Prevalence of dermatitis including allergic contact dermatitis from medical devices used by children and adults with Type 1 diabetes mellitus: A systematic review and questionnaire study

Use of medical devices (MDs), that is, glucose sensors and insulin pumps, in patients with Type 1 diabetes mellitus (T1D) has proven an enormous advantage for disease control. Adverse skin reactions from these MDs may however hamper compliance. The objective of this study was to systematically review and analyse studies assessing the prevalence and incidence of dermatitis, including allergic contact dermatitis (ACD) related to MDs used in patients with T1D and to compare referral routes and the clinical investigation routines between clinics being part of the European Environmental and Contact Dermatitis Research Group (EECDRG). A systematic search of PubMed, EMBASE, CINAHL and Cochrane databases of full-text studies reporting incidence and prevalence of dermatitis in persons with T1D using MDs was conducted until December 2021. The Newcastle-Ottawa Scale was used to assess study quality. The inventory performed at EECRDG clinics focused on referral routes, patient numbers and the diagnostic process. Among the 3145 screened abstracts, 39 studies fulfilled the inclusion criteria. Sixteen studies included data on children only, 14 studies were on adults and nine studies reported data on both children and adults. Participants were exposed to a broad range of devices. Skin reactions were rarely specified. It was found that both the diagnostic process and referral routes differ in different centres. Further data on the prevalence of skin reactions related to MDs in individuals with T1D is needed and particularly studies where the skin reactions are correctly diagnosed. A correct diagnosis is delayed or hampered by the fact that, at present, the actual substances within the MDs are not declared, are changed without notice and the commercially available test materials are not adequately updated. Within Europe, routines for referral should be made more standardized to improve the diagnostic procedure when investigating patients with possible ACD from MDs.

Gender differences in adult atopic dermatitis and clinical implication: Results from a nationwide multicentre study

BACKGROUND

Atopic dermatitis (AD) is a common inflammatory skin disease that affects both children and adults. However, limited research has been conducted on gender differences in AD.

OBJECTIVES

This study aimed to assess gender differences in adult AD patients, focusing on demographic and clinical features, comorbidities and treatment approaches.

METHODS

In this multicentre, observational, cross-sectional study, we enrolled 686 adult patients with AD (357 males and 329 females). For each patient, we collected demographic data (age and sex), anthropometric measurements (weight, height, hip circumference, waist circumference and waist-to-hip ratio), clinical information (onset age, disease duration, severity, itching intensity, impact on quality of life) and noted comorbidities (metabolic, atopic and other). We recorded past and current topical and systemic treatments. We analysed all collected data using statistical techniques appropriate for both quantitative and qualitative variables. Multiple correspondence analysis (MCA) was employed to evaluate the relationships among all clinical characteristics of the patients.

RESULTS

We found no differences in age at onset, disease duration, severity and quality of life impact between males and females. Males exhibited higher rates of hypertriglyceridaemia and hypertension. No significant gender differences were observed in atopic or other comorbidities. Treatment approaches were overlapping, except for greater methotrexate use in males. MCA revealed distinct patterns based on gender, disease severity, age of onset, treatment and quality of life. Adult males with AD had severe disease, extensive treatments and poorer quality of life, while adult females had milder disease, fewer treatments and moderate quality of life impact.

CONCLUSIONS

Our study reveals that gender differences in adult AD patients are largely due to inherent population variations rather than disease-related disparities. However, it highlights potential undertreatment of females with moderate AD and quality of life impact, emphasizing the need for equitable AD treatment. JAK inhibitors may offer a solution for gender-based therapeutic parity.

AB0915 GUSELKUMAB REAL WORD DATA: EFFICACY AND SAFETY IN A COHORT OF 69 PATIENTS WITH PSORIATIC ARTHRITIS

Background

Psoriasis (PSO) is a systemic immune-mediated disorder, characterized by inflammation skin and joint manifestations: it is known that up to 30% of PsO patients develop PsA.

PsO and PsA share common etiopathogenetic pathways, as IL-23/IL-17 axis. In Italy, Guselkumab (GUS), a selective IL-23 inhibitor, was approved in 2018 for the treatment of PsO, and recently it was also approved for PsA therapy. Today, there are few “real-world” studies regarding the use of GUS in PsA patients.

