Children with psoriasis and COVID-19: factors associated with an unfavourable COVID-19 course, and the impact of infection on disease progression (Chi-PsoCov registry)

BACKGROUND

The COVID-19 pandemic has raised questions regarding the management of chronic skin diseases, especially in patients on systemic treatments. Data concerning the use of biologics in adults with psoriasis are reassuring, but data specific to children are missing. Moreover, COVID-19 could impact the course of psoriasis in children.

OBJECTIVES

The aim of this study was therefore to assess the impact of COVID-19 on the psoriasis of children, and the severity of the infection in relation to systemic treatments.

METHODS

We set up an international registry of paediatric psoriasis patients. Children were included if they were under 18 years of age, had a history of psoriasis, or developed it within 1 month of COVID-19 and had COVID-19 with or without symptoms.

RESULTS

One hundred and twenty episodes of COVID-19 in 117 children (mean age: 12.4 years) were reported. The main clinical form of psoriasis was plaque type (69.4%). Most children were without systemic treatment (54.2%); 33 (28.3%) were on biologic therapies, and 24 (20%) on non-biologic systemic drugs. COVID-19 was confirmed in 106 children (88.3%) and 3 children had two COVID-19 infections each. COVID-19 was symptomatic for 75 children (62.5%) with a mean duration of 6.5 days, significantly longer for children on non-biologic systemic treatments (P = 0.02) and without systemic treatment (P = 0.006) when compared with children on biologics. The six children who required hospitalization were more frequently under non-biologic systemic treatment when compared with the other children (P = 0.01), and particularly under methotrexate (P = 0.03). After COVID-19, the psoriasis worsened in 17 cases (15.2%). Nine children (8%) developed a psoriasis in the month following COVID-19, mainly a guttate form (P = 0.01).

DISCUSSION

Biologics appear to be safe with no increased risk of severe form of COVID-19 in children with psoriasis. COVID-19 was responsible for the development of psoriasis or the worsening of a known psoriasis for some children.

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.

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.

Current therapeutic paradigm in pediatric atopic dermatitis: Practical guidance from a national expert panel

INTRODUCTION AND OBJECTIVES

Atopic dermatitis (AD) is the most common cutaneous inflammatory disease in both adults and children. Although emerging therapeutic approaches are being investigated for the management of pediatric AD, it still needs to be managed with conventional treatments. This consensus document is aimed at providing an update on general management and therapies of pediatric AD, defining practical recommendations for using both topical and systemic agents.

MATERIAL AND METHODS

A panel of experts consisting of dermatologists and pediatricians were convened in order to define statements, through a Delphi process, standardizing the management of AD in pediatric subjects in a real-world setting.

RESULTS

A set of practical recommendations obtaining an at least 75% agreement was presented.

CONCLUSIONS

This set of practical recommendations represents a simple and fast snapshot on the pediatric use of common anti-AD therapeutics.

Diaminodiphenylmethane Sensitization in north-eastern Italy from 1996 to 2012

BACKGROUND

4,4'-Diaminodiphenylmethane (DDM) is an aromatic amine used as a hardener, insulator and anticorrosive. Exposure implies risk of being sensitized and developing contact dermatitis.

OBJECTIVE

The aim of this study was to determine the occurrence of contact sensitization to DDM among patients with contact dermatitis and the role of occupational exposure.

PATIENTS AND METHODS

From 1996 to 2012, 24 056 consecutive patients with suspected allergic contact dermatitis were patch tested in north-eastern Italy. Individual characteristics were collected through a standardized questionnaire in eight departments of dermatology and occupational medicine.

RESULTS

The overall prevalence of DDM sensitization was 2.5% (n = 599) with a decreasing trend in considered years. Trieste area had the higher prevalence of sensitization (3.2%). Mechanics and chemical industry workers had a significant higher risk of being sensitized to DDM.

CONCLUSION

DDM sensitization is decreasing in years and is associated with some occupational exposures.

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.

