Dupilumab for atopic dermatitis: a real-world portuguese multicenter retrospective study

Introduction: Atopic dermatitis (AD) is a difficult-to-treat inflammatory skin disease with a high impact on patients' quality of life. Dupilumab, an IL-4 and IL-13 inhibitor, was the first monoclonal antibody approved for the treatment of moderate-to-severe AD and is currently approved in patients aged 6 or older.Methods: This is a nationwide, multicenter, retrospective, 48-week study designed by the Portuguese Group of AD to assess real-world efficacy and safety of dupilumab for the treatment of AD.Results: A total of 169 patients were enrolled, with a mean disease duration of 22.75 (±11.98) years. The percentage of patients achieving an improvement of at least 75% in Eczema Area and Severity Index (EASI) compared to baseline (EASI75 response) at weeks 12 and 48 was 67.6% and 74.1%, respectively. In the same timepoints, 25.0% and 44.1% achieved an EASI90 response. Patient-reported outcome measures also improved throughout the study period. Regarding safety, 32.0% of the patients developed adverse events, with conjunctivitis (26.6%), persistent facial erythema (4.7%), and arthritis/arthralgia (3.6%) as the more frequently reported.Conclusion: Data from real-world populations are crucial to guide clinicians in their daily decisions. This study provides data demonstrating that dupilumab is an effective and safe therapeutic option for AD.

Emerging Cutaneous Phaeohyphomycosis Caused by Alternaria infectoria

Alternaria species belong to a group of opportunistic fungi that causes skin infection mainly in immunosuppressed patients. The authors describe two clinically distinct cases of cutaneous alternariosis caused by Alternaria infectoria in patients under prolonged corticosteroid treatment. Additionally, a brief review of published cases in portuguese patients is conducted.

[Recommendations in Male HPV from the Portuguese Society of Andrology, Sexual Medicine and Reproduction: Prevention]

The prevention of HPV-related diseases is an important healthcare issue due to its increasing incidence. Primary prevention is most important in males as it avoids initial infection and includes the use of condom, circumcision and vaccination. Primary prevention with vaccination is effective in decreasing HPV-related lesions in women up to 45 years old and the existing data for men comes from the experience from vaccinating women. Although it is the only vaccine that prevents cancer, the worldwide rates of vaccination in males is very low due to lack of information related to efficacy and side effects, lack of recommendation from the treating doctor, price and concern about encouragement of sexual promiscuity.

Light Field Image Dataset of Skin Lesions

Light field imaging technology has been attracting increasing interest because it enables capturing enriched visual information and expands the processing capabilities of traditional 2D imaging systems. Dense multiview, accurate depth maps and multiple focus planes are examples of different types of visual information enabled by light fields. This technology is also emerging in medical imaging research, like dermatology, allowing to find new features and improve classification algorithms, namely those based on machine learning approaches. This paper presents a contribution for the research community, in the form of a publicly available light field image dataset of skin lesions (named SKINL2 v1.0). This dataset contains 250 light fields, captured with a focused plenoptic camera and classified into eight clinical categories, according to the type of lesion. Each light field is comprised of 81 different views of the same lesion. The database also includes the dermatoscopic image of each lesion. A representative subset of 17 central view images of the light fields is further characterised in terms of spatial information (SI), colourfulness (CF) and compressibility. This dataset has high potential for advancing medical imaging research and development of new classification algorithms based on light fields, as well as in clinically-oriented dermatology studies.

Digital Ulcers as Presentation of Carpal Tunnel Syndrome

Ulcerating and mutilating variant of carpal tunnel syndrome occurs in longstanding cases of untreated disease. Pa- tients present with painless ulcers of the second and third fingers, accompanied with other cutaneous and sensory changes. These patients are often misdiagnosed as having a Raynaud disease or systemic sclerosis. Clinical assessment is the gold standard for the diagnosis of carpal tunnel syndrome, but hand radiography and electromyography help supporting the diagnosis. The authors present two cases of this ulcerating variant of carpal tunnel syndrome.

Incapacitating solar urticaria: successful treatment with omalizumab

Solar urticaria is a rare form of physical urticaria mediated by immunoglobulin E. The lesions appear immediately after the sun exposure, interfering with the patient's normal daily life. Omalizumab, a monoclonal anti-IgE antibody, has been recently approved for the treatment of chronic spontaneous urticaria, and the latest reports support its role also in the treatment of solar urticaria. Hereby, we report a case of solar urticaria refractory to conventional treatment strategies, with an excellent response to treatment with omalizumab and phototesting normalization.

