Contemporary treatment patterns in plaque psoriasis and psoriatic arthritis.

INTRODUCTION: Psoriasis is a chronic inflammatory skin disease affecting about 2% of the general population. Although there are many treatment options, and new medications have been introduced, the disease is considered not curable, and it may seriously affect patients' quality of life. AIM: The authors present contemporary treatment patterns used by dermatologists in Poland to manage plaque psoriasis and psoriatic arthritis, particularly regarding systemic treatment. The authors also aimed to analyse how these treatment patterns are influenced by the guidelines of the Polish Dermatological Society. MATERIAL AND METHODS: The author's questionnaire, consisting of 13 questions was used. It included demographic and professional characteristics of questioned dermatologists, as well as the assessment of the attitudes towards management of plaque psoriasis and psoriatic arthritis. RESULTS: A total of 132 dermatologists completed the questionnaire. Most of the specialists worked in out-patient clinics and private practices. The most commonly used topicals for psoriasis included: glucocorticosteroids, a combination of glucocorticosteroid and vitamin D analogue and salicylic acid. Regarding the treatment of psoriatic arthritis, most of the specialists declared using systemic therapy and a combination of systemic therapy and phototherapy. The majority of the respondents were particularly concerned with possible side effects or difficulties in qualifying and monitoring the patients, and less frequently on the cost of the therapy. CONCLUSIONS: Observations suggest that 60% of physicians have some reservation to initiate systemic treatment in outpatient clinics, and they admit that they lack additional training. On the other hand, it seems also that the organization of systemic treatment in psoriasis may generate these difficulties and thus necessitate additional effort. Another factor could be the budget - not only regarding healthcare professionals, but also the patient, sometimes financing various investigations from private resources.

Atopic dermatitis. Interdisciplinary diagnostic and therapeutic recommendations of the Polish Dermatological Society, Polish Society of Allergology, Polish Pediatric Society and Polish Society of Family Medicine. Part II. Systemic treatment and new therapeutic methods.

The treatment goal in atopic dermatitis is eliminating clinical symptoms of the disease, preventing exacerbations and complications, as well as improving patients' quality of life. In cases of severe atopic dermatitis and lack of response it is recommended to introduce systemic therapy. Patients ofter require multi-specialist consultations, and occasionally hospitalization. It is not recommended to use acupuncture, acupressure, bioresonance, homeopathy, or Chinese herbs in the treatment of atopic dermatitis.

Atopic dermatitis. Interdisciplinary diagnostic and therapeutic recommendations of the Polish Dermatological Society, Polish Society of Allergology, Polish Pediatric Society and Polish Society of Family Medicine. Part I. Prophylaxis, topical treatment and phototherapy.

Atopic dermatitis is a chronic and recurrent inflammatory dermatosis with concomitant intensive pruritus, and is diagnosed both in children and adults. Atopic dermatitis-patients are predisposed to have bacterial, viral and fungal skin infections; they also suffer from an increased risk of developing food allergies (especially, at an infantile age), allergic rhinitis, or bronchial asthma (a so-called atopic march). Currently, an increasing atopic dermatitis incidence constitutes a serious medical problem that regards not only dermatology and allergology, but also paediatrics, and family medicine. The basis for atopic dermatitis treatment and prophylaxis is restoration of epidermal barrier functions by means of tailored emollients. Atopic dermatitis therapies should effectively eliminate clinical symptoms of the disease, prevent exacerbations as well as complications, and improve patients' quality of life.

Clinical relevance of Corylus pollen in Poznan, western Poland.

BACKGROUND: In Central Europe, hazel (Corylus sp.) pollen is considered to be an important aeroallergen in early spring. OBJECTIVE: This study examines hazel pollen levels in Poznan, western Poland, and the clinical relevance of this aeroallergen in the city. METHODS: Corylus pollen data (1996-2010) were obtained by volumetric spore trap located near the centre of Poznan. Clinical data (2006-2010), i.e. skin prick test (SPT) and allergen-specific IgE measurements (asIgE), were supplied by the Allergy Diseases Diagnostic Centre in Poznan. RESULTS: Mean diurnal hazel pollen concentrations peaked around 14:00-16:00 when mean bi-hourly pollen concentrations were ~60 P m(-3). Onset of the hazel pollen season varied up to 87 days annually, and was significantly (r=-0.647; p<0.01) related to mean maximum temperature during late December. SPT data revealed that ~11% of allergy patients had positive skin reactions to Corylus pollen allergens, and most of these (94.4%) reacted to pollen allergens from other members of the Betulaceae family - alder or birch. Of those sensitized, 53% suffered from atopic dermatitis. Of patients examined for serum asIgE, 26.0% had asIgE measurements in classes 5 and 6. CONCLUSIONS: Hazel pollen has a detrimental effect on the allergic population of Poznan, with more than half of those sensitised to hazel pollen allergens showing symptoms of atopic dermatitis. Hazel pollen concentrations reach levels recognized as being able to induce allergy symptoms, especially in the afternoon and early evening when many people are returning home from work. The cross-reactivity with other members of the Fagales order also increases the allergenic potential of hazel pollen.