Healthcare workers and skin sensitization: north-eastern Italian database

BACKGROUND

Working in healthcare is regarded as a risk factor for occupational skin disease. Workers are exposed to disinfectants, soaps, detergents and latex and need to wash their hands frequently and thoroughly.

AIMS

To investigate the association between healthcare work and patch test reactions to various potential sensitizers in a population of contact dermatitis patients in various dermatology and occupational medicine units in north-eastern Italy.

METHODS

Patients with suspected allergic dermatitis underwent patch testing. Odds ratios (ORs) and 95% confidence intervals (CIs), adjusted by age and sex, were calculated for healthcare workers (HCWs), using white-collar workers as control group.

RESULTS

HCWs represented 14% of the sample of 19088 patients (68% women, 32% men). Among HCWs, both sexes had a higher risk of developing hand/forearm dermatitis (females: OR 2.1, 95% CI 1.8-2.5; males: OR 1.6, 95% CI 1.3-2.1). HCWs had an increased risk of sensitization to formaldehyde (OR 1.65; 95% CI 1.2-2.3) and to p-phenylenediamine (OR 1.6; CI 1.1-2.3).

CONCLUSIONS

Our study suggests a significant association between healthcare work, hand/forearm dermatitis and sensitization to formaldehyde and p-phenylenediamine.

Antibiotic therapy in the management of atopic dermatitis

Atopic dermatitis (AD), also known as atopic eczema, is a syndrome characterized by a chronic eczematous dermatitis, with associated pruritus, characteristic age-specific morphology and distribution of lesions and recurrent nature. Secondary infections in patients with AD are very common and difficult to treat. S. aureus colonizes almost all eczematous lesions in atopic patients and releases several super-antigens and exotoxins (i.e., toxic shock syndrome toxin-1, enterotoxins A-D, etc.), which sustain inflammatory reactions and promote tachyphylaxis. The topical antibiotics most commonly prescribed for mild/moderate secondary infections are gentamicin, fusidic acid and mupirocine. This article reviews existing therapeutic options and provides guidance for the management of secondary skin infection among patients with AD.

Allergic contact dermatitis in children

Allergic contact dermatitis is an inflammatory skin disease (delayed type hypersensitivity reaction) that accounts for up to 20% of all childhood dermatitis. Allergic contact dermatitis represents a clinical manifestation of contact sensitization and usually occurs at skin sites that have come into contact with the allergen. The clinical features of allergic contact dermatitis are itchy eczematous lesions. Prevalence of contact sensitization varies between 27% and 96% of children with suspected contact dermatitis. The relationship between contact sensitization and atopic dermatitis has been widely discussed but only conflicting data have been reported. Epicutaneous patch testing is the gold standard for the diagnosis of allergic contact dermatitis. The most common allergens detected in children are: metals, topical medicaments, fragrances, and preservatives. The first line management of allergic contact dermatitis in children is to avoid the offending allergens identified with the patch test and a topical corticosteroid therapy.

Fusidic acid in skin infections and infected atopic eczema

Skin infections represent an important public health issue and cost-driver. Additionally, chronic skin lesions are sometimes colonized by Gram-negative species. Topical therapies are a key component in the management of mild-to-moderate skin infections. In such cases, topical antibiotics may be preferable to systemic treatment, since they maximize the effective doses at the site of infection while minimizing the systemic side effects of the drugs. However, the prevalence of resistant strains is steadily increasing and cases of sensitization are not uncommon. As a consequence, the ideal topical antibiotic should be selective (thus, minimizing cross-resistance), have weak sensitization potential, penetrate the skin efficiently, reach adequate local doses at the site of infection, and finally be available in different formulations matching patients' preferences and needs. Fusidic acid (FA) is a selective antibiotic available in several topical formulations. Pharmacokinetic and pharmacodynamic studies have shown that, contrary to other topical antibiotics such as gentamicin or mupirocin, FA reaches high antimicrobial concentration at deep skin layers after topical application either on intact or damaged epidermis. Several randomized controlled trials demonstrated that FA, in its various topical formulations, is very effective in treating skin infections, given its high bactericidal activity against S. aureus (including strains resistant to penicillin, methicillin, ampicillin, cloxacillin), S. epidermidis, Streptococcus pyogenes, Propionibacterium acnes, Corinebatteria, Clostridia. Additionally, FA presents a low risk of resistance even in methicillin-resistant S. aureus strains, a common pathogen implied in the etiology of skin infections and infected atopic eczema. Such feature makes FA particularly useful in the management of these medical conditions. Finally, possibly due to its large steric effect, FA has proved a very low risk of contact sensitization. Overall, data on FA efficacy, safety, sensitization potential, resistance profile and spectrum selectivity make it a first-choice option in the treatment of primary and secondary skin infection.