Optical characterization and adaptive optics correction of polymer adaptive lens aberrations

Adaptive lenses based on fluid-filled polymer membranes allow for great simplification of optical systems providing large focal length variation and reduction of size, weight, and power consumption. However, aberrations can reduce their optical quality and, for some demanding applications, their correction by means of adaptive optics implies increased complexity, especially if reflective wavefront correctors are used. In this work, we characterize two adaptive lenses in terms of optical power and aberrations. We then correct the gravity-induced aberrations by means of a multiactuator adaptive lens in a closed-loop adaptive optics configuration, with a minimal increase in optical setup complexity. The improvements in the performance of an imaging system are shown.

Case for diagnosis. Solitary violaceous nodule on the toe

Reticulohistiocytomas represent a group of benign histiocytic dermal proliferations, which occur either sporadically as solitary cutaneous nodules or, when multiple, in association with systemic disease. Due to its nonspecific clinical presentation, reticulohistiocytoma may mimic other benign or malignant skin neoplasms; therefore, in most cases, a biopsy is needed in order to establish the correct diagnosis. The histology is typically characterized by the presence of large histiocytes with abundant eosinophilic cytoplasm with immunohistochemical profile positive for CD68, CD163, and vimentin. The authors report the case of a patient with solitary reticulohistiocytoma with illustrative clinical, dermoscopic, and histologic features.

Multiple sclerotic fibromas of the skin: an important clue for the diagnosis of Cowden syndrome

Cowden syndrome is a rare autosomal dominant condition characterised by mucocutaneous hamartomas and, most importantly, predisposition to various extracutaneous benign and malignant tumours. This disorder is associated with a germline mutation in the phosphatase and tensin homologue gene, a tumour suppressor gene, located on 10q23 chromosome. The expressivity of this genodermatosis is highly variable, therefore many of the cases remain undiagnosed. Skin and mucous findings are very common in Cowden syndrome and may represent the initial clinical manifestation leading to the diagnosis. The authors describe a case of a 58-year-old man with multiple cutaneous sclerotic fibromas associated with a previously unrecognised Cowden syndrome.

Multiple Minute Digitate Hyperkeratosis in an Infant

A distinct variant of multiple minute digitate hyperkeratoses in a healthy 4-month-old boy, exclusively located in the anogenital area and with a transitory character, is described.

The impact of disease activity and tumour necrosis factor-α inhibitor therapy on cytokine levels in juvenile idiopathic arthritis

The aim of this study was to evaluate prospectively cytokine levels and disease activity in juvenile idiopathic arthritis (JIA) patients treated with and without tumour necrosis factor (TNF)-α inhibitors. TNF-α inhibitor-naive JIA subjects were followed prospectively for 6 months. Cytokine levels of TNF-α, interleukin (IL)-1β, IL-6, IL-8, IL-10 and IL-17 were measured at baseline for JIA subjects and healthy controls (HCs). Cytokine levels were then measured at four time-points after initiation of TNF-α inhibition for anti-TNF-α-treated (anti-TNF) JIA subjects, and at two subsequent time-points for other JIA (non-TNF) subjects. JIA disease activity by Childhood Health Assessment Questionnaire (CHAQ) disability index/pain score and physician joint count/global assessment was recorded. Sixteen anti-TNF, 31 non-TNF and 16 HCs were analysed. Among JIA subjects, those with higher baseline disease activity (subsequent anti-TNFs) had higher baseline TNF-α, IL-6 and IL-8 than those with lower disease activity (non-TNFs) (P < 0·05). TNF-α and IL-10 increased, and IL-6 and IL-8 no longer remained significantly higher after TNF-α inhibitor initiation in anti-TNF subjects. Subgroup analysis of etanercept versus adalimumab-treated subjects showed that TNF-α and IL-17 increased significantly in etanercept but not adalimumab-treated subjects, despite clinical improvement in both groups of subjects. JIA subjects with increased disease activity at baseline had higher serum proinflammatory cytokines. TNF-α inhibition resulted in suppression of IL-6 and IL-8 in parallel with clinical improvement in all anti-TNF-treated subjects, but was also associated with elevated TNF-α and IL-17 in etanercept-treated subjects.

Muscle activity of the erector spinae during Pilates isometric exercises on and off Swiss Ball

BACKGROUND

The purpose of this study was to investigate the muscle activity of the Erector spinae (ES) during Pilates isometric exercises on and off Swiss ball.

