Safety of omalizumab in chronic urticaria during pregnancy: a real-life study

BACKGROUND

Managing a pregnant patient with chronic spontaneous urticaria (CSU) is often challenging. Recent data have shown that most CSU treatments in pregnant patients are second-generation H1 antihistamines (sgAHs), while data on the safety of omalizumab are scant.

OBJECTIVES

To evaluate, in a routine clinical practice setting, the efficacy and safety of omalizumab in patients with severe CSU refractory to sgAHs who either became pregnant during treatment or who started the drug during pregnancy.

METHODS

We conducted a retrospective study of women aged ≥ 18 years who were pregnant, who received one or more doses of omalizumab at any time during their pregnancy or who were taking omalizumab at the time of, or in the 8 weeks before, conception.

RESULTS

Twenty-nine pregnant patients were evaluated: 23 (79%) conceived a child while taking omalizumab (group A), while 6 (21%) started omalizumab treatment during pregnancy (group B). Among patients in group A, we observed 23 births (21 liveborn singletons and 1 liveborn twin pair) and 1 miscarriage. Fifteen (65%) patients discontinued omalizumab after confirming their pregnancy, while eight (35%) were exposed to omalizumab during their entire pregnancy. In group B, omalizumab was introduced at a mean (SD) 10.83 (3.60) weeks' gestation and all patients were exposed to it until the end of pregnancy. In this group, there were seven liveborn infants (five singletons and one twin pair). No adverse events, pregnancy complications or congenital anomalies in newborns were recorded in either group.

CONCLUSIONS

Omalizumab for CSU treatment before and during pregnancy does not appear to have negative effects on maternal or fetal outcomes.

An easy to use, ceramide-containing skincare routine: effectiveness and improvement of quality of life in elderly patients with xerosis

BACKGROUND

Xerosis negatively impacts the quality of life (QoL) for older adults by producing pruritus (itching), burning or stinging, and an uncomfortable sensation of tightness in the skin. Furthermore, chronic illness and pharmacological therapies could worsen skin health. Severe xerosis can also result in redness or cracking of the skin. The aim of this prospective open-label trial is to evaluate the effectiveness of a ceramide-based moisturizing cream and cleanser routine on elderly xerosis.

METHODS

During the 4-week treatment study, patients followed the routine according to the established protocol. At different timepoints (baseline, visit 1; after 28±5 days, visit 2) evaluations on the skin health and QoL of the patients were conducted by a healthcare professional (HCP), along with a patients' self-evaluation.

RESULTS

The study demonstrates that the treatment with the investigated products determines an overall significant improvement in all skin dryness criteria. In particular, after the observational period: 93% of the subjects had no or minimal skin roughness; 96% of patients had no or minimal discomfort due to skin dryness; 97% of patients did not present any fissures; patient self-assessments on skin dryness were consistent with HCP evaluation. QoL has globally improved in all patients, with a significant reduction of embarrassment, and a positive impact on social and daily activities. Patients' overall satisfaction was high in 87% of patients and 93% of them stated that they would continue the treatment also after the study had been completed.

CONCLUSIONS

After 4 weeks, the daily use of a ceramide-based routine significantly improved signs and symptoms of senile xerosis and chronic discomfort associated with xerosis in elderly adults. Furthermore, the impact of senile xerosis on subjects' QoL was also reduced after 4 weeks. The subjects also reported high satisfaction with the skincare regimen and its results.

Surgical management of gingival recessions in patients with refractory gingival pemphigus vulgaris: A multidisciplinary challenge

BACKGROUND

Mucogingival surgery for root coverage of gingival recessions (GRs) is usually performed in patients with unremarkable periodontal and systemic health. However, the predictable results of surgical procedures and increasingly high aesthetic expectations of patients necessitate optimal management of GR also in patients with systemic conditions that affect the oral cavity. In patients with pemphigus vulgaris (PV), mucosal fragility and complicated surgical management of inflamed soft tissues are major challenges.

METHODS AND RESULTS

A 36-year-old female patient with PV and deep GR on the mandibular incisors is presented. After initial unresponsiveness to steroids and immunosuppressants, complete clinical remission was achieved through repeated rituximab infusions and topical platelet-rich plasma. After > 1 year of stable clinical remission off therapy the patient successfully underwent surgical procedures for vertically coronally advanced flap with connective tissue graft.