Pain identifies squamous cell carcinoma in organ transplant recipients: the SCOPE-ITSCC PAIN study

Organ transplant recipients (OTR) are at high risk for cutaneous squamous cell carcinomas (SCC). We aimed to define clinically meaningful patient-reported warning signals predicting the presence of invasive SCC.Patient-reported signs and symptoms of 812 consecutively biopsied skin lesions from 410 OTR were determined by questionnaire and physical examination and related to the subsequent biopsy-proven diagnoses. Receiver-operating characteristic (ROC) curve analyses were used as a measure of distinction between the predictive values of patient-reported warning signals and the occurrence of SCC. Pain was an independent predictive patient-reported warning signal for a biopsy-proven invasive SCC. The odds ratio from the fully adjusted model predicting SCC was 4.4(95% confidence interval: 2.4–8.2). Higher scores on the visual analog scale (VAS) for pain were associated witha greater likelihood for the presence of SCC compared to none or mild pain. The for scores on the VAS from 1to 3, 4 to 6 and 7 to 10 were 4.9 (2.2–10.5), 2.3 (0.96–5.5)and 16.5 (3.6–75.8), respectively. Pain is the most powerful patient-reported warning signal for invasive cutaneous SCC in OTR. Empowerment of patients by education could accelerate diagnosis and treatment of cutaneous SCC.

Transient symptomatic zinc deficiency resembling acrodermatitis enteropathica in a breast-fed premature infant: case report and brief review of the literature

Transient symptomatic zinc deficiency is a rare disorder clinically indistinguishable from acrodermatitis enteropathica characterized by periorificial and acral dermatitis that usually occurs in exclusively breast-fed infant especially if preterm. We describe a three-month-old breast-fed preterm boy who developed the typical skin lesions. Maternal breast milk zinc was lower than the levels from other 2 mothers of infants at the same gestational age. The disease improved and serum zinc level became normal with oral supplementation of zinc. No recurrence of the dermatosis was observed when the treatment was stopped after weaning.

The controversial management of giant congenital melanocytic nevi. When would it be better "to wait and see"?

AIM

A giant congenital nevus is a melanocytic nevus present at birth with wide extent on the skin surface. The management of this nevus remains controversial and needs to be personalized for each patient.

METHODS

A retrospective multicenter study was carried out in the Dermatological Departments of Brescia, Padua, and Pavia, Italy. The inclusion criterion was the diagnosis of a giant congenital melanocytic nevus on the basis of clinical observation.

RESULTS

Nine patients with giant congenital nevus are reported. None developed melanoma, whereas giant congenital nevi have been slowly fading in pigmentation.

CONCLUSION

Having regard to the doubts on treatment that persist in the literature, we should consider that decisional management of giant congenital melanocytic nevi can be really complex, because of the size and depth of lesions. Indeed, the ablative surgery or other treatments might cause significant troubles and complete excision of deeper layers of the lesion is almost impossible to achieve. Moreover, the treatment does not reduce the risk of melanoma and might lead to a greater difficulty in clinical and dermoscopic observation due to the scarring occurrence after therapy. In our retrospective study, the pigmentation of giant congenital melanocytic nevi slowly faded on its own and until now none developed melanoma. Therefore, we suggest a close regular follow-up which should be focused on the exclusion of possible complications. Perhaps, it would be better "to wait and see" since other procedures do not decrease the risk of melanoma, but rather might lead the patient to underestimate it.

