Videocapillaroscopic findings in the microcirculation of the psoriatic plaque during etanercept therapy.

BACKGROUND: Vascular endothelial growth factor (VEGF) is a pivotal cytokine in the pathogenesis of psoriasis, and upregulation of VEGF by tumour necrosis factor (TNF)-α and inflammatory factors causes marked alterations in the cutaneous microcirculation. Etanercept is a fully soluble TNF receptor fusion protein that primarily binds soluble TNF-α, thus blocking its pro-angiogenic function. AIM: To assess the modifications in the superficial capillary bed in psoriatic plaques during treatment with etanercept. METHODS: The study enrolled 22 patients (13 men, 9 women; age range 31-74 years) with plaque psoriasis resistant to conventional therapy. The patients were stated on etanercept 50 mg/week, which was continued for 24 weeks. At the beginning of the study (baseline), and at weeks 6, 12, 18 and 24, in vivo videocapillaroscopy analysis of a selected plaque was performed. Levels of erythema, scaling and infiltration were assessed using a four-point plaque severity score, with an overall score obtained by the sum of these three scores. The Psoriasis Activity and Severity Index (PASI) was also determined. RESULTS: Etanercept produced a significant reduction in PASI, plaque severity score and diameter of the basket-weave area at every time point. Four patients had complete remission, although none of the patients regained a normal capillaroscopic pattern. CONCLUSIONS: Similar to other conventional therapies, etanercept is able to improve PASI, plaque severity score and basket-weave area diameter, but it is unable to induce normalization of the microcirculation in psoriatic plaques.

Psoriasis vulgaris does not adversely influence the quality of sleep.

AIM: Sleep could be severely affected in psoriasis because of skin symptoms and psychological repercussions of the disease. The aim of this study was to investigate the influence of psoriasis on sleep. METHODS: A total of 202 patients with psoriasis and 202 healthy volunteers have completed a self-rated questionnaire, the Pittsburgh Sleep Quality Index, which assesses sleep quality and disturbances over a 1-month time interval. The severity of the dermatoses has been evaluated utilizing the PASI score. RESULTS: In psoriatic patients the Pittsburgh Sleep Quality Index resulted between 0 and 17 (5.56±3.93), in the controls between 0 and 18 (5.13±4.16). No statistically significant correlation was observed between the score of Pittsburgh Sleep Quality Index and PASI. The anti-psoriatic therapy, while causing a marked improvement of lesions and itching, does not affect the quality of sleep. CONCLUSION: Although literature indicated that psoriasis negatively affects the quality of sleep, in this study this correlation was not observed.

Regulation of innate immunity by the nucleotide pathway in children with idiopathic nephrotic syndrome.

Activation of the oxidative burst and failure of CD4(+) CD25(+) cell regulation have been implicated in idiopathic nephrotic syndrome (iNS). The intimate mechanism is, however, unknown and requires specifically focused studies. We investigated reactive oxygen species (ROS) generation [di-chlorofluorescein-diacetate (DCFDA)] fluorescence assay and the regulatory adenosine 5'-triphosphate (ATP) pathways in the blood of 41 children with iNS, utilizing several agonists and antagonists of nucleotide/nucleoside receptors, including the addition of soluble apyrase. The CD4(+) CD25(+) CD39(+) /CD73(+) expression was determined in vivo in parallel during disease activity. Overall, we found that the percentage of CD39(+) CD4(+) CD25(+) was reduced markedly in iNS by 80% (3·43±0·04% versus 13·14±0·07% of total lymphocytes, P<0·001). In these patients, reactive oxygen species (ROS) generation by polymorphonuclear neutrophils (PMN) at rest was a function of apyrase (CD39) expressed by CD4(+) CD25(+) , with higher rates in patients with very low CD39(+) CD4(+) CD25(+) levels (<7·5%). Addition of apyrase reduced ROS generation by 40% in both iNS and controls and was mainly effective in patients. The quota of ROS surviving ATP elimination was higher still in iNS. In vitro studies to limit ROS generation with adenosine analogues (2'-chloroadenosine and 5'-N-ethylcarboxamidoadenosine) produced minor effects. At variance, antagonizing ATP efflux with carbenoxolone or by antagonizing ATP effects (Brilliant Blue G, KN62 and A437089) reduced ROS generation comparable to apyrase. These results confirm a key role of ATP in the regulation of innate immunity and minimize the effect of adenosine. Decreased CD39(+) CD4(+) CD25(+) expression in iNS highlights an impairment of ATP degradation in this pathology. However, high ROS surviving ATP consumption implies a major role of other regulatory pathways.

Absence of clinical and dermoscopic differences between congenital and noncongenital melanocytic naevi in a cohort of 2-year-old children.

