Differences in chronic spontaneous urticaria between Europe and Central/South America: results of the multi-center real world AWARE study

Background

Global chronic urticaria (CU) disease experience and management is not well documented. This study descriptively compares these aspects among CU patients residing in Europe (EU) and Central and South America (C/SA).

Methods

AWARE (A World-wide Antihistamine-Refractory chronic urticaria patient Evaluation) is a global prospective, non-interventional study of CU in the real-world setting. Patients were ≥ 18 years with a diagnosis of H1-antihistamine-refractory CU for > 2 months. Differences between the EU and C/SA regions in demographic and clinical characteristics, quality of life (QoL), work and activity impairment, pharmacological treatment, and healthcare resource use were examined.

Results

In total, 4224 patients were included in the analysis (C/SA 492; EU 3732). Rates of untreated patients were greater in the C/SA region (45.1% vs. 31.9%; P < 0.005) and escalation to third-line therapy was rare in both regions. Differences in disease experience emerged, with C/SA patients more commonly experiencing angioedema (C/SA 50.8% vs. EU 46.1%; P = 0.03) or comorbid chronic inducible urticaria (C/SA 30% vs. EU 22%; P < 0.001). Correspondingly, rates of uncontrolled urticaria were higher among C/SA patients (82.8% vs. 77.5%; P = 0.017) and patients in the C/SA region showed significantly greater work and activity impairment (absenteeism: 10.4 ± 19.7 vs. 6.7 ± 19.0, P = 0.004; presenteeism: 30.3 ± 31.9 vs. 24.4 ± 25.8, P = 0.001; work productivity loss: 33.9 ± 33.9 vs. 26.5 ± 27.5, P < 0.001; activity impairment: 37.7 ± 34.7 vs. 32.7 ± 30.1, P = 0.001). However, QoL impairment was greater in the EU region (Dermatology Life Quality Index: C/SA 6.5 ± 5.9 vs. EU 8.3 ± 7.0; P < 0.001). There was a significant difference in use of healthcare resources, including emergency services (39.6% vs. 29.3%; P < 0.001), hospitalization (7.7% vs 21.9%; P < 0.001) general practitioners (31.7% vs 57.3%; P < 0.001), and additional allergists or dermatologists (50.6% vs. 47.3%, P < 0.001), among patients in the C/SA and EU region, respectively. In both regions, patients with a primary diagnosis of CU with angioedema had significantly greater impairment in work and non-work activities and healthcare resource utilization compared to those without angioedema.

Conclusions

This study revealed that CU is a heterogeneous condition with differences in healthcare utilization and outcomes between EU and C/SA. However, overall there is a high unmet need of H1-antihistamine-refractory CU patients, which is associated with high use of healthcare resources, and has a large negative effect on QoL and work productivity.

[Paraneoplastic pemphigus: Retrospective study of a case series]

CONTEXT

Paraneoplastic pemphigus (PNP) is a rare condition associated with poor prognosis. It associates polymorphic mucocutaneous manifestations with neoplasia. Diagnosis is difficult because of the various clinical and histological features involved and the lack of specificity of immunological examinations.

METHODS

We retrospectively analyzed the records of patients presenting with PNP in the Poitou-Charentes region between 2000 and 2015.

RESULTS

Seven patients were included. They presented 9 neoplasias (1 lymphoma, 1 melanoma, and 7 carcinomas) diagnosed from 4 months before to 25 months after the occurrence of cutaneous (6/7) and/or mucosal (6/7) polymorphic lesions. Histological examination revealed epidermal acantholysis (7/7), keratinocytic necrosis (4/7), and interface lichenoid dermatitis (5/7). Intercellular deposits of IgG and C3 or along the dermo-epidermal junction were detected with direct immunofluorescence (IF) (7/7). Four of 6 patients tested had positive indirect IF on rat bladder epithelium. Follow-up ranged from 1-132 months with a one-year survival of 85.7%.

DISCUSSION

The clinical and histopathological presentations observed in our patients were polymorphic, with overlap between the clinical and histological features of PNP and classical pemphigus. Prognosis and survival appear better in our series than in the literature. It is possible that in some cases, the association of pemphigus with neoplasia was fortuitous, which might account for the better prognosis. A new consensus on the diagnostic criteria for PNP is needed to help practitioners to consensually diagnose it for prognostic or therapeutic trials.

[Adult kwashiorkor: a rare complication of bariatric surgery]

INTRODUCTION

Kwashiorkor is a clinical manifestation of global protein-calorie malnutrition that is described mainly in children in developing countries initially presenting eczema-like skin disease associated with hydrops.

