Assessing the Impact of Atopic Dermatitis on the Patients' Parents with the Visual Instrument 'Caregiver-PRISM'.

BACKGROUND: There is a need to improve the quality of communication between clinicians and parents of young patients with atopic eczema (AE). OBJECTIVE: To create a tool to measure the suffering that caregivers experience in association with their child's AE (Caregiver Pictorial Representation of Illness and Self-Measure, Caregiver-PRISM), assess the validity and reliability, and identify factors associated with caregiver suffering. METHODS: Caregiver-PRISM was administered to 45 parents of patients from an AE outpatient service (Padua, Italy). RESULTS: Caregiver-PRISM had a good test-retest reliability (r = 0.85; t7 = 4.13; p < 0.05), content validity and construct validity when used in parents of AE children. Parents with a less positive family affective climate, higher education, or with children following a diet experienced higher suffering associated with their child's AE, demonstrated by lower Caregiver-PRISM scores (p < 0.05). CONCLUSION: Our results support the use of Caregiver-PRISM in parents of AE patients to assess suffering associated with patients' illness.

Efficacy of Biofeedback and Cognitive-behavioural Therapy in Psoriatic PatientsA Single-blind, Randomized and Controlled Study with Added Narrow-band Ultraviolet B Therapy.

Increasing data suggests that there is a connection between stress and the appearance of psoriasis symptoms. We therefore performed a clinical trial enrolling 40 participants who were randomly allocated to either an 8-week cognitive-behavioural therapy (CBT) (treatment group) plus narrow-band UVB phototherapy or to an 8-week course of only narrow-band UVB phototherapy (control group). We evaluated the clinical severity of psoriasis (PASI), General Health Questionnaire (GHQ)-12, Skindex-29 and State-Trait Anxiety Inventory (STAI) at baseline and by the end of the study. Sixty-five percent of patients in the treatment group achieved PASI75 compared with 15% of standard UVB patients (p = 0.007). GHQ-12 cases were reduced from 45% to 10% in the treatment group and from 30% to 20% in the control group (p = 0.05). The Skindex-29 emotional domain showed a significant improvement in the CBT/biofeedback group compared with control patients (-2.8 points, p = 0.04). This study shows that an adjunctive 8-week intervention with CBT combined with biofeedback increases the beneficial effect of UVB therapy in the overall management of psoriasis, reduces the clinical severity of psoriasis, improving quality of life and decreases the number of minor psychiatric disorders.

Psoriasis - The Life Course Approach.

Over the last decades, Life Course Research (LCR), predominantly the domain of sociology, has been increasingly applied in health research, as Life Course Epidemiology (LCE). The latter is concerned with disease patterns over time, accumulation of exposures over time, critical time periods and patterns of risk. We argue that concepts from LCR and LCE could be widely applied in dermatology, in general, and, more precisely, in the study of chronic inflammatory skin diseases, e.g. atopic eczema and psoriasis. The life course approach can generally be applied in two different ways. It may be used in the more traditional manner, in which the disease and its patterns over time are examined as the outcome vari-able. Conversely, it can examine life course as the outcome variable, which is dependent on the disease course, the treatments administered, and other physical or psychosocial environmental exposures. In dermatology, this second application of the LCR concepts is both promising and relevant because of the notable impact of chronic skin diseases on the patients' quality of life. In particular, we argue how LCR may be conducive to a better understanding of the concept of 'Cumulative Life Course Impairment', which is increasingly gaining acceptance. This approach helps identifying not only individuals at risk and particularly vulnerable patients but also critical periods for optimising interventions in order to avoid life course impairment. It also may facilitate more appropriate treatment decisions in clinical practice.

Contact Sensitization in Children: A Retrospective Study of 2,614 Children from a Single Center.