Psoriasis segmentation through chromatic regions and Geometric Active Contours

We present a novel approach to the segmentation of psoriasis lesions in "full body" digital photographs potentially involving dozens or even hundreds of separate lesions. Our algorithm first isolates a set of zones that certainly correspond to lesional plaques based on chromatic information, and then expands these zones to achieve an accurate segmentation of plaques through a Geometric Active Contours method. The variability in segmentation between our algorithm and different human operators appears comparable to the variability between human operators.

Variability in human and automatic segmentation of melanocytic lesions

In a double blind evaluation of 60 digital dermatoscopic images by 4 "junior", 4 "senior" and 4 "expert" dermatologists (dermatoscopy training respectively less than 1 year, between 1 and 5 years, and more than 5 years), a significant inter-operator variability was observed in melanocytic lesion border identification (with a disagreement of the order of 10 - 20% of the area of the lesions). Expert dermatologists showed greater agreement among themselves than with senior and junior dermatologists, and a slight tendency towards "tighter" segmentations. The human inter-operator variability was then used to evaluate the segmentation accuracy of 4 algorithms, representative of the 3 fundamental state-of-the-art automated segmentation techniques and of a fourth, novel, technique. Our evaluation methodology addresses a number of crucial difficulties encountered in previous studies and may be of independent interest. 3 of the 4 algorithms showed considerably less agreement with expert dermatologists than even senior and junior dermatologists did (with a disagreement of the order of 30% of the area of the lesions); the remaining algorithm, however, showed agreement with expert dermatologists comparable to that of other expert dermatologists.

Topical photodynamic therapy of actinic keratosis in renal transplant recipients

Organ transplant recipients (OTRs) show an increased risk of precancerous (mostly actinic keratosis [AK]) and cancerous (mostly squamous cell carcinomas [SCC] and basal cell carcinomas [BCC]) cutaneous lesions. Their frequency increases with time after transplantation. AKs seem to progress more often and faster to invasive SCC in OTRs compared with the general population. The steady increase of risk of cutaneous premalignancies and malignancies with time after transplantation is an alarming figure because the number of organ allograft recipients who live for many years after transplantion is rapidly growing. This points out the need to devote more resources to skin cancer prevention, detection, and management. Various therapies, including cryotherapy, topical 5-fluorouracil, imiquimod, topical diclofenac, curettage, electrosurgery, carbon dioxide laser, and surgical excision, are available for AKs. However, most of these are limited by frequent relapses and the presence of multiple lesions over a wide area. Topical photodynamic therapy (PDT) represents an innovative therapeutic approach for nonsurgical treatment of cutaneous precancerous lesions and skin cancers. In this study we confirmed the usefulness of PDT in the treatment of AKs in OTRs, even in lesions relapsing or unresponsive to conventional treatment. We showed a complete response rate of 71%, after 2 treatments sessions that were 2 weeks apart. The response rate of scalp/facial lesions (72%) was higher compared with acral lesions (40%). Topical PDT could represent a useful therapeutic alternative for AKs in OTRs because large lesions can be treated with excellent cosmetic outcome.

[Occupational contact dermatitis in metal workers and gender effect]

Contact dermatitis is more frequent among women for anatomical reasons and for extraprofessional exposure to irritants and detergents during homeworks. In addition sensitisation to contact haptens is different in sexes. The aim of our work was to evaluate the association between patch test skin sensitizations and professional exposure to metals analyzing data for gender. Of the 15.217 patients patch tested for dermatitis, 678 were metalworkers. The statistical analysis revealed a significant association between dermatitis and sensitisation to nickel in professional exposed women (OR = 1.68; LC50% 1.11-6.50) while metal sensitisation (Cr.Ni and Co) was not relevant in men: for them a significant association between dermatitis and sensitisation was found to quaternium (OR = 3.91; LC95% 1.18-12.9), to mercaptobenzothiazole (OR = 2.69; LC50% 1.11-6.50) and to ethylendiamine dichloride (OR = 2.53; LC95% 1-6.41). The authors stress the need to evaluate patch test sensitisation considering gender effects.