BACKGROUND: Congenital melanocytic naevi (CMN) are present at birth. Some naevi, tardive congenital naevi (TCN), become clinically apparent only after birth, during the first years of life. The number of naevi continues to increase due to the appearance of acquired melanocytic naevi (AMN). When AMN begin to appear has not been well defined. OBJECTIVES: To investigate the clinical and dermoscopic features of the melanocytic naevi present in 2-year-old children and to search for and highlight any differences between CMN present at birth (BPN) and naevi appearing after birth during the first 2 years of life (FLN). METHODS: A nonrandomized observational study was performed. A total of 133 melanocytic naevi in 103 children aged 21-26 months were analysed by clinical and dermoscopic examination. RESULTS: Of the subjects, 76% of children had one naevus, 20% had two naevi, 3% had three naevi and 1% had four naevi. Of the naevi, 76 were BPN and 57 were FLN. The naevi with the largest diameters were significantly associated with BPN (P = 0·025). Polycyclic edges (P = 0·0378) were observed with a higher frequency in BPN than in FLN. The predominant dermoscopic patterns were globular (BPN 51%; FLN 58%) and reticular (BPN 28%; FLN 14%). CONCLUSIONS: The number of naevi present in the first 2 years of life is small, and over half have already appeared at birth. They are distributed widely over the skin. BPN are larger than FLN, but most naevi are small. There was no significant difference in the dermoscopic features between the 133 BPN and FLN. The predominant patterns were globular and reticular. We could not identify defined criteria that allowed us to diagnose CMN with certainty and distinguish them from TCN and AMN.

Response of cutaneous microcirculation to treatment with mometasone furoate in patients with psoriasis.

BACKGROUND: In patients with psoriasis, videocapillaroscopy has been used to visualize the typical modifications in the microcirculatory architecture. AIM: To evaluate the modifications of the superficial capillary bed in a psoriatic plaque and healthy perilesional skin during treatment with a topical steroid. METHODS: In total, 24 patients affected with psoriasis vulgaris were enrolled. Each patient was instructed to apply mometasone furoate cream 0.1% once daily to a selected psoriatic lesion for 12 weeks. At baseline (T0) and after 4 (T1), 8 (T2) and 12 (T3) weeks, clinical and capillaroscopic examination was made of the psoriatic plaque and the surrounding skin. RESULTS: At the end of the study, the diameters of dilated and convoluted capillaries in the psoriatic plaque were significantly reduced (baseline, 69.2 microm; after 12 weeks, 29.3 microm; P < 0.0001) in all subjects. A marked clinical improvement was also noted (plaque score: baseline, 7.4; after 12 weeks, 0.5; P < 0.0001). The perilesional skin also showed improvement in capillaroscopic alterations, even if the drug had not been applied to those areas. Of the 24 patients, 12 were clinically healed at the end of the treatment period, although the capillaroscopic picture returned to normal in only 2 of them. CONCLUSIONS: Mometasone furoate cream proved to be effective in reducing the clinical and capillaroscopic alterations of the psoriatic plaque, but there was no association between clinical improvement and microcirculatory alterations noted. The action of mometasone furoate action on the microcirculation was not limited only to the area of application, but also extended to the surrounding areas.

Relationship between sebostatic activity, tolerability and efficacy of three topical drugs to treat mild to moderate acne.

BACKGROUND: Acne is a multifactorial disorder in which the sebum plays an important pathogenetic role. PURPOSE OF THE STUDY: To evaluate the sebostatic effect of three anti-acneic ingredients (azelaic acid, adapalene and benzoyl peroxide) conveyed in cream and to determine whether there is a correlation with the therapeutic results. MATERIALS AND METHODS: Sixty-five patients with mild or moderate acne localized on the face were divided into three therapy groups at random: 25 applied azelaic acid once a day, 20, benzoyl peroxide and 20, adapalene. All the patients were observed at the time of enrolling and a further four times at fortnightly intervals. At each visit the sebum casual level on the forehead, chin and one cheek was measured using a sebumeter. Furthermore, side-effects and clinical-therapeutic effectiveness were noted. RESULTS: Four patients did not complete the study. Azelaic acid showed an average reduction of 13.9% in sebum production on the forehead, 14.2% on the chin and 15.2% on the cheek. Benzoyl peroxide caused an increase of 10.5% in sebum production on the forehead, 10.3% on the chin and 25.4% on the cheek. Adapalene reduced sebaceous secretion by 0.2% on the forehead and 6.7% on the cheek whereas sebum production increased by 6.2% on the chin. All three drugs showed a clinical improvement in the acneic lesions with moderate adverse effects. CONCLUSION: The three topical drugs bring about good therapeutic results with scarce side-effects that do not, however, seem to be correlated with the sebostatic activity.

Leukaemia-associated eosinophilic folliculitis (Ofuji's disease).

