatment of Hailey-Hailey disease with carbon dioxide laser vaporization]. / Traitement de la maladie de Hailey-Hailey par laser ablatif CO2.

INTRODUCTION: Only ablative methods lead to long term remission of areas affected by Hailey-Hailey disease: excision/skin graft, cryosurgery, dermabrasion... The method using the CO2 laser is a recent addition in the management of this dermatitis. We report our experience with this technique in 4 patients. PATIENTS AND METHODS: Carbon dioxide laser vaporization was proposed to 4 patients exhibiting Hailey-Hailey disease resistant to classical treatments. A test under local anesthesia was performed beforehand in all the patients. A 60 year-old man had an immediate reaction and refused to continue treatment. In the other 3 cases, the result of the test at 6 months was considered satisfactory. These patients were treated under general anesthesia in a single area of 50 to 70 cm2, and a half-body for comparison. The CO2 laser was used in pulse mode, with successive irradiations, until a homogenous, whitish-yellow aspect with first retraction was obtained. RESULTS: Although the healing delays were long (a mean of 1 month) and required major analgesics over the first few days, the cosmetic results were satisfactory and no abnormal scarring was observed. After a median follow-up of 27 months, no relapse of the disease other than punctiform elements was noted. All the patients wanted treatment of the other remaining affected areas be continued. In 2 patients, CO2 laser vaporization permitted treatment of areas not easily accessible to other ablative methods (around the mouth, the anus and the vulva) with anatomy and normal function spared. DISCUSSION: These results are globally good. Although the time to healing was long, the cosmetic and functional results were always satisfactory, without abnormal scarring. Moreover, in 2 of the patients, CO2 laser was able to treat areas inaccessible to other methods. The reason for the efficacy of ablative methods is debated. Re-epidermization with keratinocytes of appendices and not expressing the molecular defect, and the constitution of dermal cicatricial tissue, are two currently proposed hypotheses.

Multiple senile lentigos of the face, a skin ageing pattern resulting from a life excess of intermittent sun exposure in dark-skinned caucasians: a case-control study.

BACKGROUND: Different patterns of skin ageing can be described depending on the predominant lesions, i.e. wrinkles, laxity, atrophy, senile lentigos (SLs), etc. They may correspond to different epidemiological contexts. OBJECTIVES: To identify and assess the epidemiological factors for a skin ageing pattern characterized by a high density of SLs on the face, or 'lentigo ageing pattern' (LAP). METHODS: An age- and sex-matched case-control study was conducted in individuals aged between 60 and 80 years, comparing cases (n = 118) with a very high number of SLs on the face for their age, and controls (n = 118) with no or very few SLs for their age. The cases and controls were recruited in two hospitals. RESULTS: In univariate and multivariate analysis, LAP was associated with skin types III and IV, with frequent sunburns, and with the part of the lifetime cumulative sun exposure which was received during vacations. Conversely, there was no link with the occupational and everyday exposures and the total cumulative exposure. LAP was associated with multiple solar lentigos of the upper back. No relationship was found with postmenopausal hormonal therapy, number of naevi, or freckles. CONCLUSIONS: Different epidemiological factors may account for the different skin ageing patterns. LAP seems to develop preferentially in dark-skinned caucasians who have repeatedly received intermittent and intense sun irradiations throughout their life, and have often developed solar lentigos on the upper back earlier in life, whereas the 'prominent wrinkling' pattern is known to affect light-skinned people and smokers with a life excess of continuous exposure.