A new computerized method for the assessment of skin lesions in localized scleroderma

OBJECTIVE

Up to now, no validated tools are in use for the assessment of the skin lesions in localized scleroderma (LS). The aim of this study is to evaluate the performance of a new computerized skin score (CSS) method for the measurement of circumscribed lesions in LS.

METHODS

The study consisted of three phases: set up of the CSS technique, measurement of target lesions of LS patients, assessment of intra- and inter-rater reliability. The CSS technique consists in delimitating the indurate lesion on an adhesive transparent film, transferring it over a cardboard and then calculating the affected area with a specifically created software. The technique was explained to a panel of 10 physicians with different expertise in LS (three paediatric rheumatologists, two dermatologists, five paediatric residents). All participants, singularly and blindly to the others, examined 10 consecutive patients twice after a time interval of at least 6 h. The intra-observer variability was evaluated by the repeatability coefficient and the inter-rater reliability by the intra-class correlation coefficient (ICC).

RESULTS

The repeatability coefficients were good, ranging between 1.90 and 7.03. The mean values of skin scores were not significantly different among the examiners. The ICC for indurate area calculation were high in both the experts (0.97) and the residents (0.91-0.94).

CONCLUSIONS

CSS has shown to be a reliable method to assess the skin lesions in patients with LS. It is reproducible, easy to use and, with the support of the CSS software, applicable worldwide.

IL-16 serum level in children with atopic dermatitis

IL-16 is a natural ligand of CD4 molecules and induces chemotaxis in CD4-expressing cells. It amplifies the inflammatory reaction by stimulating cytokine production in monocytes and activating T-cells. There is evidence that IL-16 plays a role in the pathogenesis of atopic dermatitis, and increased serum levels of IL-16 have been detected in allergic diseases. However, few data are available on IL-16 serum levels in atopic dermatitis. The aim of our study is to measure IL-16 serum levels in childhood atopic dermatitis before and after treatment and to evaluate a possible correlation between IL-16 serum levels and disease severity. IL-16 serum levels were measured by an ELISA approach in 34 children (19 males and 15 females; mean age 6.8 years) with moderate to severe atopic dermatitis, at their first visit and after 3 months of treatment, and in 10 non-atopic healthy controls of the same age group. The severity of atopic dermatitis was measured by SCORAD index. IL-16 serum levels were significantly higher in patients affected by atopic dermatitis than in controls before and after treatment with tacrolimus ointment. No clear correlation was found between IL-16 serum levels and atopic dermatitis severity. IL-16 serum levels are increased in atopic dermatitis but do not seem to correlate with disease severity.

The European standard series in 9 European countries, 2002/2003 - First results of the European Surveillance System on Contact Allergies

Since January 2001, the European Surveillance System on Contact Allergies (ESSCA), supported by European Union funding (contract QLK4-CT-2001-00343), has started to collect patch-test data. This comprises a standardized clinical history and the patch-test results using the European standard series, from 17 centres in 9 European countries listed above. In 2002 and 2003, 10 511 patients' test results have been pooled and analysed. The anamnestic data partly reflect the subspecialties of some centres. The most common allergen was nickel sulfate (17.3%); however, large international variations were observed. The prevalence of contact allergy to Myroxylon pereirae resin (balsam of Peru) (5.8%) is coming close to the frequency found with the fragrance mix (6.4%). Regarding contact allergy to chromium compounds, different frequencies were noted in the 2 centres focused on occupational dermatitis (2.3% in the FIOH versus 7.4% in the Nofer Institute). These most likely reflect the beneficial effect of addition of ferrous sulfate in one, but not the other country. As differences may partly be due to different patch-test reading, standardization may need to be refined further. By providing post-marketing surveillance in the field of contact allergy, ESSCA will meet its objective of increased consumer safety across Europe.