BACKGROUND: Contact sensitization in children is more common than previously thought, but few studies have been performed on a large population assessed by the same team. The objective was to evaluate contact sensitization in children with suspected contact dermatitis, the relationship with atopic dermatitis (AD), and the most common allergens. METHODS: The same team patch tested 2,614 children younger than 11 years old with a standard series of 30 allergens. RESULTS: A total of 1220 children (46.7%) developed at least one positive reaction, 606 of which were clinically relevant (49.7%). The most frequent reactions were to nickel sulfate (22.7%), cobalt chloride (11.1%), potassium dichromate (9.9%), neomycin sulfate (5.2%), thimerosal (4.2%), cocamidopropyl betaine (3.4%), and methylchloroisothiazolinone/methylisothiazolinone (3.2%). The prevalence of contact sensitization was similar in children with (47.3%) and without (46.1%) AD. Children with AD had a higher prevalence of positive reactions to potassium dichromate (p < 0.001), Compositae mix (p = 0.01), and disperse blue (p = 0.03). CONCLUSIONS: Contact sensitization is quite common in young children. This study adds some information on the most common contact allergens. A similar prevalence of positive patch test reactions was found in children with and without AD, but children with AD had a greater prevalence of positive patch test reactions to potassium dichromate, Compositae mix, and disperse blue.

Efficacy of switching between tumor necrosis factor-alfa inhibitors in psoriasis: results from the Italian Psocare registry.

BACKGROUND: Some studies have shown that switching patients from one tumor necrosis factor (TNF)-alfa inhibitor to another may be beneficial when they have an inadequate response or an adverse event. OBJECTIVE: We sought to assess the variables predicting the efficacy of the second TNF-alfa inhibitor in patients discontinuing the first TNF-alfa inhibitor. METHODS: Data from all 5423 consecutive patients starting TNF-alfa inhibitor therapy for psoriasis between September 2005 and September 2010 who were included in the Italian Psocare registry were analyzed. RESULTS: In 105 patients who switched to a second TNF-alfa inhibitor who had complete follow-up data, 75% improvement in the Psoriasis Area Severity Index score (PASI 75) was reached by 29% after 16 weeks and by 45.6% after 24 weeks. Patients who switched because of secondary loss of efficacy (loss of initial PASI 75 response) or adverse events/intolerance were more likely to reach PASI 75 than those who switched as a result of primary inefficacy (PASI 75 never achieved) (hazard ratio 2.7, 95% confidence interval 1.3-5.5 vs hazard ratio 2.0, 95% confidence interval 1.0-3.9 and 1, respectively). LIMITATIONS: There was a small number of patients with complete follow-up data. CONCLUSION: PASI 75 response in patients who switched from one anti-TNF-alfa agent to another was significantly reduced in patients who showed primary inefficacy of the first anti-TNF-alfa.

Quality of life assessment of patients with scalp dermatitis using the Italian version of the Scalpdex.

The aim of this study was to assess quality of life in patients with scalp dermatitis using the Italian version of the Scalpdex, and to validate the instrument in Italian. The survey was conducted in outpatients with psoriasis, seborrhoeic dermatitis, alopecia, or follicular lichen. Data were completed on 194 patients, 78% of whom had psoriasis. Scalpdex scores were always higher in women than in men, and in younger people compared to elderly people. The most frequent items were: being ashamed, embarrassed, bleeding scalp, feeling self-conscious, bothered that the condition is incurable, having the choice of colour of clothes affected, having a negative effect on daily life. The Italian Scalpdex showed good internal consistency, test-retest reliability, convergent validity, and responsiveness. In conclusion, the Italian version of the Scalpdex is a useful instrument to measure quality of life in patients with a scalp condition.

Dermoscopic changes in melanocytic naevi in children during digital follow-up.

