Cross-reactivity in beta-lactams after a non-immediate cutaneous adverse reaction: experience of a reference centre for toxic bullous diseases and severe cutaneous adverse reactions.

BACKGROUND: Cross-reactivity among beta-lactam antibiotics (BL) is essentially reported in immediate hypersensitivity. OBJECTIVES: To evaluate cross-reactivity beyond BLs in patients with non-immediate cutaneous adverse drug reaction (non-immediate CADR) managed in a dermatology reference centre of toxic bullous and severe CADRs. PATIENTS/MATERIALS/METHODS: We conducted a retrospective single-centre study in consecutive patients consulting between 2010 and 2018 with an active BL-suspected non-immediate CADR and explored by cutaneous tests [patch tests (PT) and intradermal tests (P-IDR)] for at least three penicillin's subclasses and amino- and non-amino-cephalosporins (at least one aminocephalosporin). Cross-reactivity among subclasses was investigated for patients with positive tests. RESULTS: We included 56 patients, among whom 46 amoxicillin-suspected were and seven cephalosporin-suspected. Twenty-nine had severe CADR, and 27 had non-immediate maculopapular exanthema (MPE). Twenty-two had positive tests (18 for AS and four for CS). Among the 18 positive amoxicillin-suspected, 10 (55.6%) showed cross-reactivity with one or more other BL: 9 (50%) with another penicillin and 3 (16.5%) with a non-aminocephalosporin. No amoxicillin- or cephalosporin-suspected patient showed cross-reactivity with aztreonam or carbapenems. P-IDR showed cross-reactivity only once. CONCLUSION: After a suspected BL-induced non-immediate CADR, a large allergologic exploration is needed to confirm the diagnosis and evaluate cross-reactivity. In our population including cases of severe CADRs and MPE with late delay of onset, cross-reactivity was frequent and PT was sufficient to this purpose. The frequent cross-reactivity among penicillins encourages stopping this whole family and to test cephalosporins, aztreonam and carbapenems for which cross-allergies are rarer.

[Psoriatic patients: Analysis of patients dissatisfied with their management]. / Patients atteints de psoriasis : analyse de la population insatisfaite de sa prise en charge.

BACKGROUND: The French are frequently regarded as grouchy. In a recent study, we observed a high proportion of patients initially consulting for psoriasis because they were dissatisfied with their previous therapy. We analyzed the characteristics of these patients. PATIENTS AND METHODS: This was a cross-sectional multicenter study in 40 centers belonging to the ResoPso (psoriasis treatment network) multicenter study group, with consecutive inclusions over a period of 11months in 2014. All adults (age>18 years) consulting for the first time for psoriasis at a center were included in the study. RESULTS: Among patients, 1205 were included, of whom 249 (20.3%) were consulting because of their dissatisfaction with treatment. In the univariate analysis, these patients were younger (P=0.02) and presented psoriasis that had begun earlier in life (P<0.0001). It consisted mostly of generalized plaque psoriasis (P=0.047) and more severe forms of psoriasis (PASI and/or DLQI score>10, P<0.02). There were fewer cases of psoriatic arthritis (P=0.01). The "dissatisfied" patients reported significantly more frequent use of topical treatments (P<0.0001) and alternative medicines (P=0.02), and more infrequent use of biologics (P=0.006) as well as longer treatment periods (P=0.0005). They consulted at hospitals (P=0.01) and had previously seen more GPs and dermatologists (P≤0.0008). There was no impact of gender on the dissatisfaction profile by either comorbidities (metabolic, blood pressure, alcohol and tobacco consumption, and depression), or socio-economic data. In the multivariate analysis, DLQI>10 (P=0.01; 95% CI: 1.01-1.07) and longer duration of care (P=0.004; 95% CI: 1.23-2.99) were associated with dissatisfaction. CONCLUSION: Twenty percent of our psoriatic patients seem dissatisfied with their treatment. It is difficult to draw a specific demographic and socioeconomic profile of dissatisfied patients. Only disease severity and possibly inadequate treatment at the initial consultation are associated with patient dissatisfaction. Explanations related to the individual patients and doctors may be proposed. Finally, while the French may be considered grouchy, the frequency of patient dissatisfaction seen in our study does not appear to be any greater than that observed in other countries.