The European standard series in 9 European countries, 2002/2003 -- first results of the European Surveillance System on Contact Allergies

Since January 2001, the European Surveillance System on Contact Allergies (ESSCA), supported by European Union funding (contract QLK4-CT-2001-00343), has started to collect patch-test data. This comprises a standardized clinical history and the patch-test results using the European standard series, from 17 centres in 9 European countries listed above. In 2002 and 2003, 10 511 patients' test results have been pooled and analysed. The anamnestic data partly reflect the subspecialties of some centres. The most common allergen was nickel sulfate (17.3%); however, large international variations were observed. The prevalence of contact allergy to Myroxylon pereirae resin (balsam of Peru) (5.8%) is coming close to the frequency found with the fragrance mix (6.4%). Regarding contact allergy to chromium compounds, different frequencies were noted in the 2 centres focused on occupational dermatitis (2.3% in the FIOH versus 7.4% in the Nofer Institute). These most likely reflect the beneficial effect of addition of ferrous sulfate in one, but not the other country. As differences may partly be due to different patch-test reading, standardization may need to be refined further. By providing post-marketing surveillance in the field of contact allergy, ESSCA will meet its objective of increased consumer safety across Europe.

Posttraumatic port-wine stain in a 4-year-old girl: Fegeler syndrome

A4-year-old girl presented with an acquired port-wine stain in the distribution of the first branch of the trigeminal nerve. The lesion appeared after a head injury and slowly enlarged over the next 2 years. Including our patient, 25 instances of acquired port-wine stains have been reported in children. Ten (40%) of these were trauma related. The possible etiopathogenesis of acquired posttraumatic port-wine stains is discussed.

Diaminodiphenylmethane (DDM): frequency of sensitization, clinical relevance and concomitant positive reactions

Diaminodiphenylmethane (DDM) is an aromatic diamine used in the manufacture of rubber, plastics, diisocyanates, dyes and adhesives. It may cross-react with para-(amino)compounds. Allergic patch test reactions to DDM are relatively frequent, but their relevance is often difficult to detect. We report our experience in 6809 patients (4589 female, 2220 male, mean age 39.9+/-17.8 years) with suspected contact dermatitis patch tested during the period 1997-1999 by the North-East Italy Contact Dermatitis Group (NEICDG). A positive patch test to DDM was detected in 132 (1.9%) patients (88 female, 44 male, mean age 49.5+/-16.2 years). Eczema was mostly localized on the hands. The relevance was detected in 31 patients. A logistic regression analysis showed an association with patient's age (odds ratio 5.4 for age 30-59 years), absence of atopic diseases (odds ratio 3.1) and presence of leg ulcer (odds ratio 5). We found a highly significant correlation (p<0.001) between sensitivity to DDM and to para-phenylenediamine, Disperse Yellow 3, cobalt chloride, fragrance mix, benzocaine, paraben mix and primin. Positive patch test results to DDM were relatively frequent. The difficulty in detecting the relevance of these sensitizations may be related to the surprisingly high frequency of concomitant positive reactions to other allergens.