The aim of this study was to investigate the dermoscopic changes in acquired melanocytic naevi in a large paediatric population over an interval of several years. Images of 717 melanocytic naevi were obtained from 160 consecutive patients. Dermoscopic pigment pattern changes were observed in one of two lesions after a follow-up of one year, in 34 of 295 lesions (11.5%) after 2 years, in 40 of 190 lesions (21.1%) after 3 years, in 40 of 141 lesions (28.4%) after 4 years, in 5 of 37 lesions (13.5%) after 5 years, in 12 of 31 lesions (38.8%) after 6 years, and in 7 of 21 lesions (33.3%) after 7 years. Dermoscopic changes were detected in 25.3% of the lesions in patients aged 3-6 years, in 21% of the lesions in patients aged 7-12 years, and in 15.5% of the lesions in patients over 13 years. Main pattern changes consisted of transition from globular to globular-reticular (35 naevi), from globular to reticular (14 naevi) and from globular-reticular to reticular (24 naevi). These results are consistent with the view that melanocytic naevi generally undergo a characteristic transition from a globular pattern to a reticular pattern. Most of the changes are observed in the 3-6 years age group when hormonal and/or environmental factors are not thought to play a role in pattern alterations.

Skin cancer and other cutaneous disorders in liver transplant recipients.

Patients who have received liver transplant are at increased risk of skin complications due to long-term immunosuppression regimen. The aim of this study was to analyze the incidence and risk factors of skin complications in liver transplant patients. We analyzed 161 liver transplant recipients. The mean age at transplantation was 47.4 years. Mean follow-up was 6 years. Seventy-one percent of patients presented with skin complications, including aestethic alterations, infections, precancerous lesions and malignancies, which represented 57%, 43%, 18% and 9%, respectively. Risk factors were: age at transplantation ≥ 45 years, immunosuppressive therapy with cyclosporine, and phototype II and III. Our study indicates that although liver transplant recipients are at greater risk of developing skin complications compared to the general population, the risk is lower than for other solid organ transplants, particularly for premalignant and malignant lesions.

Erythroderma in the era of biological therapies.

Erythroderma is a scaling erythematous dermatitis involving 90% or more of the cutaneous surface. Psoriasis and eczema are the most common dermatoses underlying erythroderma. Cutaneous T cell lymphomas can also cause erythroderma. Differential diagnosis between psoriatic erythroderma and lymphomatous erythroderma is often challenging. Tumour necrosis factor-alpha inhibitors are a new class of drugs used in the treatment of psoriasis, even in erythrodermic psoriasis. The effects of anti-tumour necrosis factor-alpha in cutaneous T cell lymphomas have not yet been established. Consequently, it is mandatory to treat an erythrodermic psoriatic patient with tumour necrosis factor-alpha blockers only if a lymphoproliferative cutaneous disorder has been excluded.

Current patch test results with the European baseline series and extensions to it from the 'European Surveillance System on Contact Allergy' network, 2007-2008.

BACKGROUND: The pattern of contact sensitization to the supposedly most important allergens assembled in the baseline series differs between countries, presumably at least partly because of exposure differences. Objectives. To describe the prevalence of contact sensitization to allergens tested in consecutive patients in the years 2007 and 2008, and to discuss possible differences. METHODS: Data from the 39 departments in 11 European countries comprising the European Surveillance System on Contact Allergy network (www.essca-dc.org) in this period have been pooled and analysed according to common standards. RESULTS: Patch test results with the European baseline series, and country-specific or department-specific additions to it, obtained in 25 181 patients, showed marked international variation. Metals and fragrances are still the most frequent allergens across Europe. Some allergens tested nationally may be useful future additions to the European baseline series, for example methylisothiazolinone, whereas a few long-term components of the European baseline series, namely primin and clioquinol, no longer warrant routine testing. CONCLUSIONS: The present analysis points to 'excess' prevalences of specific contact sensitization in some countries, although interpretation must be cautious if only few, and possibly specialized, centres are representing one country. A comparison as presented may help to target in-depth research into possible causes of 'excess' exposure, and/or consideration of methodological issues, including modifications to the baseline series.