Eosinophilic fascitis: a report of two cases treated with ultraviolet A1 phototherapy.

Eosinophilic fascitis (EF) (synonyms: Shulman's syndrome, diffuse fascitis with eosinophilia) is a disease characterized by a complex set of symptoms with scleroderma-like skin lesions, the absence of Raynaud's phenomenon and other non-mandatory symptoms including eosinophilia, elevated erythrocyte sedimentation rate, hypergammaglobulinemia and high levels of circulating immune complexes. EF is probably not a separate disease entity, but an acute variant of localized scleroderma. This rare disease of unknown etiology is usually seen in middle-aged adults. Sclerodermiform indurations without Raynaud's symptoms develop rapidly usually on the extremities and more rarely on the trunk or the face. The skin becomes hard, tightly bound to the underlying structures, so that contractures can develop in as little as a few weeks. The course of the disease is usually chronic but spontaneous remission is possible. Standard therapy includes high doses of corticosteroids, immunosuppressive drugs such as methotrexate, cyclosporin A, cyclophosphamide or azathioprine and others such as psoralen and ultraviolet A radiation.

Oral allergy syndrome in patients with airborne pollen allergy treated with specific immunotherapy.

According to literature, approximately 20%-70% of patients sensitized to pollen allergens experience oral allergy syndrome (OAS) symptoms after eating raw fruits and vegetables. There is no standard treatment established for OAS except avoiding implicated food. However, in patients with airborne pollen allergy treated with specific immunotherapy (SIT), an improvement of OAS symptoms has been reported in 30% to even 84% of individuals examined. The aim of the present study was to evaluate the prevalence of OAS symptoms in patients with various manifestations of pollen airborne allergy (atopic dermatitis (AD), asthma, allergic rhinitis) treated with subcutaneous type of SIT. In addition, the most common patterns of cross-reactivity in OAS were analyzed and correlations between OAS symptoms and patient age, type of sensitizing pollen allergens and atopy manifestations investigated. Also, the relationship between SIT duration and clinical improvement of both OAS symptoms and pollen allergy symptoms was analyzed. The study included 57 patients with airborne allergy treated with allergen vaccination (60% male and 40% female). Allergic rhinitis was diagnosed in 71%, AD in 19%, AD and asthma in 4%, allergic rhinitis and asthma in 4%, and both AD and allergic rhinitis in 2% of study patients. Twenty-eight percent of study patients complained of overt symptoms of OAS (22% of allergic rhinitis patients and 27% of AD patients); 69% of the subjects presenting with OAS showed polyvalent airborne allergy to pollens and 31% were sensitized to only one group of pollen allergens (mostly grass pollens, tree pollens and mugwort pollens). There was no statistically significant correlation between the presence of OAS symptoms and patient diagnosis, patient age and type of allergen vaccination used. According to patients' opinion, SIT significantly improved oral symptoms in 50% of study patients, 44% reported no impact of SIT on OAS symptoms and 6% of patients observed worsening of OAS symptoms after unintentional ingestion of implicated food during the course of SIT. The study revealed OAS as a significant problem in patients sensitized to various pollen allergens. The results on OAS prevalence in atopic subjects (28%) were consistent with some literature data. There was clear association between OAS and polyvalent airborne allergy (69%). Cross-reactivity patterns were typical (for example, tree pollen allergy - intolerance of apples, carrots and potatoes; grass pollen allergy - intolerance of kiwi fruit and tomatoes). Questionnaire analysis indicated that subcutaneous SIT significantly alleviated OAS symptoms associated with ingestion of the responsible fruit and vegetables in half of study subjects. Further evaluation of the duration/persistence and stability of the phenomenon is planned for the future.

