The challenge of diagnosing atypical exanthems: a clinico-laboratory study.

BACKGROUND: Although atypical exanthems pose a severe diagnostic challenge, they have not been studied widely. OBJECTIVE: To identify the clinical features, laboratory parameters and other characteristics that help establish the etiology of atypical exanthems. METHODS: We collected the following information from 260 consecutive patients with atypical exanthems, including 108 children and 152 adults: demographic data, exanthem and enanthem morphology, clinical symptoms, month of outbreak and total duration. Throat, rectal, and vesicle swabs as well as urine and skin samples were examined for bacterial and viral signs. Serologic studies were performed for the most common infectious agents. RESULTS: Seven morphological patterns were identified: macular erythema, papular erythema, macular-papular erythema, erythematovesicular, macular-papular erythema with petechiae, erythema with pustules, and urticarial. Ninety-four cases were due to viruses, 38 to bacteria, 65 to drugs, 3 to parasites, and one to viruses-plus-drugs. Nineteen of the 25 cases with a petechial pattern had an infectious etiology (12 viral and 7 bacterial) and only 4 were iatrogenic. Sixty-one of 69 patients with enanthems were infectious (57 viral and 4 bacterial), 6 were iatrogenic, and 2 remained undiagnosed. The petechial pattern was infectious in 80% of cases (14 viral and 2 bacterial). Four cases were iatrogenic. During the spring and summer, 60% of exanthems were infectious and 21% were iatrogenic. Picornavirus infections exhibited summer prevalence (57%), peaking in July. LIMITATIONS: There were a variable number of patients with each of the morphological patterns. CONCLUSIONS: Morphological patterns, seasonal occurrence, and enanthem are key for etiological diagnosis of atypical exanthems.

Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication.

BACKGROUND & AIMS: To better understand the role of small intestinal bacterial overgrowth (SIBO) in rosacea, we aimed to assess the presence of SIBO in patients with rosacea and the clinical effectiveness of its eradication. METHODS: We enrolled 113 consecutive rosacea ambulatory patients (31 M/82 F; mean age, 52 +/- 15 years) and 60 healthy controls who were sex- and age-matched. Patients and controls underwent lactulose and glucose breath tests (BTs) to assess the presence of SIBO. Patients positive for SIBO were randomized to receive rifaximin therapy (1200 mg/day for 10 days) or placebo. A group of patients with negative BTs were also treated with rifaximin. Eradication was assessed 1 month after the end of therapy. Two dermatologists, unblinded on therapy, evaluated rosacea patients before and after treatment on the basis of an objective scale. RESULTS: The prevalence of SIBO was higher in patients than controls (52/113 vs 3/60, P < .001). After eradication, cutaneous lesions cleared in 20 of 28 and greatly improved in 6 of 28 patients, whereas patients treated with placebo remained unchanged (18/20) or worsened (2/20) (P < .001). Placebo patients were subsequently switched to rifaximin therapy, and SIBO was eradicated in 17 of 20 cases. Fifteen had a complete resolution of rosacea. After antibiotic therapy, 13 of 16 patients with negative BTs for SIBO remained unchanged, and this result differed from SIBO-positive cases (P < .001). CONCLUSIONS: This study demonstrated that rosacea patients have a significantly higher SIBO prevalence than controls. Moreover, eradication of SIBO induced an almost complete regression of their cutaneous lesions and maintained this excellent result for at least 9 months.

Etiopathogenesis of rosacea: a prospective study with a three-year follow-up.

BACKGROUND: The aim of this study was to investigate the role of Demodex folliculorum (DF), Helicobacter pylori (HP), and small intestine bacterial overgrowth (SIBO) in the development of rosacea. METHODS: A case-control study including 60 patients with rosacea and 40 healthy controls was performed. All the patients underwent standardized skin surface biopsy to investigate DF, urea breath test for HP and lactulose breath test and glucose breath test for SIBO. Etiological therapy was started in the following order: acaricidal treatment, antibiotics for SIBO and HP. These exams were repeated after 3 years. Statistical analysis was performed. RESULTS: As regards the 88 patients who completed the entire follow-up, DF positivity was found in 47.7% of the patients, SIBO in 25.0%, and HP in 21.6%. SIBO significantly prevailed in papulopustular rosacea, while HP in erythrosis. At the 6-month follow up, the 61% of patients were in remission. After 3 years, 18% of patients dropped out, while the remaining patients repeated all the investigations. The majority of patients were still in remission and negative for HP while only 5 were positive for DF and 4 for SIBO. CONCLUSIONS: SIBO was the most relevant factor in papulopustular rosacea. Its treatment was crucial in improvement and in maintaining the clinical remission.

Rosacea treatments: What's new and what's on the horizon?

Rosacea is a common, chronic, cutaneous disorder presenting with recurrent episodes of facial flushing, erythema, papules, pustules and telangiectasias. It is a multifactorial disease and its various clinical presentations probably represent the consequence of combined different triggers upon a specific background. Its management is largely based on long-established treatments empirically tailored to the specific presenting symptoms and no real breakthrough has occurred to date. However, recent insights into the still rather obscure pathophysiology of rosacea seem to open the way for etiologically oriented treatments. These may include, on the one side, the more effective application of traditional drugs, such as tetracyclines and metronidazole, to specifically selected patients or, on the other side, new therapeutic options, such as vitamin D receptor antagonists. It is to be remarked that the quality of most studies evaluating rosacea treatment is rather poor, mainly due to a lack of proper standardization. For a major breakthrough to occur in the management of rosacea, we need both a better understanding of its pathogenesis and the adherence of future clinical trials to clearly defined grading and inclusion criteria, which are crucial for investigators to correctly compare and interpret the results of their work.

Reactivation of human herpesvirus 6 (HHV-6) infection in patients with connective tissue diseases.

BACKGROUND: Little is known about the involvement of human herpesviruses 6 and 7 (HHV-6 and HHV-7) in autoimmune connective tissue diseases (ACTD). OBJECTIVE: To determine the prevalence of active infection with HHV-6 and HHV-7 in patients with ACTD. STUDY DESIGN: The presence and quantity of HHV-6 DNA was determined by quantitative real-time PCR in a cross-sectional study of serum, peripheral blood mononuclear cells, and tissues obtained from 58 ACTD patients and 38 healthy subjects (HS). Specific anti-HHV-6 antibody titer was also measured. RESULTS: HHV-6 serum viremia occurred in a significantly higher proportion of ACTD patients compared to HS [26/58 (44.8%) vs. 1/38 (2.6%), p=0.001] with the highest reactivation frequency [7/10 (70%)] observed in patients with scleroderma. Moreover, HHV-6 in serum was associated with ACTD activity (22/38 vs. 4/20, p<0.05). Higher titers of HHV-6 antibodies were found in ACTD patients than in HS, although HHV-6 seroprevalence among patients with ACTD and HS was similar. HHV-7 viremia was not detected in any patients or HS controls. CONCLUSION: The frequent reactivation of HHV-6 in scleroderma and other ACTD, especially when active, suggests that HHV-6 may play a role in the pathogenesis of these diseases.