Creación del distintivo Soludable / Creation of the "Soludable" Sun Protection Accreditation Program

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Factores predictores de respuesta y revisión de la toxicidad cutánea de cetuximab y panitumumab en 116 pacientes / Predictors of Tumor Response to Cetuximab and Panitumumab in 116 Patients and a Review of Approaches to Managing Skin Toxicity

INTRODUCCIÓN Y OBJETIVOS: Cetuximab y panitumumab son anticuerpos anti-factor de crecimiento epidérmico (anti-EGFR) usados para el cáncer colorrectal metastásico. La mayoría de los pacientes desarrollan una erupción papulopustulosa que podría predecir la respuesta tumoral. Además, producen otros efectos adversos cutáneos, por lo que hemos estudiado si estos también podrían ser predictores clínicos de respuesta. Así mismo, hemos realizado una revisión del tratamiento de la erupción papulopustulosa, ya que no existen directrices basadas en la evidencia. MATERIAL Y MÉTODOS: Estudio retrospectivo de 116 pacientes. Se incluyeron pacientes afectos de cáncer colorrectal metastásico en tratamiento con los anticuerpos anti-EGFR, cetuximab o panitumumab, en el Hospital Universitario Donostia. RESULTADOS: El 81,9% de los pacientes desarrolló la erupción papulopustulosa, siendo el riesgo mayor y de mayor intensidad cuantos más ciclos de anti-EGFR se administraban (p = 0,03). Todos los pacientes que obtuvieron una respuesta tumoral completa desarrollaron la erupción. Cuanto peor era la respuesta tumoral, menor era la frecuencia de la erupción (p = 0,03). También se encontró una asociación entre la xerosis y la respuesta tumoral (el 53,4% de los que obtuvieron respuesta tumoral desarrollaron xerosis, p = 0,002). El manejo de la erupción papulopustulosa se llevó a cabo mediante un algoritmo desarrollado por nuestro servicio. CONCLUSIONES: En la práctica clínica la erupción papulopustulosa grave y la xerosis pueden ser predictores clínicos de buena respuesta al tratamiento anti-EGFR. Los pacientes con esta erupción deben tratarse precozmente, ya que el tratamiento subóptimo de estos efectos secundarios puede conllevar un retraso en la dosis o su interrupción

INTRODUCTION AND OBJECTIVES: Cetuximab and panitumumab are monoclonal antibodies that target the epidermal growth factor receptor (EGFR) in the treatment of metastatic colorectal cancer. Most patients develop a papulopustular rash, which may predict tumor response. We studied whether the other adverse cutaneous effects associated with these monoclonal antibodies are also clinical predictors of response. We also reviewed publications describing approaches to treating the papulopustular rash since no evidence-based guidelines have yet been published. MATERIAL AND METHODS: We performed a retrospective study of 116 patients with metastatic colorectal cancer receiving anti-EGRF therapy with cetuximab or panitumumab at Hospital Universitario Donostia. RESULTS: In total, 81.9% of the patients developed a papulopustular rash. Patients who received the most cycles of treatment with the EGFR inhibitor were at the highest risk of developing the rash, and these patients also had the most severe rash reactions (P = .03). All of the patients who exhibited a complete tumor response had the rash, and the incidence of rash was lower in patients with poor tumor response (P = .03). We also observed an association between tumor response and xerosis (53.4% of the patients who developed xerosis also exhibited tumor response, P = .002). The papulopustular rash was managed according to an algorithm developed by our department. CONCLUSIONS: Severe papulopustular rash and xerosis may be clinical predictors of good response to anti-EGFR therapy. Patients who develop a papulopustular rash should be treated promptly because suboptimal treatment of this and other adverse effects can lead to delays in taking the prescribed anti-EGFR dose or to interruption of therapy

Predictors of Tumor Response to Cetuximab and Panitumumab in 116 Patients and a Review of Approaches to Managing Skin Toxicity.

INTRODUCTION AND OBJECTIVES: Cetuximab and panitumumab are monoclonal antibodies that target the epidermal growth factor receptor (EGFR) in the treatment of metastatic colorectal cancer. Most patients develop a papulopustular rash, which may predict tumor response. We studied whether the other adverse cutaneous effects associated with these monoclonal antibodies are also clinical predictors of response. We also reviewed publications describing approaches to treating the papulopustular rash since no evidence-based guidelines have yet been published. MATERIAL AND METHODS: We performed a retrospective study of 116 patients with metastatic colorectal cancer receiving anti-EGRF therapy with cetuximab or panitumumab at Hospital Universitario Donostia. RESULTS: In total, 81.9% of the patients developed a papulopustular rash. Patients who received the most cycles of treatment with the EGFR inhibitor were at the highest risk of developing the rash, and these patients also had the most severe rash reactions (P=.03). All of the patients who exhibited a complete tumor response had the rash, and the incidence of rash was lower in patients with poor tumor response (P=.03). We also observed an association between tumor response and xerosis (53.4% of the patients who developed xerosis also exhibited tumor response, P=.002). The papulopustular rash was managed according to an algorithm developed by our department. CONCLUSIONS: Severe papulopustular rash and xerosis may be clinical predictors of good response to anti-EGFR therapy. Patients who develop a papulopustular rash should be treated promptly because suboptimal treatment of this and other adverse effects can lead to delays in taking the prescribed anti-EGFR dose or to interruption of therapy.