Objectives

A multicenter Italian study group of dermatologists and rheumatologists aimed at evaluate GUS efficacy and safety in patients with concomitant PsO and PsA in real word setting on both skin and joint domains.

Methods

An observational retrospective, multicentric study was performed in 69 PsO patients with a confirmed diagnosis of moderate to severe PsA. PASI and DLQI were used for the evaluation of skin response, and the number swollen/tender joints, presence or absence of dactylitis or enthesitis or axial involvement and painVAS were evaluated for the articular and periarticular efficacy. These analyses were performed at baseline T0 (beginning of the therapy), T1 (12 weeks) and T2 (24 weeks).

Results

38/69 patients (55,1%) presented oligoarthritis, 31/69 (44,9%) showed polyarthritis, none of the patients had enthesitis or axial involvement. Moreover, co-morbidities were diagnosed: hypertension (52,2%), hypercholesterolemia (34,8%), Hypertriglyceridemia (29%), diabetes (24,6%), obesity (23,2%), HIV-positive (20,3%), psychiatric disorders (17,4%), cardiopathies (15,9%), inflammatory bowel disease (7,3%), Latent Tubercolosis (4,4%), Chronic B-Hepatitis (2,9%), Chronic C-Hepatitis (1,5%). In all these patients, skin and joint responses were evaluated at week 12 and week 24.

Concerning skin efficacy, PASI 90 was achieved at week 24. Concerning Joint response: painVAS progressively improved till T2, tender joint count decreased in patients with oligo and polyarthritis at T1 and maintained at T2, while swollen joint count decreased in polyarthritis patients at T1 and maintained at T2. In oligo-arthritis patients, this parameter was not improved. The number of dactylitis did not decrease during the period of study (see Table 1). No safety concerns were reported in this population.

Conclusion

Efficacy and safety of GUS was confirmed in this study group of PsO patients with concomitant PsA and several comorbidities in a real-life setting.

Disclosure of Interests

None declared

Moderate to severe atopic dermatitis in adolescents treated with dupilumab: a multicenter Italian real-world experience

Background

Moderate‐to‐severe atopic dermatitis (AD) in the adolescence is a high burden disease, and its treatment can be very challenging due to paucity of approved systemic drugs for this age and their side‐effects. Dupilumab was recently approved for treatment of adolescent AD.

Objectives

A multicentre, prospective, real‐world study on the effectiveness and safety of dupilumab in adolescents (aged from ≥12 to <18 years) with moderate‐to‐severe AD was conducted. The main AD clinical phenotypes were also examined.

Methods

Data of adolescents with moderate‐to‐severe AD treated with dupilumab at label dosage for 16 weeks were collected. Treatment outcome was assessed by EASI, NRS itch, NRS sleep loss and CDLQI scores at baseline and after 16 weeks of treatment. The clinical scores were also evaluated according to clinical phenotypes.

Results

One hundred and thirty‐nine adolescents were enrolled in the study. Flexural eczema and head and neck eczema were the most frequent clinical phenotypes, followed by hand eczema and portrait‐like dermatitis. Coexistence of more than 1 phenotype was documented in 126/139 (88.5%) adolescents. Three patients (2.1%) contracted asymptomatic SARS‐CoV‐2 infection and 1 of the discontinued dupilumab treatment before the target treatment period. A significant improvement in EASI, NRS itch, NRS sleep loss and CDLQI was observed after 16 weeks of treatment with dupilumab. This outcome was better than that observed in clinical trials. Dupilumab resulted effective in all AD phenotypes, especially in diffuse eczema. Twenty‐eight (20.1%) patients reported adverse events, conjunctivitis and flushing being the most frequent. None of patients discontinued dupilumab due to adverse event.

Conclusions

Dupilumab in adolescent AD showed excellent effectiveness at week 16 with consistent improvement of all clinical scores. Moreover, dupilumab showed a good safety profile also in this COVID‐19 pandemic era.

