Mild to moderate hidradenitis suppurativa treated with local excision and primary closure.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic skin disease with a great impact on quality of life. Treatment with antibiotics or anti-inflammatory drugs, such as prednisone or TNF-alpha-inhibitors usually achieves only temporary improvement. Surgical intervention is considered as the only curative treatment for recurrent lesions. OBJECTIVE: To determine the efficacy and patient satisfaction of local excision followed by primary closure. METHODS: Between 2005 and 2010, 92 local excisions with primary closure were performed in 57 patients with mild to moderate HS. All patients were treated on an outpatient basis, under local anaesthesia. Local excision was defined as complete excision of the affected tissue, beyond the borders of activity, leaving clear margins. The medical records were reviewed retrospectively in 2010. The final outcome of the procedure, cosmetic appearance and patient satisfaction was measured using a questionnaire. RESULTS: Successful treatment, without recurrence, was accomplished in 66% of the cases. The intervention was generally well tolerated: 84% of the patients stated that they would undergo the same surgical procedure again if necessary, and 89% would recommend the procedure to other patients. CONCLUSION: Local excision followed by primary closure is a valuable treatment for patients with mild to moderate HS (Hurly stage I & II), with low morbidity and a high patient satisfaction rate.

New-onset polyarthritis during successful treatment of hidradenitis suppurativa with infliximab.

BACKGROUND: Hidradenitis suppurativa (HS) can be associated with several forms of arthritis, usually considered as reactive arthritis. A new observation is that some patients with HS develop arthritis after treatment with infliximab (antitumour necrosis factor-α). OBJECTIVES: A retrospective study was performed to establish the frequency and clinical presentation of new-onset arthritis during infliximab treatment. METHODS: Between 2005 and 2009, 27 individuals with severe HS were treated with infliximab and followed up closely. Laboratory parameters and side-effects were recorded. The frequency of arthritis was compared with control groups consisting of 227 patients with HS not treated with any biological, 22 patients with HS treated with adalimumab and 28 patients with psoriasis treated with infliximab, in the same period at the same clinic. RESULTS: Five of the 27 patients with HS (18%) treated with infliximab developed an acute and painful polyarthritis during treatment. The arthritis occurred on average after 12 months of treatment, was not clearly associated with anti-infliximab antibodies and resolved on average after 4 months. Interestingly, none of the patients had suffered from arthritis before despite the long duration of HS and all showed a good skin response to infliximab. Moreover, arthritis was not observed in any of the control groups. Compared with the adalimumab group and the psoriasis group, odds ratios of 7·241 [95% confidence interval (CI) 1·15-45·6] and 9·025 (95% CI 1·45-55·82) were calculated. CONCLUSIONS: The five cases described in this article suggest that infliximab treatment in HS can induce a transient but severe polyarthritis. The underlying mechanisms remain to be investigated further.

Review and expert opinion on prevention and treatment of infliximab-related infusion reactions.

Infliximab (Remicade; Schering-Plough, Kenilworth, NJ, U.S.A.) is a chimeric monoclonal antibody that acts as a tumour necrosis factor-alpha inhibitor. Infliximab is registered for the treatment of rheumatoid arthritis, psoriatic arthritis, Crohn disease, ulcerative colitis, ankylosing spondylitis and plaque-type psoriasis. Like other foreign protein-derived agents, infliximab may lead to infusion reactions during and after infusion. Infusion reactions occur in 3-22% of patients with psoriasis treated with infliximab. Most of these reactions are mild or moderate and only few are severe. Nevertheless, they may lead to discontinuation of treatment. As infliximab for psoriasis is prescribed as a last resort and is in most cases very effective, discontinuation of treatment is undesirable. With proper care and prevention of the infusion reactions the need to discontinue treatment with infliximab can be diminished. The objective of this article is to present a guideline for the management of infliximab-related infusion reactions, based on the best available evidence. This guideline can be used in patients with psoriasis as well as in dermatology patients receiving infliximab for off-label indications such as hidradenitis suppurativa or pyoderma gangrenosum.

[Loss of cranial-nerve function caused by early syphilitic meningitis: the comeback of a pre-war syndrome]. / Hersenzenuwuitval door vroege syfilitische meningitis: terugkeer van een vooroorlogs ziektebeeld.

Two men aged 39 and 38 who had had unprotected insertive and receptive anal sexual contact with men are presented: one had paralysis of the right half of his face and the other man had erythematous macules on the palms of his hands and the soles of his feet as well as partial alopecia, earache and progressive loss of hearing in his left ear. The latter one was also HIV-seropositive and on antiretroviral medication. Syphilitic meningitis was diagnosed in both men. The 2 patients recovered after being treated with intravenous benzyl penicillin. Syphilitic meningitis is a complication seen during the early stages of a syphilis infection. Since the introduction of penicillin it has become a rare disease. Early diagnosis is of importance since syphilitic meningitis has irreversible sequelae.

Differences in cellular infiltrate and extracellular matrix of chronic diabetic and venous ulcers versus acute wounds.