Granuloma anular lineal / Linear granuloma annulare

Presentamos el caso de un varón de 60 años que consultó por lesiones violáceas, de morfología lineal, ligeramente infiltradas al tacto, localizadas en ambos flancos y región proximal de las extremidades, de 10 años de evolución y asintomáticas. El examen histopatológico resultó compatible con granuloma anular. El granuloma anular lineal es una entidad muy poco frecuente, siendo aún menos usual su presentación tan extensa (AU)

A 60 year-old man with a 10 year’s history of progressive a symthomatic eruption characterized by violaceous bands on the lateral aspect of trunk and internal part of the extremities is reported. The histopathological examination showed a granuloma annulare. Linear granuloma annulare is a very uncommon variant, and such an extensive eruption is exceptional to our knowledge (AU)

[Update of the topical treatment of psoriasis]. / Revisión actualizada del tratamiento tópico de la psoriasis.

Topical therapy continues to be one of the pillars of psoriasis management. Topical corticosteroids and vitamin D analogs are the drugs of choice during the induction phase, and vitamin D analogs continue to be drugs of choice for maintenance therapy. Tazarotene and dithranol are suitable options in patients with certain, specific characteristics. The calcineurin inhibitors can be considered to be second-line treatment for psoriasis of the face and flexures. The efficacy and safety of the fixed-dose combination of betamethasone and calcipotriol in the induction phase is greater than that of either drug alone. The combination of corticosteroids with salicylic acid achieves better results than corticosteroids in monotherapy. None of the drugs evaluated stands out over the others in all clinical situations, and their use must therefore be individualized in each patient and adjusted according to the course of the disease.

Revisión actualizada del tratamiento tópico de la psoriasis / Update of the topical treatment of psoriasis

La terapia tópica sigue representando un pilar fundamental y de actualidad en el manejo de la psoriasis. Los corticoides tópicos y los análogos de la vitamina D son los principios activos de elección durante la fase de inducción, mientras que estos últimos se mantienen como alternativa de elección en el mantenimiento. El tazaroteno y el ditranol resultan alternativas adecuadas en pacientes con determinadas características. Los inhibidores de la calcineurina pueden considerarse tratamientos de segunda línea en la psoriasis de la cara y las flexuras. La eficacia y la seguridad en la fase de inducción de la combinación en dosis fija de betametasona y calcipotriol es superior a la obtenida por ambos principios activos por separado. La combinación de corticoides con ácido salicílico aporta ventajas con respecto a los corticoides en monoterapia. Ninguno de los principios activos evaluados presenta ventajas sobre el resto en todas las situaciones clínicas, por lo que su empleo debe individualizarse para cada paciente y para cada momento evolutivo de la dermatosis (AU)

Topical therapy continues to be one of the pillars of psoriasis management. Topical corticosteroids and vitamin D analogs are the drugs of choice during the induction phase, and vitamin D analogs continue to be drugs of choice for maintenance therapy. Tazarotene and dithranol are suitable options in patients with certain, specific characteristics. The calcineurin inhibitors can be considered to be second-line treatment for psoriasis of the face and flexures. The efficacy and safety of the fixed-dose combination of betamethasone and calcipotriol in the induction phase is greater than that of either drug alone. The combination of corticosteroids with salicylic acid achieves better results than corticosteroids in monotherapy. None of the drugs evaluated stands out over the others in all clinical situations, and their use must therefore be individualized in each patient and adjusted according to the course of the disease (AU)

Síndrome de Lyell asociado a lamotrigina / Lyell's syndrome associated with lamotrigine