METHODS

Fifteen women (22.9±2.1years, 171.7±4.7 cm, 65.7±5.3 kg and 11.2±3.2% of body fat) with previous Pilates experience (1±0.9 years) participated as subjects in this study. In the first test session, the anthropometric data and maximal voluntary contraction (MVC) was measured. In the second test session, three isometric exercises were conducted on and off the Swiss ball: back extension (BE), back extension with elbows flexed (BTF) and back extension with elbows extended (BTE). During all exercises, average integrated electromyography (IEMG) from ES muscle was collected and analyzed. A one-way ANOVA with repeated measures followed by Bonferroni post hoc was adopted to compare the muscle activity (P<0.05).

RESULTS

ES activity was higher for BT, BTF and BTE on stable surface than on Swiss ball, respectively. Significant differences were observed for the ES activity during BTE exercise when compared to BTF and BT on and off Swiss ball, respectively.

CONCLUSION

The Swiss ball may not provide a potential effect on ES activity during Pilates isometric exercises with similar posture when compared to stable surfaces. Therefore, the combination of BT, BTF and BTE exercises may be an interesting alternative to provide progressive increases in the ES activity.

Identification of a new HLA-C allele, HLA-C*08:75 in a Caucasian individual

HLA-C*08:75 differs from C*08:02:01 by a non-synonymous mutation at codon 229 (GAG to AAG) in exon 4.

Identification of a new HLA-C allele, HLA-C*08:76 in a Caucasian individual

HLA-C*08:76 differs from HLA-C*08:02:01 by one nonsynonymous nucleotide change at the codon 144 (CAG to AAG) in exon 3.

HIPERSENSIBILIDADE RETARDADA A HEPARINA DE BAIXO PESO MOLECULAR – QUE ALTERNATIVA À ANTICOAGULAÇÃO?

Um doente de 75 anos de idade, obeso, realizou terapêutica anticoagulante por trombose venosa profunda (TVP) do membro inferior: heparina clássica endovenosa durante 3 dias e dalteparina subcutânea durante 10 dias. Três dias depois do término do tratamento o doente é observado por placas eczematiformes nos locais de administração da heparina de baixo peso molecular (HBPM). Os testes epicutâneos, prick, intradérmicos e subcutâneos realizados se- quencialmente com várias HBPM e fondaparinux foram negativos nas leituras imediatas e às 48h. Às 72 horas sugiram lesões eczematiformes nos testes intradérmicos e subcutâneos à enoxaparina, fraxiparina e dalteparina, confirmando o diagnóstico de hipersensibilidade retardada a HBPM. Os testes com o fondaparinux foram negativos, considerando-o uma alternativa anticoagulante segura. Os testes epicutâneos revelaram discreta reacção em D7 apenas à dalteparina e fraxiparina. Os testes de alergia, sobretudo os intradérmicos, com várias heparinas e heparinóides são essenciais para confirmar o diagnóstico e identificar alternativas seguras em caso de necessidade de anticoagulação futura, como neste doente com factores de risco para TVP.PALAVRAS-CHAVE – Anticoagulantes; Hipersensibilidade Retardada; Heparinas de baixo peso molecular; Erupções Cutâneas; Testes Cutâneos.

Intralesional rituximab in the treatment of indolent primary cutaneous B-cell lymphomas: an epidemiological observational multicentre study. The Spanish Working Group on Cutaneous Lymphoma

BACKGROUND

Intravenous rituximab is a safe and effective option for the treatment of systemic non-Hodgkin B-cell lymphoma. The effectiveness of intralesional rituximab (ILR) in primary cutaneous B-cell lymphomas (PCBL) has been described in a small number of patients.

OBJECTIVES

To evaluate the effectiveness, tolerance and adverse effects of ILR in patients with follicle centre (FCL) and marginal zone (MZL) PCBL.

METHODS

This was an epidemiological observational multicentre study of patients with PCBL treated with ILR.

RESULTS

Seventeen patients with MZL and 18 with FCL PCBL were included. The median number of lesions treated was two per patient. The treatment regimen used in 74% of the patients was a course of three injections in a single week at 1-month intervals. The dose per lesion and day of treatment was 10 mg in 71% of the patients. The median cumulative dose of rituximab per lesion was 60 mg (range 13-270) and per patient was 150 mg (range 20-360 mg). Complete response (CR) and partial response were achieved in 71% and 23% of patients, respectively. The median time to CR in patients who received 10 mg of ILR per lesion was 8 weeks. Similar response rates were observed in MZL and FCL. Median disease-free survival was 114·1 weeks. No parameters that significantly predicted CR were identified. Adverse reactions were recorded in 19 patients; the most frequent was localized pain at the injection site. Median follow-up was 21 months.