CONCLUSIONS

To the best of our knowledge, no studies have described the surgical management of GR in PV patients. Although controlled studies are required to confirm present results, complete and stable clinical remission is necessary to avoid complications. Collaboration among dermatologists, oral medicine specialists, and periodontologists is essential to determine whether mucogingival surgery for root surface exposure is indicated for PV patients.

KEY POINTS

Why are these cases new information? This is the first report of root coverage in a patient with oral PV What are the keys to the successful management of these cases? The achievement of complete and stable clinical remission from oral PV Multidisciplinary collaboration among dermatologists, oral medicine specialists, and periodontologists What are the primary limitations to success in these cases? The refractoriness of gingival lesions induced by PV Poor mucogingival conditions of inflamed gingival tissues exacerbated by PV.

Dimethyl Fumarate Treatment in Patients with Moderate-to-Severe Psoriasis: A 52-week Real-life Study

Abstract is missing (Short communication)

Reconstructing historical exposure to asbestos: the validation of 'educated guesses'

BACKGROUND

In both the epidemiological and legal context, the causal attribution of asbestos-related lung diseases requires retrospective exposure assessment (REA).

AIMS

To assess the correlation between the retrospective assessment of occupational and anthropogenic environmental exposure to asbestos and its content in the lung tissue.

METHODS

Based on the available exposure information, a team of occupational physicians retrospectively assessed cumulative exposure to asbestos in 24 subjects who died of asbestos-related diseases. The asbestos lung content was analysed using analytical scanning electron microscope (SEM-EDS). The Log10 asbestos fibre count in the autoptic samples was predicted as a function of the Log10 estimated cumulative exposure using univariate regression analysis.

RESULTS

The median count of asbestos fibres by grams of dry weight (ff/gdw) in the lung tissue was 81 339 (range 0-2 135 849.06); it was 287 144 (range 0-2 135 849.06) among the occupationally exposed, and 29 671 (range 0-116 891) among the subjects who only had anthropogenic environmental and/or household exposure. Amphiboles, and particularly amosite (52%) and crocidolite (43%), were detected in all the study subjects. Chrysotile was not detected in any of the samples. Overall, the retrospective estimate of lifetime cumulative exposure to asbestos showed a moderate correlation with the total asbestos fibre count in the autoptic lung, with the regression model explaining 38-55% of the total variance.

CONCLUSIONS

Detailed information on occupational, environmental and household exposure circumstances would be indispensable for experienced industrial hygienists and/or occupational physicians to reliably assess past exposure to amphiboles or mixed types of asbestos.

Stable Operation of a Free-Electron Laser Driven by a Plasma Accelerator

The breakthrough provided by plasma-based accelerators enabled unprecedented accelerating fields by boosting electron beams to gigaelectronvolt energies within a few centimeters [1-4]. This, in turn, allows the realization of ultracompact light sources based on free-electron lasers (FELs) [5], as demonstrated by two pioneering experiments that reported the observation of self-amplified spontaneous emission (SASE) driven by plasma-accelerated beams [6,7]. However, the lack of stability and reproducibility due to the intrinsic nature of the SASE process (whose amplification starts from the shot noise of the electron beam) may hinder their effective implementation for user purposes. Here, we report a proof-of-principle experiment using plasma-accelerated beams to generate stable and reproducible FEL light seeded by an external laser. FEL radiation is emitted in the infrared range, showing the typical exponential growth of its energy over six consecutive undulators. Compared to SASE, the seeded FEL pulses have energies 2 orders of magnitude larger and stability that is 3 times higher.

Guselkumab for the treatment of psoriasis: a 60-week real-life multicenter retrospective experience

BACKGROUND

Real-world data for guselkumab, the first interleukin-23 inhibitor approved to treat moderate-to-severe psoriasis, are scarce. This study represents the first 60-week, real-life, multicenter, retrospective experience to investigate the effectiveness, safety, tolerability, and drug retention of guselkumab in psoriatic patients.

RESEARCH DESIGN AND METHODS

Clinical information was collected at baseline and at weeks 12, 24, 36, 48, and 60.