Introducción. La lamotrigina (LTG) es un nuevo antiepiléptico de uso habitual en monoterapia tanto en epilepsias parciales como en generalizadas, que presenta entre otros efectos adversos la aparición de erupciones cutáneas leves y, con menos frecuencia, graves como el síndrome de Stevens-Johnson y el síndrome de Lyell o necrólisis epidérmica tóxica, sobre todo en combinación con valproato (VPA). Caso clínico. Mujer de 44 años en tratamiento por epilepsia toxicoalcohólica con VPA. Presenta neutropenia, probablemente secundaria, por lo que se intentó cambiar a LTG, siguiendo una pauta ascendente de LTG y descendente de VPA. En la sexta semana de tratamiento desarrolló una erupción cutánea eritematosa que, tras exposición solar, una semana después, se agravó con fiebre y malestar general, presentando en cabeza, región torácica anterior y posterior, abdomen, extremidades superiores e inferiores lesiones eritematosas con áreas costrosas, áreas de despegamiento de epidermis con signo de Nikolsky positivo y afectación severa de mucosas, siendo diagnosticada de síndrome de Lyell. Las lesiones mejoraron lentamente con sueroterapia, antibioterapia, corticosteroides parenterales y tratamientos tópicos. Conclusiones. Hay una probabilidad de erupción cutánea grave asociada a LTG que se debe tener en cuenta, se aconseja por lo tanto a los pacientes la suspensión de la medicación ante la mínima erupción cutánea (AU)

[Lyell syndrome associated with lamotrigine]. / Síndrome de Lyell asociado a lamotrigina.

INTRODUCTION: Lamotrigine (LTG) is a new antiepileptic of habitual use in monotherapy as much in partial epileptic as in generalised, which presents among other adverse effects: slight rashes and less frequently severe rashes such as Stevens-Johnson syndrome and Lyell syndrome or toxic epidermal necrolysis, above all in combination with valproate (VPA). CLINICAL CASE: A 44-yr-old woman in toxico-alcoholic epileptic treatment with VPA, showed a neutropenia possibly of secondary type which it was intended to change to LTG, following an ascending dose of LTG joined to a descending dose of VPA. In the sixth treatment week, the patient developed an erythematous rash which after a week of solar exposure, presented temperature, general discomfort, and in the head, on the front and back part of the thoracic and upper and lower limbs, erythematous lesions with scabbed areas, loosening epidermis areas with a positive Nikolsky sign and severe mucous membrane involvement, being diagnostic of Lyell syndrome. The lesions got slowly better with serum therapy, antibiotherapy, parenteral corticoids and topical treatments. CONCLUSIONS: There is a probability of severe rash associated with lamotrigine which has to be taken into account, and we advise patients to suppress the medication when they present a minimum rash.

Trichothiodystrophy associated with urologic malformation and primary hypercalciuria.

Trichothiodystrophy (TTD) is a hair abnormality that may be associated with a large number of alterations affecting the skin phenotype and skin appendages, nervous system, eyes, bones, and immune, gonadal, and endocrine systems. We report the first case of TTD associated with a urologic malformation and primary hypercalciuria. Our patient had congenital ichthyosis, physical and mental retardation, and a dysmorphic facies associated with a complex urologic malformation and primary hypercalciuria. Characteristic features of his hair under microscopic examination (trichoschisis, alternating light and dark bands under polarizing microscopy, and a severely defective cuticle) and low sulfur content by radiographic microanalysis confirmed the diagnosis. We discuss the meaning of this new association in the spectrum of abnormalities related to TTD.

[Pulmonary Kaposi's sarcoma in a heterosexual parenteral drug addict patient with the acquired immunodeficiency syndrome]. / Sarcoma de Kaposi pulmonar en un paciente heterosexual adicto a drogas por vía parenteral con síndrome de inmunodeficiencia adquirida.

A case of Kaposi syndrome is described in a 28-year-old heterosexual male with acquired immunodeficiency syndrome. The disease began clinically with pulmonary disease, without mucocutaneous lesions. This form of presentation is extremely infrequent and has not been described in non-homosexual subjects. Clinical manifestations were fever, cough and dyspnea. Thoracic radiography observed a perihilar interstitial pattern which evolved to a bilateral nodular pattern with perihilar adenopathy. There was endobronchial disease, however pulmonary biopsy was required for diagnosis. Complete tumoral remission was achieved with adriamycin, bleomycin and vincristine.

Eosinophilic histiocytosis. A subset of lymphomatoid papulosis.

A 43-year-old male with a 23-year history of small-plaque-type parapsoriasis developed a chronic recurrent self-healing papulonodular and tumoral cutaneous eruption. The microscopic findings were consistent with eosinophilic histiocytosis. Immunohistochemical and ultrastructural studies revealed a population of T lymphocytes, eosinophils and monocyte-macrophage cells in the dermal infiltrate. These findings confirm the similarities between eosinophilic histiocytosis and lymphomatoid papulosis suggesting that the former may be a clinicopathologic variant of the latter.

Perforating lichen striatus.

A case of lichen striatus with transepidermal elimination of clusters of necrotic keratinocytes is reported. On the basis of the morphologic findings, we suggest that transepidermal elimination may be a mechanism of healing in some cutaneous lichenoid eruptions.