Regional importance of Alnus pollen as an aeroallergen: a comparative study of Alnus pollen counts from Worcester (UK) and Poznan (Poland).

Daily average Alnus pollen counts (1996-2005) from Worcester (UK) and Poznan (Poland) were examined with the aim of assessing the regional importance of Alnus pollen as an aeroallergen. The average number of Alnus pollen grains recorded annually at Poznan was more than 2.5 times that of Worcester. Furthermore, daily average Alnus pollen counts exceeded the thresholds of 100, 500 and 1,000 grains/m3 more times at Poznan than Worcester. Skin prick test results (1996-2005) and allergen-specific IgE (asIgE) measurements using the CAP (Pharmacia) system (2002-2005), were supplied by the Allergic Diseases Diagnostic Centre in Poznan. The annual number of positive skin prick tests to Alnus pollen allergens was significantly related (p<0.05) to seasonal variations in the magnitude of the Alnus pollen catch recorded at Poznan (r=0.70). The symptoms of patients with positive skin prick tests to Alnus pollen allergens were: 51% pollinosis, 43% atopic dermatitis, 4% asthma, 1% chronic urticaria and 1% eczema. On a scale of 0-6, 20.5% of patients examined for serum asIgE in relation to Alnus pollen allergens had asIgE measurements in classes 5 and 6. Alnus pollen is generally considered to be mildly allergenic. However, the amount of Alnus pollen released into the atmosphere in places such as Poznan may increase its impact on the population and make it one of the more important aeroallergens present.

Immunological parameters in the sera of patients with atopic dermatitis and airborne allergy treated with allergy vaccines.

Patients with atopic disorders present an increased production of IgE, which is usually limited to specific antibodies against various environmental allergens. It has also been suggested that the production of these antibodies may be influenced by effective specific immunotherapy (SIT). Of course, a decline of serum antigen specific IgE in the course of such a treatment cannot explain the clinical efficacy of SIT and is probably not a key mechanism. However, SIT may at least participate in the final clinical result. In this study, 37 patients with atopic dermatitis were treated with allergy vaccines (Novo-Helisen Depot) for a time period of 48 months. The control group consisted of 29 patients with atopic dermatitis who were treated with classical methods. The clinical score (W-AZS), total IgE and antigen specific IgE (asIgE) in the sera of patients were assessed before treatment and after 24 and 48 months of therapy (FEIA CAP System, Pharmacia). There was a significant difference between the two investigated groups from both the clinical and immunological standpoints after 2 and 4 years of observation. There was a significant decrease of serum total IgE and asIgE (directed against airborne allergens) in the course of specific immunotherapy. In the control group, the total IgE level tended to increase, and this tendency was also recorded in case of asIgE measurements. We also evaluated the influence of specific immunotherapy on the serum level of IFN-G, sIL-2R, IL-4, IL-5 and IL-10 before treatment and after 4 years of therapy with the quantitative 2-step colorimetric sandwich ELISA method (R and D Systems). In the group of patients treated with allergy vaccines, a significant decrease of the serum sIL-2R level was observed after 48 months of therapy (p<0.01). In the control group, a significant increase of serum IL-4 (p<0.01) as well as IL-5 (p<0.05) was registered at the end of the observation period. There was no significant correlation between the clinical score and serum level of any of the investigated cytokines in either group of patients before the treatment or after 48 months of therapy.

[Specific immunotherapy in the treatment of patients with atopic dermatitis--results of double blind placebo controlled study]. / Immunoterapia swoista w leczeniu chorych na atopowe zapalenie skóry--wyniki badania prowadzonego w warunkach podwójnie slepej próby.