In diabetic patients, wound healing is impaired. We studied the pathogenesis behind this clinical observation by characterizing the pattern of deposition of extracellular matrix (ECM) molecules and the cellular infiltrate in chronic (>8 wk) diabetic wounds, compared with chronic venous ulcers and an acute wound healing model. Punch biopsies were obtained from the chronic ulcer margins and control samples were collected from upper leg skin 5, 19, 28 d and 12 and 18 mo postwounding (p.w.). T cells, B cells, plasma cells, granulocytes and macrophages, and the ECM molecules fibronectin (FN), chondroitin sulfate (CS), and tenascin (TN) were visualized using immunohistochemical techniques. Expression of FN, CS, and TN was detected in dermal tissue early in normal wound healing (5-19 d p.w.). Abundant staining was seen 3 mo p.w., returning to prewounding levels after 12-18 mo p.w. In the dermis of chronic diabetic and venous ulcers with a duration of 12 mo or more, a prolonged presence of these ECM molecules was noted. Compared with normal wound healing: (i) the CD4/CD8 ratio in chronic wounds was significantly lower (p < 0.0027) due to a relatively lower number of CD4+ T cells; (ii) a significantly higher number of macrophages was present in the edge of both type of chronic ulcers (p < 0.001 versus day 29 p.w.); and (iii) more B cells and plasma cells were detected in both type of chronic wounds compared with any day in the acute wound healing model (p < 0.04 for CD20+ and p < 0.01 for CD79a+ cells). These data indicate that important differences exist in the cellular infiltrate and ECM expression patterns of acute, healing versus chronic wounds, which may be related to the nonhealing status of chronic wounds.

In vitro tissue-digesting properties of krill enzymes compared with fibrinolysin/DNAse, papain and placebo.

Wound debridement, the removal of necrotic tissue, can be achieved with proteolytic enzymes. Recently, a new multi-enzyme preparation, krill enzyme, isolated from Antarctic shrimp-like organisms (Euphausia superba), was reported to possess powerful proteolytic activity towards protein substrates. In this paper, we study the in vitro digestive properties of krill enzymes towards whole tissue, compared with placebo, papain, and fibrinolysin/DNAse. Freshly obtained skin specimens were exposed for 3 days to krill enzymes (3; 0.6 and 0.06 U/ml), papain (120; 60; 6 and 0.6 U/ml), fibrinolysin/DNAse (2.5/1500 E and 1/600 E), and phosphate-buffered saline control solution. Tissue digestion was estimated by measuring wet wt, dry wt, and histological examination. After 72 hr of exposure to 3 U/ml krill enzymes, the dry wt of the specimens was reduced to 2.7% +/- 1.9 (SEM, n = 5), compared with 31.0% +/- 2.7 for placebo, 25.7% +/- 2.5 for 120 U/ml papain, and 24.5% +/- 3.3 for 2.5/1500 E/ml fibrinolysin/DNAse. The differences between krill enzymes and fibrinolysin/DNAse, papain, and control solution were statistically significant (p < 0.007). These data suggest that krill enzymes are more active than other commonly available proteolytic agents used for wound debridement.

The effectiveness of a history-based diagnostic approach in chronic urticaria and angioedema.

OBJECTIVE: To assess the value of extensive laboratory screening for the identification of causes in patients with chronic urticaria and/or angioedema. DESIGN: In a prospective study involving 220 patients, 2 diagnostic strategies were compared: the combination of detailed history taking and limited laboratory investigations vs detailed history taking and extensive laboratory screening. The results of the extensive screening program were initially kept secret from the patients and the physicians. Later, all results were disclosed, and an investigation was undertaken to find out whether this information changed the initial diagnosis. The patients were followed up for 1 year to evaluate the results of interventions and to detect latent causes. SETTING: The study was performed in the outpatient department of a secondary and tertiary care center with institutional practice. PATIENTS: A total of 238 consecutive new patients with chronic urticaria and/or angioedema edema were referred; 18 of them refused participation. One patient was unavailable for follow-up. MAIN OUTCOME MEASURE: The difference in the number of identified causes between both approaches and the nature of the causes that would have been missed by omitting extensive laboratory screening. RESULTS: With a questionnaire and the limited laboratory tests, a cause was found in 45.9% of the patients, compared with 52.7% with the questionnaire and the extended screening program. Except for one parasitic infection, missed diagnoses were mainly adverse reactions to drugs or food detected by standard elimination procedures, not by laboratory investigations. CONCLUSION: Routine laboratory screening did not contribute substantially to the diagnosis of chronic urticaria or to the detection of underlying disorders.

Extracorporeal photochemotherapy (photopheresis) induces apoptosis in lymphocytes: a possible mechanism of action of PUVA therapy.