PIBI(D)S: clinical and molecular characterization of a new case

The term PIBI(D)S has been used to indicate a rare recessively inherited genetic disorder characterized by photosensitivity, mild non-congenital ichthyosis, brittle sulphur-deficient hair with trichoschisis (trichothiodystrophy), impaired intelligence, occasionally decreased fertility and short stature. To the best of our knowledge, about 20 cases have been reported in the literature. Here we report the characterization of the hair, brain, ultraviolet sensitivity and DNA excision repair defects of a new patient affected by PIBI(D)S. The diagnosis of PIBI(D)S syndrome was made in our patient on the basis of the clinical features and then confirmed by hair microscopy and biochemical analysis. Our patient has increased muscular tone, alteration of the deep tendon reflexes and psychomotor retardation, all consistent with hypomyelination of the brain showed by magnetic resonance imaging and computed tomography. A deficiency of DNA repair capacity was demonstrated in our patient. Furthermore, complementation analysis by cell fusion assigned our patient to xeroderma pigmentosum group D. The nucleotide excision repair defect of the other reported patients with PIBI(D)S falls generally into the same group as xeroderma pigmentosum group D and carry a mutation on the same repair gene (XPD). The relationship between these molecular characteristics and the clinical spectrum of PIBI(D)S is discussed.

Risk of nonmelanoma skin cancer in Italian organ transplant recipients. A registry-based study

BACKGROUND

Organ transplant recipients are at an increased risk of nonmelanoma skin cancer. Few data concern heart transplantation and populations from southern Europe.

METHODS

A total of 1,329 patients who received their first kidney (1,062 subjects) or heart allograft (267 subjects) were included in a partly retrospective cohort study to evaluate the risk of skin cancer. The incidence rate per 1,000 person-years and the cumulative incidence were computed. Standardized morbidity ratio was estimated by comparison with Italian cancer registry data. To analyze the role of potential prognostic factors, Cox's regression method was used.

RESULTS

The overall incidence rate of nonmelanoma skin cancer was 10.0 cases per 1,000 posttransplant person-years (95% confidence interval 8.2-11.7). This estimate was far higher than expected in the general population. The overall risk of developing skin cancer increased from a cumulative incidence of 5.8% after 5 posttransplant years to an incidence of 10.8% after 10 years of graft survival. In a Cox proportional hazard risk model, the most important factors that appeared to favor the development of skin cancer were age at transplantation and sex. After adjustment for age at transplantation and sex, no definite increased risk was documented among heart as compared with kindney transplant recipients.

CONCLUSIONS

Our study confirms the increased risk of nonmelanoma skin cancer among organ transplant recipients in a southern European population.

Skin cancer in heart transplant recipients: risk factor analysis and relevance of immunosuppressive therapy

BACKGROUND

The frequency of skin tumors of all types and specifically of squamous cell carcinoma (SCC) is increased in heart transplantation (HT), but the predisposing risk factors are controversial.

METHODS AND RESULTS

We studied 300 patients (age 49+/-15 years, 258 men, mean follow-up 4.6 years, follow-up range 1 month to 12 years) who were receiving standard double (cyclosporin plus azathioprine) or triple (cyclosporin plus azathioprine plus prednisone) therapy. The first-year rejection score was calculated for endomyocardial biopsy samples (International Society for Heart and Lung Transplantation grade 0=0, 1A=1, 1B=2, 2=3, 3A=4, 3B=5, and 4=6) and used as an indirect marker of the level of immunosuppression. Multivariate analysis (Cox regression) included age at HT, sex, skin type, first-year rejection score, presence of warts and solar keratosis, lifetime sunlight exposure, and first-year cumulative dose of steroids. The incidence of skin tumors of all types increased from 15% after 5 years to 35% after 10 years after HT according to life-table analysis. Age at HT of >50 years (P:=0.03, RR=5.3), skin type II (P:=0.05, RR=2.6), rejection score of 19 (P:=0.003, RR=5.7), solar keratosis (P:=0.001, RR=6.9), and lifetime sunlight exposure of >30 000 hours (P:=0.0003, RR=7.6) were risk factors for SCC.

CONCLUSIONS

Older age at HT, light skin type, solar keratosis, greater sunlight exposure, and high rejection score in the first year were independently associated with an increased risk of SCC. The progressive increase in cancer frequency during follow-up and the association with high rejection scores suggest that both the length and level of immunosuppression may be relevant. Because cumulative immunosuppressive load is cumbersome to calculate, a high rejection score in the first year may provide a useful predictor for patients at risk.