BACKGROUND: Specific immunotherapy (SIT) is the only causative method of treatment in the case of IgE-mediated allergic disease. There is extensive literature on the use of SIT in the management of respiratory allergies and insect venom hypersensitivity, but a paucity of published data concerning its use as a therapeutic approach in atopic dermatitis (AD). OBJECTIVE: A double blind placebo controlled trial was conducted over a period of 12 months in order to evaluate the efficacy of SIT in the management of atopic dermatitis attributable to house dust mites or grass pollens. METHODS: A total of 20 patients (5-40 years) with AD and monovalent sensitization to airborne allergens (house dust mites or grass pollens) were enrolled in the study. SIT was performed using aluminium hydroxide adsorbed allergen preparations administered by subcutaneous injection. Clinical efficacy of the treatment was assessed using the clinical score--W-AZS index. Serum concentration of total IgE and allergen specific IgE were measured, as were various immunological parameters including ECP, sIL-2R, IFN-gamma, IL-4, IL-5 and IL-10). RESULTS: The mean value of W-AZS index in the SIT group before treatment was 87.6 +/- 15.8 pts, and this decreased to 38.8 +/- 34.4 pts after 12 months of therapy (p < 0.01). In the placebo group the mean W-AZS index before treatment was 86.3 +/- 15.7 pts and after 12 months of therapy it increased to 111.9 +/- 41.7 pts. Comparative statistical analysis indicated a significant difference between the two groups in favour of patients treated with the active allergy vaccines (p < 0.01). Serum levels of specific IgE in the SIT group showed a tendency to decrease, whilst those in the placebo group tended to increase. Serum concentrations of selected immunological parameters including ECP, sIL-2R, IFN-gamma, IL-4, IL-5 and IL-10 were monitored before and after treatment, but did not show significant differences. CONCLUSION: Allergen specific immunotherapy appeared to be an effective method of treatment for atopic dermatitis as judged by significant improvement in clinical index in cases with well documented IgE-mediated allergic disease.

[Efficacy of specific immunotherapy in the treatment of children and youngsters suffering from atopic dermatitis Part II. Evaluation of skin reactivity and concentration of serum antigen specific immunoglobulin E directed against selected airborne allergens]. / Ocena skutecznosci alergenowej immunoterapii swoistej w leczeniu atopowego zapalenia skóry u dzieci i mlodziezy. Czesc II. Wyniki oceny reaktywnosci skóry i stezenia antygenowo swoistych immunoglobulin klasy E w surowicy krwi w odniesieniu do wybranych alergenów powietrznopochodnych.

Atopic dermatitis (AD) still remains a difficult clinical problem in terms of effective therapy. The aim of our study was to evaluate efficacy of specific immunotherapy performed with Novo-Helisen Depot allergy vaccines in the group of 36 children and youngsters with atopic dermatitis allergic to house dust mites (24 persons) and grass pollen allergens (12 patients), for the time period of 3 years. Skin reactivity (skin prick tests) and serum concentrations of antigen specific IgE were monitored in the course of treatment. The control group consisted of 20 patients with atopic dermatitis and IgE-mediated airborne allergy who were treated with conventional methods. Specific immunotherapy resulted in negativization of skin prick tests results and decrease of serum antigen specific IgE concentrations. On the contrary in the control group there was no tendency for negativization of skin prick tests and we observed an increase of serum concentration of antigen specific IgE directed against grass pollen allergens. Specific immunotherapy seems to be an effective therapeutic approach in selected cases of atopic dermatitis.

[Efficacy of specific immunotherapy in the treatment of children and youngsters suffering from atopic dermatitis. Part I. Evaluation of clinical score]. / Ocena skutecznosci alergenowej immunoterapii swoistej w leczeniu atopowego zapalenia skóry u dzieci i mlodziezy. Czesc I. Ocena stanu klinicznego.

Despite undoubted progress in the field of allergology and clinical immunology we still lack an effective and secure therapeutic methods in many cases of atopic dermatitis. The aim of the study was to evaluate efficacy of specific immunotherapy performed for the time period of 3 years with Novo-Helisen Depot allergy vaccines in the group of 36 children and youngsters with atopic dermatitis, allergic to house dust mites (24 patients) and grass pollen allergens (12 patients). The control group consisted of 20 patients with atopic dermatitis and analogous IgE-mediated airborne allergy treated with conventional methods. Clinical evaluation of patients was performed before treatment and after 36 months of therapy and was based on severity and extensiveness of skin inflammation in atopic dermatitis index: W-AZS. Clinical efficacy of specific immunotherapy was significantly higher than efficacy of conventional methods (p < 0.001). It was concluded that in selected patients with atopic dermatitis with IgE-mediated airborne allergy this method of treatment could be a promising alternative.

Atopy patch test reaction to airborne allergens in the diagnosis of atopic dermatitis.