OBSERVATION

We report the case of a 44-year-old woman with dark skin who had undergone bariatric surgery for treatment of stage-III obesity without regular monitoring and who was hospitalized in our dermatology department four years later. She had diffuse oedema and asteatotic eczema-like cutaneous lesions on pigmented skin that had developed for two months despite daily application of topical corticosteroids. Clinical signs, the collapse of serum albumin and histopathological analysis of skin tissue were evocative of kwashiorkor. Her symptoms subsided after several weeks of a nutritional programme.

DISCUSSION

Kwashiorkor is a clinical entity described chiefly in children in developing countries. Cutaneous involvement comprising asteatotic eczema-like skin associated with diffuse oedema is prominent. Treatment with protein supplementation alone is effective and avoids many complications such as infections and haemodynamic disorders. Obesity is a serious and common disease in Western countries affecting one third of the world's population, and for which treatment with bariatric surgery may be indicated. Without regular monitoring, this surgery can cause severe protein deficiency. Consequently, in the future there will seemingly be a greater likelihood of kwashiorkor in adults as an iatrogenic complication of obesity treatment. Its semiology needs to be underlined because of the simplicity and efficacy of treatment.

[Endogenous endophthalmitis as a complication in erysipelas]

BACKGROUND

Endogenous endophthalmitis is a devastating infection of the eye that leads to blindness in about two-thirds of patients. It results from the haematogenous spread of a microorganism from a focus of sepsis, mainly gastro-intestinal, genitourinary or cardiac.

PATIENTS AND METHODS

We describe the case of a diabetic subject presenting endogenous endophthalmitis following erysipelas of the leg due to Streptococcus agalactiae. The outcome was favourable thanks to prompt initiation of appropriate antibiotic treatment.

DISCUSSION

Endogenous endophthalmitis as a complication of a skin infection is a rare entity, with only about 30 reported cases in the literature. Awareness of this condition among dermatologists would allow prompt intervention, which is essential for sparing of the patient's eyesight.

[An uncommon cutaneous presentation of cat scratch disease]

BACKGROUND

Herein we report a case of cat scratch disease on account of its atypical presentation.

PATIENTS AND METHODS

A 21-year-old woman presented erythema nodosum associated with painful bilateral inguinal adenopathy, odynophagia, joint pain and evening urticaria in a setting of impaired general condition. Initial serological testing for Bartonella henselae was negative. PCR for Bartonella henselae performed on an adenectomy fragment was positive. A favourable outcome was achieved with azithromycin.

COMMENTS

This case shows an atypical and severe presentation of cat scratch disease and raises the problem of sensitivity of serotyping.

[Graves' dermopathy on the big toe]

BACKGROUND

Localized myxoedema is a rare dermopathy in patients with Graves' disease. The pretibial area is the most commonly affected region but herein we present a case of myxoedema of the big toe.

PATIENTS AND METHODS

A 44-year-old male with Graves' disease ongoing for seven years presented bilateral ophthalmopathy and myxoedema of the big toes. The myxoedema was treated successfully with intralesional steroids.

DISCUSSION

The physiopathology of myxoedema involves fibroblast activation and glycosaminoglycan production. This activation could result from stimulation of TSH receptors at their surface by TSH receptor antibodies (TRAK) or from an inflammatory process. The pretibial topography may be related to the high frequency in this area of microtrauma, with modulation of the cytokine microenvironment.

CONCLUSION

The atypical localization seems to correlate with a Koebner phenomenon. Treatment of Graves' disease is generally insufficient to resolve the cutaneous problems. Topical corticosteroid therapy generally results in rapid improvement of recent lesions.

[Gorlin syndrome: photodynamic therapy, as a useful adjunct to surgery]

Gorlin syndrome, also called nevoid basal cell carcinoma syndrome, is well known by dermatologists. Since its onset, 10 years ago, photodynamic therapy has found new applications and is now currently used to cure single or multiple basal cell carcinomas, with good results and without residual scars. We recall some of the basic principles of this technique, as well as its indications in Gorlin syndrome, which we illustrate with one case. Plastic surgeons must consider this relatively new technique, developed by dermatologists, as a useful adjunct to surgery in the management of Gorlin syndrome.

[Iatrogenic cutaneous emphysema]

BACKGROUND

Tracheal perforation following orotracheal intubation is a rare but classic complication of general anaesthesia, and marked cutaneous emphysema can occur. We report a rare case of facial cutaneous emphysema revealed by swelling with pseudovesicles on the eyelids.

CASE REPORT

A 99-year-old woman developed extensive facial swelling with pseudo-vesicles on the upper and lower eyelids following right hip replacement surgery. Swelling of the upper members and thoracic area was also seen. Chest X-rays showed marked cutaneous emphysema of the thoracic wall. Bronchial endoscopy revealed perforation of the posterior aspect of the trachea. The patient was presenting cutaneous emphysema as a result of post-intubation tracheal perforation.