Comorbidities and treatment patterns in adult patients with atopic dermatitis: results from a nationwide multicenter study

Adult atopic dermatitis (adult AD) is a systemic inflammatory disorder, whose relationship with immune-allergic and metabolic comorbidities is not well established yet. Moreover, treatment of mild-to-moderate and severe atopic dermatitis needs standardization among clinicians. The aim of this study was to evaluate the distribution of comorbidities, including metabolic abnormalities, rhinitis, conjunctivitis, asthma, alopecia and sleep disturbance, according to severity of adult AD, and describe treatments most commonly used by Italian dermatologists. Retrospective, observational, nationwide study of adult patients over a 2-year period was performed. Clinical and laboratory data were obtained through review of medical records of patients aged ≥ 18 years, followed in 23 Italian National reference centres for atopic dermatitis between September 2016 and September 2018. The main measurements evaluated were disease severity, atopic and metabolic comorbidities, treatment type and duration. Six-hundred and eighty-four adult patients with AD were included into the study. Atopic, but not metabolic conditions, except for hypertension, were significantly associated with having moderate-to-severe AD in young adult patients. Disease duration was significantly associated with disease severity. Oral corticosteroids and cyclosporine were the most widely used immunosuppressant. Our study seems confirm the close relationship between adult AD and other atopic conditions, further long-term cohort studies on patients affected by adult AD need to be performed to evaluate the complex relationship between adult AD disease severity and metabolic comorbidities.

Dupilumab therapy of atopic dermatitis of the elderly: a multicentre, real-life study

BACKGROUND

Treatment of moderate-to-severe atopic dermatitis (AD) in the elderly may be challenging, due to side-effects of traditional anti-inflammatory drugs and to comorbidities often found in this age group. Furthermore, efficacy and safety of innovative drugs such as dupilumab are not yet well known.

OBJECTIVES

A multicentre retrospective, observational, real-life study on the efficacy and safety of dupilumab was conducted in a group of patients aged ≥65 years and affected by severe AD. Their main clinical features were also examined.

METHODS

Data of elderly patients with severe (EASI ≥24) AD treated with dupilumab at label dosage for 16 weeks were retrospectively collected. Treatment outcome was assessed by comparing objective (EASI) and subjective (P-NRS, S-NRS and DLQI) scores at baseline and after 16 weeks of treatment.

RESULTS

Two hundred and seventy-six patients were enrolled in the study. They represented 11.37% of all patients with severe AD. Flexural eczema was the most frequent clinical phenotype, followed by prurigo nodularis. The coexistence of more than one phenotype was found in 63/276 (22.82%) subjects. Data on the 16-week treatment with dupilumab were available for 253 (91.67%) patients. Efficacy of dupilumab was demonstrated by a significant reduction of all the scores. No statistically significant difference regarding efficacy was found in elderly patients when compared to the group of our AD patients aged 18-64 years, treated with dupilumab over the same period. Furthermore, only 18 (6.52%) patients discontinued the drug due to inefficacy. Sixty-one (22.51%) patients reported adverse events, conjunctivitis and flushing being the most frequent. One (0.36%) patient only discontinued dupilumab due to an adverse event.

CONCLUSIONS

Therapy with dupilumab led to a significant improvement of AD over a 16-week treatment period, with a good safety profile. Therefore, dupilumab could be considered as an efficacious and safe treatment for AD also in the elderly.

HIDRAdisk: validation of an innovative visual tool to assess the burden of hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, relapsing, inflammatory skin disease characterized by painful inflamed nodules, recurrent abscesses and fistulas located in apocrine gland-bearing body sites. The negative impact of HS on patient's quality of life (QoL) has been reported to be greater than other dermatologic conditions as psoriasis and atopic eczema, and its improvement is an important goal in disease management. Nowadays, there are no specific validated QoL instruments available for HS and generic dermatologic questionnaires are used.

OBJECTIVE

The objective of this study was to demonstrate the validity, reliability and responsiveness of HIDRAdisk, a new innovative tool designed for rapid assessment of HS burden and, at the same time, an intuitive graphic visualization of the measurement outcome.

METHODS

A multicentre, longitudinal, observational study was conducted to validate the HIDRAdisk compared with other validated questionnaires [Skindex-16, Dermatology Life Quality Index (DLQI), Work Productivity and Activity Impairment-General Health (WPAI:GH)] and to evaluate its correlation with disease severity in Italian patients with any degree of HS severity, as measured by Hurley stage and HS Physician Global Assessment (HS-PGA).