RESULTS

The mean baseline Psoriasis Activity Severity Index (PASI) reduced from 14.2 to 3.1 at week 12 and decreased to around 0 at weeks 36, 48, and 60. PASI 75, PASI 90, and PASI 100 were 100%, 96.8%, and 83.9% at week 60, respectively. Multiple logistic regression analysis showed that neither body mass index >30, smoking, ≥3 comorbidities, difficult-to-treat areas, nor a failure to ≥2 prior biologic treatments significantly influenced PASI reduction (p > 0.05).

CONCLUSIONS

Our findings confirm guselkumab as an appropriate therapeutic option in routine clinical practice, especially when dealing with complex patients with comorbidities or previous failure to biologic treatments.

Eruptive Non-melanoma Skin Cancers/Squamous Atypia Following Skin Surgery. Report of Two New Cases, Concise Review of the Literature With Special Emphasis on Treatment Options

INTRODUCTION

Eruptive cutaneous squamous cell carcinomas (ESCC), eruptive squamous atypia (ESA) and eruptive keratoacanthomas (EKA) are different terms used to describe the occurrence of multiple cutaneous squamous neoplasms after skin surgery, laser treatment, traumas, such as tattoos, and local or systemic medical treatments. ESCC have been reported to arise at the sites of skin surgery, including the area affected by the primary tumor and split thickness skin graft (STSG) donor and recipient sites.

OBJECTIVES

The aim of this study is to report 2 additional cases of ESCC after skin surgery and make a critical revision of the literature, analyzing the clinical, histological features and outcomes of ESCC after cutaneous surgery.

METHODS

Up to August 2021, according to our systematic review of the literature, we have collected 19 published articles and a total of 34 patients, including our 2 cases.

RESULTS

The results of this review highlight five red flags that clinicians should consider: (i) lower and upper limbs represent the cutaneous site with the highest risk, representing 83,78% of the cases in the literature; (ii) the median time to onset of ESCC is approximately 6 weeks; (iii) primary cutaneous squamous cell carcinomas were completely excised with free margins on histologic examination in the totality of the cases of the literature, and therefore ESCC should not be considered recurrences; (iv) any surgical technique involves a risk to promote ESCC; (v) treatment of ESCC includes medical treatment, surgery or combined surgical and medical treatment.

CONCLUSIONS

This review highlights 5 red flags which could support clinicians in the diagnosis and management of ESCC after skin surgery.

Diagnostic accuracy of transvaginal ultrasound for detection of endometriosis using International Deep Endometriosis Analysis (IDEA) approach: prospective international pilot study

OBJECTIVE

To evaluate the diagnostic accuracy of transvaginal ultrasound (TVS) in predicting deep endometriosis (DE) following the International Deep Endometriosis Analysis (IDEA) consensus methodology.

METHODS

This was an international multicenter prospective diagnostic accuracy study involving eight centers across six countries (August 2018-November 2019). Consecutive participants with endometriosis suspected based on clinical symptoms or historical diagnosis of endometriosis were included. The index test was TVS performed preoperatively in accordance with the IDEA consensus statement. At each center, the index test was interpreted by a single sonologist. Reference standards were: (1) direct visualization of endometriosis at laparoscopy, as determined by a non-blinded surgeon with expertise in endometriosis surgery; and (2) histological assessment of biopsied/excised tissue. Surgery was performed within 12 months following the index TVS. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV and NPV) and positive and negative likelihood ratios (LR+ and LR-) of TVS in the diagnosis of DE were calculated.

RESULTS

Included in the study were 273 participants with complete clinical, TVS, laparoscopic and histological data. Of these, based on histology, 256 (93.8%) were confirmed to have endometriosis, including superficial endometriosis, and 190 (69.6%) were confirmed to have DE. Based on surgical visualization, 207/273 (75.8%) patients had DE. For DE overall, the diagnostic performance of TVS based on surgical visualization as the reference standard was as follows: accuracy, 86.1%; sensitivity, 88.4%; specificity, 78.8%; PPV, 92.9%; NPV, 68.4%; LR+, 4.17; LR-, 0.15, and the diagnostic performance of TVS based on histology as the reference standard was as follows: accuracy, 85.9%; sensitivity, 89.8%; specificity, 75.9%; PPV, 90.4%; NPV, 74.6%; LR+, 3.72; LR-, 0.13.