CONCLUSIONS

Intralesional rituximab is a well-tolerated and effective treatment for FCL and MZL PCBL. It should be considered a useful alternative in patients with recurrent lesions and in which the sequelae of radiotherapy or surgery would be significant.

Adverse cutaneous reactions to epidermal growth factor receptor inhibitors: a study of 14 patients

BACKGROUND

Cetuximab and erlotinib, epidermal growth factor receptor inhibitors, often cause peculiar adverse cutaneous reactions.

OBJECTIVES

Our aim was to evaluate adverse cutaneous reactions and their management in patients undergoing treatment with cetuximab and erlotinib.

PATIENTS AND METHODS

Between March/2005 and September/2009, we observed 14 patients with a mean age of 59.6 years undergoing treatment with cetuximab (7) or erlotinib (7), due to lung(10) or colorectal cancer (4). We evaluated the interval between introduction of the drug and onset of symptoms, treatment response, and the clinical pattern of evolution of the cutaneous reaction retrospectively.

RESULTS

Twelve patients presented papular-pustular eruption typically affecting the face, chest and back, which appeared in average 13.5 days after starting the drug treatment. The patients underwent oral treatment with minocycline or doxycycline and topical treatment with metronidazole, benzoyl peroxide and/or corticosteroids. All patients showed improvement of the lesions. Five patients presented periungual pyogenic granulomas, which were associated with paronychia in 4 cases, after an average of 8 weeks of treatment. There was improvement of the lesions with topical treatment (antibiotics, corticosteroids and antiseptics). Xerosis was observed in some patients. Other less frequent adverse side effects such as telangiectasia and angiomas, hair and eyelash alterations, and eruptive melanocytic nevi were also described. Treatment with epidermal growth factor receptor inhibitor was maintained in most patients.

CONCLUSION

The increasing use of these targeted therapies requires knowledge of their adverse cutaneous side effects to ensure timely intervention in order to allow the continuation of the therapy.

Case for diagnosis

Henoch-Schönlein Purpura (HSP) is the most common vasculitis in children. In the absence of significant renal disease it has an excellent prognosis. In the case described, HSP initially presented together with orchitis. This infrequent event required the exclusion of testicular torsion.

Acrodermatitis enteropathica: a novel SLC39A4 gene mutation found in a patient with an early-onset

We report the case of a 3-month-old full-term, breast-fed infant with clinical and laboratorial findings consistent with acrodermatitis enteropathica. In addition, the mother had low zinc levels in her breast milk. Mutation analysis revealed a novel insertion in the SLC39A4 gene.

Coexistence of reticulate acropigmentation of Kitamura and Dowling-Degos disease

Reticulate acropigmentation of Kitamura (RAK) and Dowling-Degos Disease (DDD) are rare genodermatosis inherited as an autosomal dominant trait with variable penetrance. They are part of a spectrum of diseases with hyperpigmented macules coalescing in a reticular pattern, facial and palmoplantar pits, breaks in dermatoglyphics, comedo-like lesions and epidermoid cysts, and a unique histological picture of hyperpigmented digitate epidermal downgrowths. The authors describe the case of a 45-year-old female with reticulate acropigmentation of the dorsa of the hands and feet, hyperpigmented macules on the axilla and around the mouth, and palmar pitting. Clinical and histological findings, together with a relevant family history, allowed the authors to consider this case an example of the rare event of an overlap RAK-DDD.

[Digital ulcers in systemic sclerosis: use of endotheline antagonists]

INTRODUCTION

Systemic sclerosis (SSc) is a systemic disease, characterized by fibrosis and vasculopathy, with variable internal organ involvement. Skin is very often involved, namely digital ulcers (DU), seldom treatment resistant, responsible for important functional limitation. The DU can evolve from sclerodactily with superficial ulcers, isquemic lesions, deep necrosis, gangrene, loss of tissue, and consequently, to finger amputation.

METHODS

The authors describe the case of a 36 year old female patient, with SSc diagnosed 6 years previously, with skin, lung and gut manifestations. The patient showed uncontrolled Raynaud's phenomenon (RF), despite the adequate treatment using nifedidpine and general local warming measures, with progressively worsening DU and isquemia, especially in cold seasons. Bosentan, 62.5 mg twice daily was started, and a significant improvement in the peripheral isquemic lesions was achieved. The ulcers' healing was fast, the patient totally recovered function and regained quality of life, and no further lesions developed.