Psoriasis associated with idiopathic CD4+ T-cell lymphopenia: a regulatory T-cell defect?

Idiopathic CD4(+) lymphocytopenia (ICL) is a rare immunodeficiency syndrome of unknown origin for which the increased risks of opportunistic infections and of malignancies have been well established; however, skin dysimmune diseases, including psoriasis, have been scarcely reported up to now. We report herein the severe course of psoriasis in four patients with ICL, and show evidence for a defect in the skin recruitment of regulatory CD4(+) FoxP3(+) T cells. These data raise the apparent paradigm of the occurrence of a severe immunomediated disease together with a profound T-cell defect, a model that might also apply to other immune deficiencies associated with psoriasis.

Combination therapy with clindamycin and rifampicin for hidradenitis suppurativa: a series of 116 consecutive patients.

BACKGROUND: Antibiotics are frequently used to treat hidradenitis suppurativa (HS); however, few data on their efficacy are available. OBJECTIVE: To evaluate the efficacy of a combination of systemic clindamycin (300 mg twice daily) and rifampicin (600 mg daily) in the treatment of patients with severe HS. METHODS: Patients (n = 116) who received this combination were studied retrospectively. The main outcome measure was the severity of the disease, assessed by the Sartorius score, before and after 10 weeks of treatment. RESULTS: The Sartorius score dramatically improved at the end of treatment (median = 29, interquartile range = 14.5, vs. median = 14.5, interquartile range = 11; p < 0.001), as did other parameters of severity as well as the quality of life score. Eight patients (6.9%) stopped the treatment because of side effects. CONCLUSION: The combination of clindamycin and rifampicin is effective in the treatment of severe HS.

[Systematic screening for methicillin-resistant Staphylococcus aureus (MRSA) in the nasal cavities of patients hospitalized in the dermatology departments of the Saint-Louis Hospital]. / Dépistage systématique du portage nasal du Staphyloccocus aureus résistant à la méticilline (SARM) chez les patients hospitalisés en dermatologie : expérience de l'hôpital Saint-Louis.

OBJECTIVES: In a bid to combat methicillin-resistant Staphylococcus aureus (MRSA) more efficiently in our department, we performed a study to 1) clarify the MRSA carriage rate in patients hospitalized in the department; 2) evaluate the rate of MRSA acquisition during hospitalization; 3) describe the MRSA carrier profile; 4) study the morbidity and mortality associated with MRSA. PATIENTS AND METHODS: We conducted a three-month prospective study in all patients hospitalized for more than 24hours in the dermatology department of the Saint-Louis Hospital. Nasal swab cultures were performed on the day of admission, once a week thereafter and on the day of discharge. Clinical and epidemiological data were individually reviewed by means of a standardized questionnaire. RESULTS: In 310 patients, the prevalence of nasal MRSA carriage at admission was 6.5%. During hospitalization, 1.9% of our patients became colonized with MRSA. MRSA carriers were significantly older than non-carriers and had been hospitalized more frequently over the previous 12 months, principally in intensive care or in intermediate or long-term care facilities, and erosive and/or ulcerated dermatitis was more common in this population. Of the 27 patients colonized with MRSA, only three had MRSA infections, and these were successfully treated with antibiotics. DISCUSSION: The observed rate of MRSA carriage was close to that seen in intensive care units (7%). While systematic screening for MRSA in patients with erosive and/or ulcerated dermatitis would allow detection of twice as many cases of MRSA than the usual screening recommendations, this would be associated with little tangible benefit and high costs, and we therefore decided not to change the usual MRSA screening politic in our dermatology department.