CONCLUSIONS

Using the IDEA consensus methodology provides strong diagnostic accuracy for TVS assessment of DE. We found a higher TVS detection rate of DE overall than that reported by the most recent meta-analysis on the topic (sensitivity, 79%), albeit with a lower specificity. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Mortality and prognostic factors in patients with bullous pemphigoid: a retrospective multicenter Italian study

INTRODUCTION

Bullous pemphigoid is the most common autoimmune bullous dermatosis. In recent years several studies have tried to identify the main factors of the disease related with an increased risk of death. The aim of this multicenter Italian study was to assess the risk score of death considering epidemiologic, clinical, immunological, and therapeutic factors in a cohort of patients affected by bullous pemphigoid and try to identify the cumulative survival up to 120 months.

METHODS

We retrospectively reviewed the medical records of patients with bullous pemphigoid who were diagnosed between 2005 and 2020 in the 12 Italian centers. Data collected included sex, age at the time of diagnosis, laboratory findings, severity of disease, time at death/censoring, treatment, and multimorbidity.

RESULTS

A total of 572 patients were included in the study. The crude mortality rate was of 20.6%, with an incidence mortality rate of 5.9x100 person/year. The mortality rate at 1,3,5 and 10 years was 3,2%, 18,2%, 27,4% and 51,9%, respectively. Multivariate model results showed that the risk of death was significantly higher in patients older than 78 years, in presence of multimorbidity, anti-BP180 autoantibodies>72 U/ml or anti-BP230>3 U/ml at diagnosis. The variables jointly included provided an accuracy (Harrel's Index) of 77% for predicting mortality.

CONCLUSION

This study represents the first nationwide Italian study to have retrospectively investigated the mortality rates and prognostic factors in patients with bullous pemphigoid. A novel finding emerged in our study is that a risk prediction rule based on simple risk factors (age, multimorbidity, steroid-sparing drugs, prednisone use and disease severity) jointly considered with two biomarkers routinely measured in clinical practice (anti-BP230 and anti-BP180 autoantibodies) provided about 80% accuracy for predicting mortality in large series of patients with this disease.

P-747 Prevalence of Caesarean scar defect (CSD) and clinical impact on reproductive outcomes in patients undergoing in vitro fertilization (IVF)

Study question

Can sonohysterography-detected CSD have a deleterious effect on reproductive outcomes in women with secondary infertility undergoing IVF?

Summary answer

A 68% prevalence of CSD has been estimated in the study population. CSD significantly reduces the ongoing pregnancy rates in women undergoing IVF cycles.

What is known already

here is limited and conflicting evidence about the relation between Caesarean section, CSD and IVF treatment outcomes. Notably, most of the previous studies did not investigate the presence of CSD in infertile women with a history of Caesarian delivery. Furthermore, even if considered, the diagnosis of CSD is commonly based on transvaginal ultrasound assessment. Given the lower sensitivity of this method compared to saline infusion sonohysterography, an underestimation of the real effect is plausible.

Study design, size, duration

Retrospective cohort study of 122 women with a history of Caesarean delivery and an indication to IVF for secondary infertility referred to an Italian public assisted reproductive centre between 1 January 2016 and 30 April 2021.

Participants/materials, setting, methods

Women aged 18-43 with secondary infertility and a history of Caesarean delivery, tested for CSD with a saline infusion sonohysterography were included. Women with congenital uterine anomalies, intra-cavitary uterine pathologies, adenomyosis or previous myomectomy were excluded. CSD was defined as an anechoic indentation on the cesarean scar at the midsagittal plane, with a depth ≥ 2 mm.

Main results and the role of chance

Among the 122 women included, 83 (68%) were diagnosed with CSD by saline infusion sonohysterography. One hundred and fourteen patients underwent at least one IVF cycle: 76 (case group) had a CSD, 38 (control group) had a normal Caesarean scar. Groups were similar in patients and treatment characteristics. Clinical pregnancy rate was 43% in the CSD group and 71% in the control group (odds ratio [OR] 0.31; 95% confidence interval [CI], 0.14-0.72; p = .006). Ongoing pregnancy rates were 33% and 58%, respectively (OR, 0.34; 95% CI, 0.15-0.76; p = .015). Similar results were obtained after adjusting for potential confounders on the regression analysis. Ectopic pregnancy and miscarriage rate along with obstetric and neonatal complications were similar in both groups. In a subgroup-analysis comparing women with CSD who achieved pregnancy and those who did not, pregnant patients had a greater residual myometrial thickness compared to those who did not get pregnant, even if this finding did not reach statistical significance (5.3 mm versus 4.4 mm, p .07).