BACKGROUND: Ofuji's disease is an eosinophilic dermatosis mostly affecting male subjects. It is characterized by the appearance of follicular papulopustolosis, at times on an erythematous base, which tend to form an annular configuration. PATIENTS AND METHODS: Two cases are described: the first is a 45-year-old man affected by acute myeloid leukaemia and Ofuji's disease; the second is a 61-year-old man affected by chronic lymphatic leukaemia and Ofuji's disease. Culture tests were negative in both cases. In both patients no hypereosinophilia was found. CONCLUSIONS: The simultaneous presence of the two pathologies in these patients can only give rise to hypothesis. In the first case it could be attributed to interleukin (IL)-5, which causes both eosinophilic hyperproduction and blast differentiation. In the second case the hypersecretion of intercellular adhesion molecule type 1 (ICAM-1) in Ofuji's disease could be attributed to a modified transcriptional gene belonging to the class of immunoglobulin codifying genes located on the altered chromosomes in a certain percentage of leukaemic patients.

[Complications of pseudoainhum]. / Komplikationen bei Pseudoainhum.

A 39 year old man presented with recurrent episodes of leukocytoclastic vasculitis and a large ulcer at the distal part of the stump of his right leg. Since birth the patient showed a clinical picture of pseudoainhum as part of the amniotic band syndrome (Simonart syndrome). Radiologic examination of the right foot showed only an hypoplastic talus and calcaneus which had been designated as a "stump":, which have been detected by x-ray. On both upper limbs there were missing phalanges, syndactyly and some constrictive fibrotic bands. Since the ulcer worsened with therapy, the patient underwent the amputation of the stump just below under the knee. Since then no further vasculitic lesions have been observed. We consider this case remarkable both because pseudoainhum is so rare and because of these equally unusual complications.

Ofuji's disease: diagnostic and therapeutic problems. A report of three cases.

BACKGROUND: Ofuji's disease is an eosinophilic dermatosis affecting mostly male subjects. It is characterized by the appearance of follicular papulopustules, at times on an erytemathous base, which tend to form an annular configuration. The evolution is relapsing remitting. The histopathological examination demonstrates a dense dermal infiltrate with a prevalence of perifollicular and perivascular eosinophilia. Peripheral blood eosinophilia is observed in a high percentage of cases. The pathogenesis is unclear. METHODS: We report three cases of patients affected by Ofuji's disease with presentation on different sites. Our case reports concern three male subjects otherwise in good health and whose hematologic results were normal. Before they came to our observation, an erroneous diagnosis had been made and they had been subjected to improper treatment. RESULTS: To make a definite diagnosis it was necessary to evaluate the following features as a whole: the clinical aspect, the evolution, the result of the histological examination, the negativity of cutaneous cultures and the lack of response to previous treatments. All three patients were treated with dapsone 100 mg/day with regression of the clinical manifestations. In one case there was a relapse which was treated with isotretinoin 0.5 mg/kg/day. CONCLUSIONS: From our experience we can deduce that in cases of follicular pathologies which do not respond to conventional therapies, it is necessary to take into consideration the possibility of Ofuji's disease and, in that case, patients should be monitored because of the frequent relapses.

Validation of flow convergence region method in the assessment of carotid artery stenoses during color-flow duplex studies.

PURPOSE: The flow convergence region (FCR) method (also known as the proximal isovelocity surface area method) is currently used in echocardiography to evaluate the flow through cardiac valves and septal defects. The FCR method is based on the characteristic alterations in flow dynamics that occur proximal to a stenotic orifice. Blood converges uniformly and radially towards an orifice that is small relative to the section of the vessel and forms concentric isovelocity hemispheric shells where velocity progressively increases and flow remains laminar. The purpose of the article is to validate the use of this principle in the detection and assessment of carotid stenoses in the course of color-flow duplex studies. METHODS: In this prospective study, 80 patients affected by unilateral or bilateral carotid artery stenoses were evaluated for the presence of the FCR from February 1997 to March 1999. The results were compared with digital subtraction angiography. RESULTS: Color-flow duplex diagnosis of carotid artery stenoses of 70% or more was confirmed in 100% of the carotid artery stenoses (40/40 patients) with angiography. The FCR was detected in 72.2% (13/18) of carotid arteries affected by stenoses greater than 80%, in 54.4% (12/22) of carotid arteries affected by stenoses 70% to 80%, and in 13.6% (6/44) of carotid arteries affected by stenoses 50% to 69% (P <.001). In 5% of cases (2/40 of stenoses) the FCR was the only detectable sign of carotid stenosis. CONCLUSION: Our data suggest that a routine search for FCR in the course of color-flow duplex study of carotid arteries may further improve the reliability of this examination in the detection of carotid artery stenoses, particularly in the presence of heavily calcified lesions.