RESULTS

A total of 140 patients (59% women; mean age 34.9 ± 11.0 years) were enrolled in 27 dermatologic centres. HIDRAdisk showed a strong correlation with Skindex-16 and DLQI, and a good one with WPAI:GH (correlation coefficient: 0.7568, 0.6651 and 0.5947, respectively) and a statistically significant correlation with both Hurley stage and HS-PGA. Very good internal consistency (Cronbach coefficient >0.80; intraclass correlation coefficient >0.6), with correlation between the 10 items, good test-retest reliability (Spearman correlation coefficient, 0.8331; P < 0.0001) and responsiveness to changes were demonstrated.

CONCLUSION

Our study shows that HIDRAdisk, a short and innovative visual HS QoL instrument, has been psychometrically validated in Italian language and it may help improve the management of HS once implemented in routine clinical practice.

Predictors of response to omalizumab and relapse in chronic spontaneous urticaria: a study of 470 patients

BACKGROUND

Chronic spontaneous urticaria (CSU) is defined as spontaneous occurrence of wheals and/or angioedema for ≥6 weeks. Omalizumab is a monoclonal anti-IgE antibody effective in refractory CSU, but its mechanism of action and markers predictive of response remain not completely defined.

OBJECTIVES

To correlate baseline levels of two proposed biomarkers, total IgE (bIgE) and d-dimer (bd-dimer), and clinical parameters to omalizumab response and to relapses after drug withdrawal.

METHODS

In this retrospective Italian multicentre study, clinical data were collected in 470 CSU patients, and bIgE and bd-dimer were measured in 340 and 342 patients, respectively. Disease activity was determined by Urticaria Activity Score 7 (UAS7) at week 1 and 12 after omalizumab starting. Relapses were evaluated during a 2- and 3-month interval after a first and a second course of treatment, respectively.

RESULTS

bIgE correlated to a good response to omalizumab since levels were significantly higher in responders than non-responders (P = 0.0002). Conversely, bd-dimer did not correlate to response. There was no correlation between both bIgE and d-dimer and either first or second relapse. Disease duration was significantly longer in patients who experienced either first or second relapse (P < 0.0001 and P = 0.0105, respectively), while baseline UAS7 correlated only to first relapse (P = 0.0023).

CONCLUSIONS

Our study confirms bIgE as a reliable biomarker predicting response to omalizumab in CSU, while it does not support the usefulness of bd-dimer unlike previous findings. CSU duration before omalizumab and baseline UAS7 may be clinical markers of relapse risk.

Dermatitis caused by arthropods in domestic environment: an Italian multicentre study

BACKGROUND

Skin diseases caused by mites and insects living in domestic environments have been rarely systematically studied.

OBJECTIVES

To study patients with dermatitis induced by arthropods in domestic environment describing their clinical features, isolating culprit arthropods and relating the clinical features to the parasitological data.

METHODS

The study was performed in 105 subjects with clinical and anamnestic data compatible with the differential diagnosis of ectoparasitoses in domestic environments. Clinical data and arthropods findings obtained by indoor dust direct examination were studied.

RESULTS

Indoor dust direct examination demonstrated possible arthropods infestation in 98 subjects (93.3%), more frequently mites (56.1%) (mainly Pyemotes ventricosus and Glycyphagus domesticus) than insects (43.9%) (mainly Formicidae and Bethylidae). Strophulus (46.9%) and urticaria-like eruption (36.7%) in upper limbs and trunk with severe extent were prevalent. Itch was mostly severe (66.3%) and continuous (55.1%). Ectoparasitoses occurred frequently with acute course in summer (44.9%) and spring (30.6%).

CONCLUSIONS

Possible correlation between clinical and aetiological diagnosis of arthropods ectoparasitoses in domestic environments needs the close cooperation between dermatologist and parasitologist. This is crucial to successfully and definitely resolve skin lesions by eradicating the factors favouring infestation.