Limitations, reasons for caution

Retrospective nature of the study does not permit to infer a causal association between CSD and the reduced chance of pregnancy. Our results are representative of an infertile population but generalization needs further investigation. The sample size was too small to reveal the potential effect on obstetric and neonatal outcomes.

Wider implications of the findings

In infertile patients with a previous Caesarean section, the presence of CSD is more common than previously thought. The presence of CSD might significantly reduce the IVF success rate. This finding is important in relation to the rising of Caesarean section rates and the possible application of CSD surgical repair.

Trial registration number

not applicable

P-438 Fertility outcomes in male cancer recipients of hematopoietic cell transplantation who stored their semen for fertility preservation

Study question

What are the prevalence estimates of post-hematopoietic cell transplantation (HCT) natural conceptions or after ART using stored semen?

Summary answer

Natural live birth rate following HCT can be estimated at 9% (95%CI:4-22%) but can be increased to 58% (95%CI:43-72%) with the use of frozen semen.

What is known already

With the improvements and expanding indications of HCT, the number of adult male cancer survivors who received HCT is increasing. These men face the risk of treatment-induced infertility and are generally recommended to store their semen prior to embark in HCT. However, information on long term usage and on effectiveness of frozen sperm samples in this specific population is not well defined.

Study design, size, duration

All male cancer recipients of autologous or allogeneic transplantation who cryopreserved semen between 1987 and 2016 in the biobank of the Assisted Reproductive Technology Unit of the Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico in Milan were considered. Information was obtained from patients’ charts or through active investigation. The main studied topics included results from semen analyses, attempt to parenthood, use of stored spermatozoa and both natural and Assisted Reproductive Technique (ART) mediated conceptions.

Participants/materials, setting, methods

The study is restricted to men who met the following eligibility criteria: i) semen cryopreserved for fertility preservation between 1987 and 2016; ii) post-banking follow-up documenting HCT iii) survival of at least 5 years from HCT.

Main results and the role of chance

One-hundred and two HCT survivors were selected. The median [IQR] age at sperm banking was 29 [23-34]. About half of subjects had autologous HCT (n = 50), the remaining 52 received allogenic HCT. Lymphomas were the most frequent indications. The median spermatozoa concentration at the time storage was 39 [7-85] millions/ml. Fifty-four (53%) men performed a post-treatment sperm analysis and azoospermia was documented in 45 of them (83%, 95%CI: 71-91%). The remaining nine showed viable spermatozoa, of whom six had severe oligospermia (concentration <1 million/mL). The other three had semen concentration >5 Millions/ml, compatible with a natural conception. Overall, based on semen analyses, one could infer the necessity to use ART in 51 out of 54 subjects, corresponding to 94% (95%CI: 85-98%). Forty-three of the 102 included men (42%) sought childbearing. Four had a natural live birth (9%, 95%CI: 4-22%). Thirty-three used their cryopreserved sperm samples, corresponding to 32% (95%CI: 24-42%) of the whole cohort. Twenty-one of these 33 men had at least one live birth (64%, 95%CI: 47-78%). Finally, six men seeking pregnancy and who did not conceive have not used their frozen semen. Overall, 25 out of 43 men interested in fatherhood had a live birth (58%, 95%CI: 43-72%).

Limitations, reasons for caution

Limitation of our study is missing detailed information on status of illness and comorbidities (in particular the frequency of Graft-versus host disease) and lack precise information on the myeloablative regimen used. Furthermore, our sample size is not very large and therefore the 95%CI of the reported proportions are wide.

Wider implications of the findings

Autologous or allogeneic HCT induces infertility in a very high percentage of patients. These findings support the need to prioritize sperm preservation before HCT also in cancer patients who are not candidate for HCT at first instance but who may need this treatment for failure of first line treatments.