The mechanism of action of psoralen plus UVA (PUVA) and photopheresis is not entirely understood. These therapies are assumed to be immunomodulating partly by gradually decreasing leukocyte viability. We investigated whether this delayed form of cell death was due to apoptosis. Untreated and treated (PUVA exposed) leukocytes obtained from six patients with systemic sclerosis and (untreated) leukocytes from healthy control individuals were studied. Qualitative gel electrophoresis and quantitative in situ nick translation analysis of DNA fragmentation was performed. Apoptosis of the treated cells did occur (gel electrophoresis) after 24 h. At t = 0 h, immediately after exposure to PUVA, there was no evidence of DNA fragmentation in the treated cells. The percentage of treated cells undergoing apoptosis was 20-55% at t = 24 h (in situ nick translation). The untreated leukocytes of the patients and the healthy individuals showed no distinctive rise in apoptotic cells. Apoptosis of the leukocytes after PUVA or photopheresis treatment might be a mechanism of action and might explain the therapeutic response.

Quantitative and objective evaluation of wound debriding properties of collagenase and fibrinolysin/desoxyribonuclease in a necrotic ulcer animal model.

Proteolytic enzymes have been used for wound debridement for many years. The two enzymes most widely used in Europe are fibrinolysin/desoxyribonuclease and collagenase. Despite their frequent use, very few placebo-controlled studies comparing the enzymes with vehiculum only, or with each other, are available. In a specially developed necrotic ulcer animal model, combined with a computer image analysis technique to measure necrotic and total wound surface areas quantitatively, we assessed the wound-cleansing properties of fibrinolysin/DNase oleogel, collagenase ointment, saline-soaked gauze control treatment, and new galenic formulations of collagenase, including placebos. The average relative area of necrotic tissue present in the wound after 1 week was 31% for collagenase ointment and 56% for fibrinolysin/DNAse oleogel (P = 0.0037). Collagenase gel was significantly (P = 0.0007) better in removing necrosis than placebo (gel only). Fibrinolysin/DNAse was not significantly more effective than the three placebo or control treatments (placebo film, placebo gel, saline-soaked gauzes). We conclude that collagenase is a suitable enzyme for wound debridement, but we were not able to detect clinical efficacy of fibrinolysin/DNAse in this model.

Cultured fibroblasts from chronic diabetic wounds on the lower extremity (non-insulin-dependent diabetes mellitus) show disturbed proliferation.

Patients with diabetes mellitus experience impaired wound healing often resulting in chronic foot ulcers. Hospital discharge data indicate that 6-20% of all diabetic individuals hospitalized (mostly with type 2 diabetes) have a lower extremity ulcer. Maintaining glucose levels at acceptable levels (below 10 mmol/l) is considered to be an important part of the clinical treatment, but the exact mechanism by which diabetes delays wound repair is not yet known. We studied this phenomenon by determining the potential of fibroblasts isolated from the ulcer sites of four patients with non-insulin-dependent diabetes mellitus to proliferate in vitro. Controls were fibroblasts isolated from normal skin of the upper leg of five healthy age-matched volunteers and of six non-insulin-dependent diabetes patients. Proliferative capacity was analysed by evaluation of plates after trypsinization and [3H]thymidine incorporation. Fibroblast morphology was studied by light and transmission electron microscopy. Diabetic ulcer fibroblasts, measured by [3H]thymidine incorporation, proliferated significantly more slowly than the nonlesional control fibroblasts (P < 0.00047) and age-matched control fibroblasts (P < 0.00003). After culturing the fibroblasts for a prolonged period in high-glucose (27.5 mM) and low-glucose (5.5 mM, i.e. physiological) medium, this difference in proliferation rate between diabetic ulcer fibroblasts and nonlesional diabetic fibroblasts remained (P < 0.0001 for high-glucose and P < 0.0009 for low-glucose on day 7). Fibroblast proliferation in all three groups was slightly lower in high-glucose than in low-glucose medium, although not significantly at any time-point. Light microscopy showed diabetic ulcer fibroblasts to be large and widely spread. Transmission electron microscopy of cultured diabetic ulcer fibroblasts and nonlesional diabetic skin fibroblasts revealed a large dilated endoplasmic reticulum, a lack of microtubular structures and multiple lamellar and vesicular bodies. These results show a diminished proliferative capacity and abnormal morphology of fibroblasts derived from diabetic ulcers of non-insulin-dependent diabetes patients.

Image processing in the study of wound healing.

All wound care products that are said to be suitable for wound cleaning should preferably be evaluated with an observer-blind, quantitative system, as described above.

[Cryosurgical treatment of basal cell carcinoma of the eyelids]. / Cryochirurgische behandeling van basale-celcarcinomen van de oogleden.

Fifty-nine basal cell carcinomas of the eyelids were treated by cryosurgery and followed up for at least three years. Only one recurrence was seen after three years. All lesions except one healed with good cosmetic results.

[A questionnaire for patients with chronic urticaria; a diagnostic approach based on structured anamnesis]. / Een vragenlijst voor patiënten met chronische urticaria: gestructureerde anamnese als basis voor diagnostisch beleid.

In only a minority of chronic urticaria patients an underlying cause or illness can be detected. Previous studies demonstrated that detailed history taking is more important than routine laboratory investigations. To improve the process of history taking, the use of a detailed urticaria questionnaire is highly recommended. By using such a history-based diagnostic approach, the costs of laboratory investigations could be reduced from an average of 538 NLG per patient to 84 NLG per patient. The percentage of patients in whom a cause could be found increased from 29% to 53%. No severe underlying illnesses were missed by using this approach.