The aim of the study was to evaluate the possible use of atopy patch test in the diagnosis of atopic dermatitis and to characterize an optimal standardized system for atopy patch test in terms of allergen concentrations and time of allergen exposure. The study included 36 patients with atopic dermatitis and IgE-mediated airborne allergy. Patients presented positive results of skin prick tests and serum antigen specific IgE against house dust mite allergens and/or selected grass pollen allergens. Control groups consisted either of patients with allergic rhinitis (control group 1) or healthy volunteers with no signs or symptoms of atopy (control group 2). Allergologic diagnostic workup consisted of skin prick test, serum antigen specific IgE and total IgE evaluation, atopy patch test with selected airborne allergens of different concentrations (0.1xSPT, 1xSPT and 10xSPT), time of allergen exposure (8, 24 and 48 h), and readings of the results (8, 24, 48 and 72 h). Positive results of atopy patch test with airborne allergens were obtained in 47.2% of atopic dermatitis patients and none of control subjects. Contact reaction itself and the intensity of reaction were demonstrated to correlate with allergen concentration and time of allergen exposure on atopy patch test. The dose and time response analysis showed the optimal concentration of allergens for atopy patch test to be 10xSPT, 500000 SBE/ml, and optimal evaluation time 24 and 48 h of allergen application. There was no correlation between atopy patch test results and mean serum concentrations of total or antigen specific IgE. Atopy patch test results did not correlate with localization of skin lesions, severity and extensiveness of skin inflammation. A significantly higher contact reactivity to airborne allergens was recorded in the group of atopic dermatitis patients with polyvalent allergy in comparison with atopic dermatitis patients allergic to only one aeroallergen. It is concluded that atopy patch test is the only provocation test currently available with clinical relevance for contact IgE-mediated sensitization in atopic dermatitis patients. Using petrolatum as a vehicle, allergen concentration of 500000 SBE/ml and evaluation time of 24 and 48 h of allergen application may lead to improved atopy patch test results.

[Diagnostic, prophylactic and therapeutic guidelines in patients with atopic dermatitis. Position paper by the task force of the National Specialists on Dermatology, Venereology and Allergology]. / Postepowanie diagnostyczno-profilaktyczno-lecznicze w atopowym zapaleniu skóry. Konsensus grupy roboczej specjalistów krajowych ds. dermatologii i wenerologii oraz alergologii.

Treatment modalities of patients with atopic dermatitis (AD) are dependent on patient age, on the intensity of both skin symptoms and subjective signs of the disease i.e. itch and sleep disturbances, on the body surface involved with lesions, as well as on the type of sensitizing allergens. The characteristic of these allergens is crucial to start prophylaxis and to make decision about specific immunotherapy. In asymptomatic period of the disease the most important factor is to prevent dryness of the skin using emollients, which reconstruct integrity and continuity of stratum corneum. This procedure prevents penetration of air-borne allergens across damaged skin barrier into the skin. In mild AD cases, pimecrolimus (mainly in children) and corticosteroids of the lowest potency alternatively with their basis should be recommended. In moderate intensity AD either topical treatment with calcineurin inhibitors i.e. tacrolimus and pimecrolimus or topical corticosteroids from 4-5 group of American classification should be applied. In addition, PUVA/UVB phototherapy may be beneficial, as well as immunotherapy with specific airborne allergen/s. Coexisting bacterial skin infections should be treated with systemic antibiotics (macrolides, quinolones, and cephalosporins), viral herpes infection systemically using acyclovir for 5-7 days, and fungal infections applying ketoconazole orally, accompanied by topical treatment with miconazole or other antimycotics. Severe AD is an indication for the systemic use of cyclosporin A (rather than corticosteroids), and antibiotics as mentioned above. Prolonged 3-5 year specific immunotherapy is significant concern for selected cases. Sensitive skin areas such as face, orbicular skin, flexures should be treated with pimecrolimus and tacrolimus rather than with corticosteroids, however, topical corticosteroids are recommended on involved skin of the trunk and the extremities besides of flexures. While the improvement of severe AD is reached, the treatment modalities for benign and mild AD should be observed. In all AD patients with active skin lesions antihistaminic drugs of 2nd generation reactive with H1 receptor are a gold standard (or short treatment with these drugs of 1st generation to achieve a sedative effect, followed by the 2nd generation drug), as well as tranquilizers as the combined treatment. There is no reason for the use of anti-leukotriene drugs.