Trial registration number

not applicable

Free-electron lasing with compact beam-driven plasma wakefield accelerator

The possibility to accelerate electron beams to ultra-relativistic velocities over short distances by using plasma-based technology holds the potential for a revolution in the field of particle accelerators^1-4. The compact nature of plasma-based accelerators would allow the realization of table-top machines capable of driving a free-electron laser (FEL)⁵, a formidable tool to investigate matter at the sub-atomic level by generating coherent light pulses with sub-ångström wavelengths and sub-femtosecond durations^6,7. So far, however, the high-energy electron beams required to operate FELs had to be obtained through the use of conventional large-size radio-frequency (RF) accelerators, bound to a sizeable footprint as a result of their limited accelerating fields. Here we report the experimental evidence of FEL lasing by a compact (3-cm) particle-beam-driven plasma accelerator. The accelerated beams are completely characterized in the six-dimensional phase space and have high quality, comparable with state-of-the-art accelerators⁸. This allowed the observation of narrow-band amplified radiation in the infrared range with typical exponential growth of its intensity over six consecutive undulators. This proof-of-principle experiment represents a fundamental milestone in the use of plasma-based accelerators, contributing to the development of next-generation compact facilities for user-oriented applications⁹.

Use of apremilast in the psoriasis treatment: a real-life multicentre Italian experience

BACKGROUND

Apremilast is the first small molecule approved for the treatment of moderate-to-severe psoriasis in adult patients; however, real-life data are still limited. We investigated the effectiveness and safety of this drug in a multicentre real-world setting.

METHODS

We retrospectively reviewed data from all psoriatic patients who received at least one dose of apremilast, collecting demographic data and medical history, at baseline and periodically until 36 months.

RESULTS

A total of 111 patients entered in the study. The mean drug survival duration was 21.8±10.6 months, significantly shorter when comorbidities were≥3 and if biologic drugs were previously administered.ΔPASI90 was achieved in 29% of patients and ΔPASI50 in 68% at T4;the rate of ΔPASI improvement increased progressively at T12, T24, T36 in patients who continued to receive apremilast.At the end of the study 50 patients discontinued the treatment because of adverse events (19.8%), primary failure(19%) or secondary failure(6.3%).

CONCLUSIONS

Apremilast proved to be an effective, safe, and manageable drug, showing effectiveness also in difficult-to-treat patients with psoriasis, with a favourable tolerability profile and a potentially valid weight loss effect. We believe that treating patients with few comorbidities who are naive to biological therapy may result in higher response rates and longer mean drug survival.

Efficacy and safety of dimethylfumarate in elderly psoriasis patients: a multicentric Italian study

The number of psoriatic elderly patients is steadily increasing in the Western world, nevertheless they are frequently excluded from clinical trials and described as a high-risk group for adverse events.We conducted a retrospective multicentric study of DMF use in elderly (>65 years) psoriatic patients. DMF efficacy was evaluated up to 24 weeks by Psoriasis Area and Severity Index (PASI) score. We also evaluated drug maintenance and safety.Our study population included 81 elderly psoriatic patients treated with DMF up to 24 weeks. The PASI score at the baseline (week 0) ranged from 3,7-24 (mean ± SD, 9,8 ± 4,1), which changed after DMF administration to 4,3 ± 3,2 at week 16 and 2,7 ± 3,2 at week 24. Among 81 elderly psoriatic patients 59 (72,8%) adverse events were reported during the observation period. The most common were gastrointestinal complaints (n = 24, 29,6%) and flushes (n = 10, 12,3%). Lymphocytopenia (n = 10, 12,35%) was frequently observed.In daily practice, DMF seems to be efficacy and well tolerated in elderly psoriatic patients. DMF may be a first-line systemic treatment option to manage elderly psoriasis, provided that also the long-term safety data are closely monitored, in particular lymphocytopenia.