Safety of anti-TNFα agents in the treatment of psoriasis and psoriatic arthritis.

CONTEXT: The efficacy and favorable safety profile of anti-tumor necrosis factor (TNF) agents in the treatment of psoriasis and psoriatic arthritis (PsA) are supported by several randomized controlled studies and meta-analyses. However, some concerns on the long-term safety of these drugs still exist, as these studies generally included small patient numbers and were performed in selected patient populations. OBJECTIVE: This review presents and discusses current evidence on the safety of anti-TNFα agents in patients with psoriasis and PsA, with a focus on European registry studies and case reports of particular importance. METHODS: Key studies on the safety of anti-TNFα agents in the treatment of adult patients with psoriasis or PsA were identified by a MEDLINE search (last updated 10 November 2011) based on several interrelated queries, with a focus on European registries. Other studies and case reports were included if deemed relevant. Studies concerning other conditions, such as rheumatoid arthritis (RA), were included as appropriate when data in psoriatic disease were unavailable or insufficient. RESULTS: Available data on the safety of anti-TNFα agents such as etanercept in psoriasis and PsA appear reassuring, even if some concerns still exist. Most notably, data suggest a higher incidence of infection and lymphoma amongst patients treated with the anti-TNFα monoclonal antibodies infliximab and adalimumab compared with etanercept. CONCLUSION: The overall safety profile of monoclonal antibodies in patients with psoriasis, PsA and RA seems less favorable than that of etanercept, particularly in terms of risk of infection and hepatotoxicity.

Contact sensitization in very young children.

BACKGROUND: Allergic contact dermatitis is an increasingly recognized clinical problem in children. OBJECTIVE: The aim of our study was to evaluate contact sensitization in patients younger than 3 years of age with suspected contact dermatitis. METHODS: During a 6-year period (2002-2008), 321 children underwent routine patch testing with a screening pediatric standard series of 30 allergens. RESULTS: Two hundred children (62.3%; 102 girls and 98 boys aged 3-36 months [mean age 27 + 5.6 months]) developed at least one positive reaction. The most frequent reactions were to nickel sulfate (26.8%), followed by potassium dichromate (9%), cocamidopropylbetaine (7.2%), cobalt chloride (6.2%), neomycin sulfate (5%), and methylchloroisothiazolinone/methylisothiazolinone (4.4%). The prevalence of contact sensitization was similar in children with (61.3%) and without (63%) atopic dermatitis. LIMITATIONS: The prevalence of contact sensitization in children younger than 3 years of age was not compared with the prevalence in older children. CONCLUSION: A high prevalence of contact sensitization was found in preschool children, even younger than 3 years of age. Patch testing should be considered in this age group when persistent dermatitis does not respond to conventional treatment.

p-Phenylenediamine sensitization and occupation.

BACKGROUND: p-Phenylenediamine (PPD) is an extreme delayed-type skin sensitizer, and is relevant in both occupational and non-occupational exposures. OBJECTIVES: To estimate the prevalence of PPD sensitization in a population of consecutive patients with suspected allergic contact dermatitis who attended units of dermatology or occupational medicine in north-eastern Italy and to investigate the association between their PPD sensitization and occupation. PATIENTS/MATERIALS/METHODS: A total of 14,464 patients (67.6% women and 32.4% men) with suspected allergic dermatitis underwent patch testing. The associations between patch test results and occupations were studied by multivariate logistic regression analysis. RESULTS: In both sexes, PPD sensitization was significantly associated with hairdressing and beauty occupation [women, odds ratio (OR) 6.58, 95% confidence interval (CI) 3.76-11.50; men, OR 22.3, 95% CI 4.18-119]. In the female group, PPD sensitization was also significantly higher in professional drivers (OR 5.31, 95% CI 1.76-16.1), barmaids (OR 1.89, 95% CI 1.04-3.44), and cleaners (OR 1.82, 95% CI 1.24-2.68). In the male group, PPD sensitization was significantly higher in bakers and waiters (OR 13.0, 95% CI 1.38-123), household workers (OR 8.46, 95% CI 1.68-42.8), and printers (OR 5.68, 95% CI 1.50-21.5). CONCLUSIONS: Our study showed that workers in several occupations may be at higher risk of developing sensitization to PPD. It is of importance to reduce possible exposure to PPD-crossreacting substances in these occupations.