CONCLUSION

The authors review the RF and DU in SSc, as well as the use of bosentan, an endotheline receptor antagonist, and its indications. Although it is not formally approved, the use of bosentan in SS has shown benefits in reducing the incidence of DU, and despite no influence in the healing process, this drug prevents the development of new lesions.

Caso para diagnóstico

Descreve-se um paciente com características clínicas e histopatológicas típicas da hiperplasia angiolinfoide com eosinofilia. Trata-se de uma hiperplasia vascular benigna que importa reconhecer e distinguir da doença de Kimura

Effects of HIV infection and antiretroviral therapy with ritonavir on induction of osteoclast-like cells in postmenopausal women

SUMMARY

Ritonavir (RTV) is a commonly used antiretroviral associated with bone loss. We show that peripheral blood mononuclear cells (PBMCs) from human immunodeficiency virus (HIV)-positive women on RTV are more likely to differentiate into osteoclast-like cells when cultured with their own sera than PBMCs and sera from HIV- women or HIV+ on other antiretrovirals.

INTRODUCTION

RTV increases differentiation of human adherent PBMCs to functional osteoclasts in vitro, and antiretroviral regimens containing RTV have been associated with low bone mineral density (BMD) and bone loss.

METHODS

BMD, proresorptive cytokines, bone turnover markers (BTMs), and induction of osteoclast-like cells from adherent PBMCs incubated either with macrophage colony-stimulating factor (MCSF) and receptor activator of nuclear factor κB ligand (RANKL) or with autologous serum were compared in 51 HIV- and 68 HIV+ postmenopausal women.

RESULTS

BMD was lower, and serum proresorptive cytokines and BTMs were higher in HIV+ versus HIV- women. Differentiation of osteoclast-like cells from adherent PBMCs exposed to either MCSF/RANKL or autologous serum was greater in HIV+ women. Induction of osteoclast-like cells was greater from PBMCs exposed to autologous sera from HIV+ women on RTV-containing versus other regimens (172 ± 14% versus 110 ± 10%, p < 0.001). Serum-based induction of osteoclast-like cells from adherent PBMCs correlated with certain BTMs but not BMD.

CONCLUSIONS

HIV infection and antiretroviral therapy are associated with higher BTMs and increased differentiation of osteoclast-like cells from adherent PBMCs, especially in women on regimens containing RTV. HIV+ postmenopausal women receiving RTV may be at greater risk for bone loss.

Multiple glomus tumors and segmental neurofibromatosis: there are no coincidences

Segmental neurofibromatosis is a rare subtype of neurofibromatosis type 1 (NF1). Glomus tumors are uncommon benign tumors. The authors report the association between these two rare conditions, not yet reported.

Incidence and factors associated with recurrence after incomplete excision of basal cell carcinomas: a study of 90 cases

BACKGROUND

Management of incompletely excised basal cell carcinomas (BCC) remains controversial.

OBJECTIVE

The aim of this study was to assess the rate and the factors associated with the recurrence of incompletely excised BCC.

METHODS

In this retrospective monocentric study, data from all surgically excised BCC during 4 years (2000 to 2003) were analysed.

RESULTS

A total of 947 BCC were excised. Of these, 90 were incompletely excised (9.5%). This group was kept under clinical follow-up for a median period of 62.5 months (range 12-84). Recurrence was confirmed in 29 patients (32.2%). The median interval to recurrence was 12 months (range 1-57). Recurrence of incompletely excised BCC was significantly higher (P < 0.05) in younger patients, in aggressive histological types and in localizations like postauricular and nasogenian folds.

CONCLUSION

Observation might be an acceptable option in many situations, but for patients with aggressive types of BCC, or with tumours localized in risk areas of the face, immediate re-excision appears to be the treatment of choice. A careful follow-up is indicated for at least 3 years; however, long lasted recurrence should not be underestimated.

Linear psoriasis - a case report

A 56-year-old woman presented with a 3-month history of erythematous plaques covered by scales and limited to the right side of her body. The plaques were arranged along Blaschko's lines with a marked mid-line cutoff. The histopathologic analysis of a skin biopsy in conjunction with the anamnesis allowed the diagnosis of linear psoriasis. Our patient showed a good clinical response to antipsoriatic treatment.