Italian guidelines on the systemic treatments of moderate-to-severe plaque psoriasis

Psoriasis is a common disease, which has a considerable impact on the healthcare system. Therefore, appropriate use of therapeutic resources is very important. Management of psoriasis in daily clinical practice is highly variable because many issues are still debated and not definitely addressed by the evidence-based medicine. Moreover, the different availability and reimbursability of drugs in each country justifies national guidelines. Expert consensus can provide helpful guidelines for optimizing patient care. A total of 20 dermatologists from different areas of Italy and with large experience in the treatment of psoriasis agreed to participate in the guidelines expert panel who aimed to reach consensus on the factors influencing psoriasis severity, the indications for systemic treatments, the parameters to be considered in the choice of treatment, and the factors to be considered in the choice of biological treatment. The recommendations for the use, screening and monitoring of systemic therapies were based on the 2015 S3 European Dermatology Forum/European Academy of Dermatology and Venereology psoriasis guidelines. Recommendations on the treatment of psoriasis in special patient populations were also agreed. The final document was discussed in a meeting moderated by a facilitator with participation of the entire group and adopting a nominal group technique to reach consensus. A statement was regarded as consented when agreement was achieved by at least 75% of the voting experts according to the Delphi procedure.

Effectiveness and safety of cyclosporine in pediatric plaque psoriasis: A multicentric retrospective analysis

BACKGROUND

Cyclosporine (CysA) is effective for psoriasis in adult patients but little data exist about its efficacy and safety in childhood and adolescence psoriasis.

OBJECTIVES

To assess the effectiveness and safety of CysA for childhood and adolescence psoriasis.

METHODS

Retrospective analysis of a group of children and adolescents (age < 17 years) with plaque psoriasis treated with CysA at several Italian dermatology clinics.

RESULTS

Our study population consisted of 38 patients. The median age at the start of treatment was 12.3 years. Therapy duration varied from one to 36 months. The median maintenance dosage per day was 3.2 mg/kg (range 2-5 mg/kg). Fifteen patients (39,4%) achieved a complete clearance or a good improvement of their psoriasis defined by an improvement from baseline of  ≥75% in the psoriasis area and severity index (PASI) at week 16. Eight patients (21.05%) discontinued the treatment due to laboratory anomalies or adverse events. Serious events were not recorded.

CONCLUSIONS

In this case series, CysA was effective and well-tolerated treatment in a significant quote of children. CysA, when carefully monitored, may represent a therapeutic alternative to the currently used systemic immunosuppressive agents for severe childhood psoriasis.

Relapsed actinic keratosis evaluation: an observational Italian multicenter prospective study. Does gender have a role?

AIM

Relapsed actinic keratoses evaluation study (RAKE) was performed in nine Italian centers of dermatology in order to observe the outcome of the treatments of these common skin neoplasms.

METHODS

A total of 182 patients were enrolled in 2 cohorts: the first included 144/182 patients (79.1%) evaluated after 6 months from clinical remission, and the second 116/182 (63.7%) evaluated for at least 12 months after clinical remission. Patients were previously treated with topical diclofenac 3% in hyaluronic acid, cryotherapy, photodynamic, curettage or imiquimod cream.

RESULTS

Subjects with history of malignant skin diseases showed an increased number of new lesions at 16 months from baseline (12 months from remission) compared to patients without history of cancers (mean 1.58 versus 1.17). Hyperkeratotic lesions healed more rapidly but relapsed at 6 months more frequently than non-hyperkeratotic ones (32.9% versus 20.7%). The results showed gender-related differences: male patients recovered better and independently from the treatment used; in contrast, men showed a higher recurrence (32% at 6 months and 6.6% between 6 and 12 months versus 16% at 6 months and 5.9% between 6 and 12 months for females) and a higher average number of new lesions after 12 months from remission (1.6 versus 0.88 for females).

CONCLUSION

The results may suggest a lower adherence to photoprotection in male patients. Hyperkeratotic lesions recurred mostly at 6 months in comparison to non-hyperkeratotic lesions.

Optimization of systemic treatments for chronic plaque psoriasis. Recommendations for switching and transitioning

AIM

The aim of this study was to provide practical recommendations for optimizing the use of conventional and biological systemic treatments for moderate-severe chronic plaque psoriasis, particularly in case of transitioning and switching.

METHODS

A total number of 147 dermatologists from 33 different countries including Italy achieved consensus in providing practical recommendations for the use of conventional and biological treatments for moderate to severe psoriasis based on systematic literature review and/or expert opinion.

RESULTS

In general, the continuous treatment regimen should be preferred in order to achieve a complete and long-term control of psoriasis. However, the treatment could be stopped or the dose reduced in case of complete disease clearance. A conventional drug could be associated to biological treatment in selected cases. Transitioning and/or switching could be considered in case of inefficacy or intolerance. A period of wash up is required if transitioning or switching is due to safety issues.