Dimethyl fumarate treatment for psoriasis in a real-life setting: A multicentric retrospective study

Dimethyl fumarate (DMF) is a fumaric acid esters derivate approved for plaque psoriasis as first‐line systemic therapy. It has been available in Italy since 2017 and an increasing number of patients are treated with this drug. To evaluate DMF effectiveness, side effects and drug survival in a dermatological real‐life setting. We performed a retrospective multi‐center study in five dermatologic clinics in Emilia‐Romagna, Northern Italy, which included all consecutive patients affected by moderate–severe psoriasis treated with DMF. We assessed effectiveness (in terms of PASI50 and PASI75 in an intention to treat observation) and safety (occurrence of side effects) of DMF and their association with demographic and disease characteristics, mean daily dose taken and treatment discontinuation. We included 103 patients, 78 (75.72%) had at least one comorbidity including 19 (18.44%) with a history of cancer; the mean treatment duration was 23.61 ± 17.99 weeks (min 4, max 130) and the mean daily dose was 262.13 ± 190.94 mg. Twenty‐four patients (23.30%) reached PASI75 at week 12, while a further 18 patients (17.47%) reached it at week 26. Side effects occurred in 63 patients (61.16%), the most frequent were diarrhea, epigastric discomfort, nausea, and flushing. Sixteen patients (15.53%) showed an alteration of laboratory tests. In some cases side effects were transitory, while in 53 patients (51.45%) they led to cessation of therapy. The median daily dose showed a direct association with PASI50 achievement and an indirect association with treatment discontinuation. Our study shows the peculiarities of DMF in a real‐world setting: effectiveness is often reached after 12 weeks of treatment and side effects could limit the continuation of the therapy but, at the same time, DMF has no major contraindications and, due to the wide range of dosage, it can allow both to manage side effects and to personalize the prescription for each patient.

Fractional CO2 laser and vulvar lichen sclerosus: an alternative resource during maintenance therapy? A prospective study

BACKGROUND

Lichen sclerosus is an autoimmune dermatosis that in women typically involves vulvar area. This condition can strongly impact on the quality of life.To date, topical steroids are the most effective treatment, although adverse effects are possible, especially in long-term application. The aim of this study is to investigate the efficacy of fractional CO2 laser in reducing symptoms of vulvar lichen sclerosus (VLS) during maintenance therapy with topical steroids (application twice weekly or less);(ii) to assess how long this reduction of symptoms persists during followup; (iii) histological comparison before and after treatment.To our knowledge, this is the first prospective study evaluating this treatment in women with VLS.

METHODS

Women with a diagnosis of VLS were prospectively enrolled and treated with fractional CO2 laser every 2 months, for a total of 3 sessions.Four questionnaires were periodically administered: the Dermatology Quality of Life Index (DLQI), the Female Sexual Functional Index (FSFI) and 2 specific questionnaires created to assess the severity of disease.

RESULTS

23 adult women were enrolled. The fractional CO2 laser treatment significantly improved the scores of all scales from baseline to T4 questionnaires.

CONCLUSIONS

Fractional CO2 laser proved to be effective on VLS symptoms and can be considered an alternative to corticosteroids during maintenance therapy. Larger studies with a control group and randomization are needed to safely generalize our findings.

Therapeutic approaches and targets for treatment of autoimmune bullous diseases

Autoimmune bullous diseases are a heterogeneous group of diseases characterized by the development of cutaneous and mucosal vesicles, blisters, and finally erosions. The common pathogenetic mechanism is the presence of autoantibodies targeting structural proteins of the skin and mucous membranes (demosomes and hemidesmosomes): in the case of pemphigus, the antigens are intraepidermal, whereas in the case of pemphigoid, dermatitis herpetiformis, and epidermolysis bullosa acquisita they are subepidermal. Mucosal involvement typically affects the oral and ocular mucosa, but in some cases, the upper airways or the upper digestive tract are affected. The burden on patients' lives could be severe due to the impairment of normal feeding or breathing. In other cases, they may represent paraneoplastic syndromes. Since autoimmune bullous diseases may result in significant morbidity and mortality, depending on the grade of cutaneous and mucosal involvement, a prompt therapeutic approach is mandatory and, in recalcitrant cases, may be challenging. The first line therapy consists of corticosteroids, both topical and systemic. Once remission or control of the acute phase is obtained, adjuvant therapies need to be introduced in order to spare the corticosteroid load and minimize side effects such as iatrogenic diabetes or osteoporosis. Herein, we describe all current therapeutic approaches to autoimmune bullous diseases, also including emerging therapies.