Cost-effectiveness analysis of TNF-alpha blockers for the treatment of chronic plaque psoriasis in the perspective of the Italian health-care system.

The cost-effectiveness of biological treatments for psoriasis is not well determined and may vary from country to country. The objectives of this study was to perform a cost-effectiveness analysis of infliximab compared with other anti-tumor necrosis factor-alpha agents for the treatment of psoriasis in Italy. The incremental cost-effectiveness ratio per patients achieving at least 75% improvement in the psoriasis area and severity index assessed over 24- and 48-50-week periods was calculated. Efficacy data were drawn from randomized controlled trials when available or from open label studies. Considering patients achieving psoriasis area and severity index at week 24 and 48-50, infliximab was dominant (more effective and less costly) over etanercept given at 50 mg twice weekly. In contrast, infliximab was not dominant over etanercept at other dosages or over adalimumab. When considering the impact of therapy on quality of life at Week 12 using the Dermatology Life Quality Index equal to zero, infliximab resulted more effective and less costly than etanercept. Therefore, infliximab seems to be cost-effective in the therapy of psoriasis. Further cost-efficacy evaluations based on head-to-head trials are necessary to address health economic considerations.

Incidence of psoriasis and association with comorbidities in Italy: a 5-year observational study from a national primary care database.

An observational study was conducted to estimate the incidence of psoriasis in Italy, as well as the utilization of healthcare resources and the association with selected comorbidities in psoriasis patients. The data source was the Health Search/Thales Database, containing computer-based patient records from over 900 primary care physicians (PCPs) throughout Italy. The study cohort comprised all adults receiving a first-ever diagnosis of psoriasis during the years 2001-2005. From a total sample of 511,532 individuals, the incidence of psoriasis was 2.30-3.21 cases per 1,000 person-years. Psoriatic arthritis was present in 8% of psoriasis patients. The comparison with matched controls showed that psoriasis patients were more likely to have comorbidities (e.g., chronic bronchitis, chronic ischemic heart disease, obesity and diabetes mellitus) and to undergo PCP visits and hospitalizations, and to refer for specialist visits. The use of non-steroidal anti-inflammatory drugs appeared to be significantly more prevalent in patients as compared to controls. Topical therapy with corticosteroids and non-steroidal preparations accounted for 45.3% and 47.2% of all cases, respectively. Only a minority of cases used systemic immunosuppressive drugs or acitretin. The incidence rate of psoriasis in our study was particularly high and might reflect an overestimation by PCPs. Our results show the association between psoriasis and multiple comorbidities.

Nickel, cobalt and chromate sensitization and occupation.

BACKGROUND: Exposure to nickel, cobalt and chromate are important causes of occupational contact dermatitis. OBJECTIVES: To estimate the prevalence of nickel, cobalt and chromate allergy in a population of consecutive patients and to investigate the possible association with individual and occupational risk factors. PATIENTS/METHODS: A total of 14 464 patients (67.6% women and 32.4% men) with suspected allergic dermatitis underwent patch tests. The associations between patch test results and occupations were studied by multivariate logistic regression analysis. RESULTS: About 24.6% of the patients reacted positively to nickel sulphate, 10.2% to cobalt chloride and 8.7% to potassium dichromate. Nickel sensitization was higher in women aged 26-35 years in comparison with the youngest group (15-25 years) and the older group (> 45 years). In women, the prevalence of positive reactions to nickel was positively associated with metal and mechanical work (OR 1.54; 95%, CI 1.16-2.05). Chromate sensitization was more prevalent in building trade workers for both women (OR 1.58; 95% CI 1.00-2.49) and men (OR 2.24; 95% CI 1.55-3.22). Cobalt sensitization was associated with textile and leather work in women (OR 1.52; 95% CI 1.09-2.12) and with cleaning work in men (OR 1.86; 95% CI 1.18-2.93). CONCLUSIONS: Our study showed interesting associations between some occupations and nickel, chromate and cobalt allergy.