CONCLUSION

This study provides practical suggestions for the optimal use of conventional and biological treatments for chronic plaque psoriasis.

Investigation of new vehicles to patch test corticosteroids: our experience with ethoxydiglycol to detect contact allergy to hydrocortisone butyrate

Topical corticosteroids (CS) are widely used in dermatology because of their anti-inflammatory, anti-proliferative and immuno-suppressive properties. On the other hand, the prolonged application of corticosteroids may induce adverse reactions such as allergic contact dermatitis (ACD). Patch testing CS often poses methodological issues correlated to their drug properties that may hide the manifestations of a positive reaction. Furthermore, the ideal concentration to patch test corticosteroid is still a matter of study and some vehicles have some well-known limitations. This article is divided into two parts: the first one investigated vehicles that may efficiently dissolve the corticosteroids, according to the polarity of the latter; the second part compared the results of the patch tests with hydrocortistone-17-butyrate using two different vehicles: ethanol, which is the standard one, and another vehicle selected as suitable from our CS solubility test.

Reactivity to euro coins and sensitization thresholds in nickel-sensitive subjects

BACKGROUND

The 1- and the 2-euro coins consist of nickel alloys, which release nickel. The nickel released by far exceeds the amount allowed by the European Union Nickel Directive referring to products intended to come into direct and prolonged contact with the skin. As there is only temporary contact with the skin, the clinical relevance of nickel-containing coins with regard to nickel dermatitis is a matter of debate, although there is evidence that the nickel released from the coins affects some nickel-sensitive subjects through occupational exposure.

OBJECTIVES

Our aim was to study skin reactivity to euro coins, and to correlate the frequency and intensity of coin patch test responses to sensitization thresholds to nickel.

PATIENTS AND METHODS

Sixty-four nickel-sensitized and 30 non-nickel-sensitized subjects were patch tested with serial dilutions of nickel sulfate (5, 1, 0.5, 0.1, 0.05, 0.01 and 0.005% in distilled water) and with coins. Italian coins (500, 200, 100 and 50 lira) and euro coins (2 and 1 euros, 20 and 5 euro cents) were used for patch testing and compared.

RESULTS

The application of 1- and 2-euro coins to the skin induced eczematous reactions, being more frequent and intense in comparison with those provoked by other coins. A correlation between intensity of responses to coin patch tests and sensitization threshold to nickel was observed. Patients with the strongest reactions to 1- and 2-euro coins showed positive responses to the lowest nickel concentrations.

CONCLUSIONS

The nickel content in euro coins represents a possible health hazard, especially for highly nickel-sensitive subjects. We recommend that nickel sulfate patch tests should be performed at different concentrations to determine sensitization thresholds at least in individuals with occupational exposure to coins.

T-lymphocyte cytokine profiles in compositae airborne dermatitis

Compositae airborne dermatitis is a well-recognized disorder characterized by erythematosquamous lesions and papules on light-exposed areas. The presence of positive patch test reactions and the absence of specific serum IgE suggest delayed-type hypersensitivity, the murine model of which is characterized by a Th1 cytokine production profile [high amounts of interferon (IFN)-gamma and interleukin (IL)-2; little or no IL-4 and IL-5]. The aim of this study was to evaluate the cytokine profile of T-cell lines and T-cell clones from peripheral blood in a 38-year-old non-atopic male woodcutter affected by seasonal airborne contact dermatitis. The patient showed positive patch test reactions to several Compositae extracts (Achillea millefolium, Chamomilla recutita, Tanacetum parthenium, T. vulgare) and sesquiterpene lactone mix. On prick testing with Compositae and other plants, serum-specific IgE levels and phototesting were negative or normal. Allergen-specific T-cell lines produced with Compositae extracts showed a good in vitro cell proliferation only to C. recutita extract. Serial cloning performed using the C. recutita-specific T-cell lines revealed an alphabeta+CD4+ phenotype with high amounts of IFN-gamma and IL-4 in T-cell clones. Thus, these cells expressed a preferential Th0 phenotype. These data suggest that in addition to IFN-gamma, other T-cell derived cytokines, such as IL-4, may play a part in the immunopathogenesis of contact dermatitis.