The impact of psoriasis on marriage

BACKGROUND

Psoriasis frequently affects partners and intimacy and sometimes leads to a break in relationships. The aim of this study was to evaluate the possible negative impact of psoriasis on married life through the use of the Quality Marriage Index (QMI), a score used to assess marital satisfaction.

METHODS

In this prospective case-control study married or divorced patients with moderate-to-severe plaque psoriasis were compared to a control group made up of married or divorced healthy patients without psoriasis. Each patient enrolled in the study was given the questionnaire to assess the QMI.

RESULTS

201 patients were included in the study sample: 100 suffered from moderate-tosevere plaque psoriasis and the other 101 did not. A significantly higher number of psoriatic patients was divorced than patients without psoriasis. By analyzing the QMI questionnaire, patients with psoriasis scored lower than patients without psoriasis in all single questions and in the total QMI value. By assessing how much each question weighed in the QMI final score, a significant difference between the two groups of patients was found in questions 3 and 6: the first one regarding the strength of marriage weighed more in psoriatic patients, while the second one regarding the happiness of marriage weighed more in non-psoriasis patients.

CONCLUSIONS

Psoriasis can contribute to marriage breakdown in affected patients. The concept of happiness seems to be greatly affected by the repercussions of psoriasis, while the strength of marriage plays a fundamental role in these patients.

Mortality of patients with bullous pemphigoid in Italy: a retrospective study of a monocentric experience

BACKGROUND

Mortality of bullous pemphigoid(BP) is a variable parameter,depending especially on the area where the study was conducted.The 1-year mortality rate and the identification of clinictherapeutic factors with potential prognostic value in patients with BP were evaluated in a cohort from a single referral center.

METHODS

We have reviewed medical records of patients with BP diagnosed at the Sant'Orsola-Malpighi Hospital in Bologna(Italy) between 2005 and 2019.Data collected included sex,age at diagnosis,laboratory findings,severity of disease,dosage of systemic treatments,age at death and comorbidities.Only patients who had at least 1 year of follow-up were included.

RESULTS

85 patients were included; the mortality rate was 7.1%.The mortality rate of patients treated with a moderate dosage of corticosteroids was no higher than that of patients treated with a low dosage.The log-rank test showed a statistically significant correlation between mortality and patients aged≥85,BP230 positive,and CCIS≥4.

CONCLUSIONS

Compared with similar studies,our results show a lower 1-year mortality rate.Advanced age at diagnosis and CCIS were confirmed as major independent factors associated with poor prognosis in BP.Administration of moderate dosage of oral corticosteroids seems to have an overall positive benefit-risk ratio,providing a good control of the disease and minimizing the risk of hospitalization,possible related complications and the mortality rate.

Chloracne: a case series on cutaneous expression of CYP1A1 as diagnostic biomarker

Chloracne, also known as metabolizing acquired dioxin-induced skin hamartomas (MADISH), is a rare disfiguring disease related to dioxin exposure. There is a paucity of literature on the clinical manifestations and pathogenesis of chloracne/MADISH. The aim of this study was to assess the clinical features of this very unusual acneiform eruption and to explore the pathogenesis of the disease. This was a retrospective, observational report study was conducted on five patients belonging to the same nuclear family (father, mother and three children) and a relative (father's brother) living in the same house. Histopathological, immunohistochemical, laboratory and toxicological analyses were performed for all patients. The results suggest that CYP1A1 in human skin is a diagnostic biomarker in chloracne, and was positive for all the patients in our sample. Tetrachlorodibenzo-p-dioxin is the most investigated dioxin responsible for chloracne; however, several other agonists, whether dioxin-like or not, can activate the aryl hydrocarbon receptor. To our knowledge, this Italian case series is the first study to suggest polychlorinated biphenyls as a possible cause of an overstimulation of aryl hydrocarbons causing the consequent acneiform eruption.

Nevocentric erythema multiforme in a child

A 9-year-old girl presented with multiple, ring-shaped, erythematous, nonscaly plaques on the trunk, face and arms, most surrounding preexisting melanocytic nevi. She had experienced recurring episodes of herpes simplex labialis over several years (average 4/year), the last occurring 10 days prior.