Perception of disease and doctor-patient relationship experienced by patients with psoriasis: a questionnaire-based study.

Many studies have addressed the impact of psoriasis on quality of life, but few studies have investigated patient perception of the disease or the patient-physician relationship. As with most chronic diseases, improvement in the patient-physician relationship may be important in the proper management of patients with psoriasis. To assess how psoriasis and its treatments are subjectively experienced by patients as well as patient expectations with regard to the patient-physician relationship. A discussion agenda for 'focus group meetings' was organized by a group of sociologists, psychologists, educators, researchers, and clinicians active in the field of psychodermatology. Four meetings were held in Northern and Central Italy and participants included one moderator and either eight dermatologists or eight patients. Discussions were based on a predefined agenda and included: (i) the psychological representation of psoriasis; (ii) the hetero- and self-perception of the patient; (iii) the patient-physician relationship; and (iv) the development of an educational intervention for dermatologists in order to improve the patient-physician relationship. A questionnaire, based on the information gathered at the focus groups, was administered to 323 patients with moderate to severe chronic plaque psoriasis from 17 dermatology clinics throughout Italy. Three hundred patients completed the questionnaire. Psoriasis elicited anger, annoyance at the inconvenience of the disease, and irritation in approximately 50% of the patients, whilst 38% of patients were unable to describe their emotional state. Aspects of life that were limited by psoriasis included clothing (57%), social interactions (43%), and personal hygiene (31%). The disease was often seen by patients as incomprehensible, incurable, and uncontrollable. More than half of the patients stressed their need to be listened to by the treating physician, and their wish that the physician should use simple language and should improve their psychological skills and interpersonal communication techniques. Dermatologists need to convey to patients with psoriasis the feeling of 'understanding the disease,' of hope about its curability, and the 'perception of control.' These elements should be taken into account when treating patients and whenever educational interventions are planned.

Detection of autoantibodies against recombinant desmoglein 1 and 3 molecules in patients with pemphigus vulgaris: correlation with disease extent at the time of diagnosis and during follow-up.

The recent availability of cDNA clones for pemphigus antigens has allowed the production of recombinant desmoglein 1 and desmoglein 3 molecules and the development of an ELISA approach in order to determine levels of antibodies to them. The aim of the study was to determine the relationship between autoantibodies levels and the extent of both mucosal and skin lesions in 20 patients with pemphigus vulgaris at the time of diagnosis and during follow-up. For the detection of autoantibodies by ELISA we used the recombinant proteins expressing overlapping sequences with the entire extracellular desmoglein 1 and desmoglein 3 domains. We showed that in presence of mucosal lesions there was a correlation between extension of mucosal involvement and autoantibodies titres against both desmoglein 1 and desmoglein 3, whereas in presence of skin lesions there was a statistically significant correlation between extension of skin lesions and autoantibodies titres against desmoglein 3, but not against desmoglein 1. A not negligible number of patients showed variations of the desmoglein 3 autoantibodies titre which did not correlate with the severity of both cutaneous and mucosal involvement. Similar results were obtained analyzing autoantibodies titres against desmoglein 1. In conclusion, we believe that the utilization of recombinant desmoglein 1 and desmoglein 3 proteins by ELISA should be used with caution to monitor disease severity and response to therapy, although it remains a high specific test for the initial diagnosis of pemphigus and the identification of a change in the clinical phenotype of this condition.