DISCUSSION

We report a rare case of cutaneous emphysema in a 99-year-old woman after tracheal perforation following orotracheal intubation. The significant feature of our case report is the actual manifestation of the condition. Our patient developed swelling of the eyelid with pseudovesicles. When confronted with sudden onset of pseudovesicles of the eyelids after surgery, dermatologists must not misdiagnose cutaneous emphysema and must examine their patient carefully for other clinical signs. Bronchial endoscopy should be undertaken immediately to investigate for tracheal perforation.

Comparison of the efficacy of levocetirizine 5 mg and desloratadine 5 mg in chronic idiopathic urticaria patients

BACKGROUND

Nonsedating H(1)-antihistamines are recommended for the treatment of urticaria by the recent EAACI/GA(2)LEN/EDF guidelines. The aim of this study was to compare the efficacy, after 4 weeks of treatment, with levocetirizine 5 mg and desloratadine 5 mg, both once daily in the morning, in symptomatic chronic idiopathic urticaria (CIU) patients.

METHODS

This multi-center, randomized, double-blind study involved 886 patients (438 on levocetirizine and 448 on desloratadine). The primary objective was to compare their efficacy on the mean pruritus severity score after 1 week of treatment. Mean pruritus severity score over 4 weeks and pruritus duration score, number and size of wheals, mean CIU composite score (sum of the scores for pruritus severity and numbers of wheals), quality of life, and the patient's and investigator's global satisfaction with treatment, were secondary efficacy measures.

RESULTS

Levocetirizine led to a significantly greater decrease in pruritus severity than desloratadine over the first treatment week; mean pruritus severity scores of 1.02 and 1.18 for levocetirizine and desloratadine, respectively (P < 0.001). The result was similar for the entire 4-week treatment period (P = 0.004). In addition, levocetirizine decreased pruritus duration and the mean CIU composite scores to a significantly greater extent than desloratadine during the first week (P = 0.002 and 0.005, respectively) and over the entire study (P = 0.009 and P < 0.05, respectively). Similarly, levocetirizine increased the patients' global satisfaction after one and 4 weeks (P = 0.012 and 0.021, respectively), compared with desloratadine. Safety and tolerability were similar in both groups.

CONCLUSIONS

Levocetirizine 5 mg was significantly more efficacious than desloratadine 5 mg in the treatment of CIU symptoms.

[Publication rate for oral presentations made at the Journées Dermatologiques de Paris meeting]

BACKGROUND

The fate of oral presentations presented at a dermatological meeting has not been assessed to date. Our aim was to determine the publication rate for oral presentations presented at the "Journées dermatologiques de Paris" (JDP) meeting in peer-reviewed journals. Our secondary goals were to identify factors associated with publication and to examine the consistency of reporting of research findings presented in the conference abstract and subsequent full publication.

METHODS

Abstracts presented orally at the JDP 1999-2004 were identified in the book of congress abstracts. Two independent operatives performed a Medline search cross-referencing lead and last authors and keywords.

RESULTS

The publication rate was 57.6% with mean time to publication of 20.3months. The median impact factor was 2.8. Factors associated with subsequent publication were study topic (p=0.04 for oncology) and study type (p=0.03 for fundamental research and p=0.005 for randomized controlled trials). The congress abstracts and full-text publication differed primarily in terms of sample size and data given in the "Results" section.

DISCUSSION

More than half of all abstracts presented orally at the JDP congress are subsequently published in journals with a median impact factor comparable to those seen for other scientific congresses for which similar analysis has been conducted. These results confirm the scientific quality of this particular congress, in addition to its vocation of continuous medical training.

[Cutaneous fissures in collodion babies: incidence and treatment]

BACKGROUND

Collodion baby syndrome (CBS) is a pathological cutaneous condition present at birth and is due to the presence of a thick horny layer of the skin. Exfoliation begins early with drying and cracking of the collodion membrane. The cracks may either remain superficial or they may be deeper and affect the superficial dermis, in which case, fissures form. This study of CBS provides information on the clinical aspect of fissures, their incidence, their pathological consequences and therapeutic approaches.

PATIENTS AND METHODS

In our study, diagnosis of CBS was made clinically based on the presence of neonatal collodion membrane. Identification of typical cracks and fissures was made on clinical examination and their site, chronology and consequences were assessed. Routine bacteriological examination of fissures was performed twice weekly on a clinically infected specimen taken from an inguinal fissure. The therapeutic protocol for CBS has been validated and involved use of sterile vaseline oil. Fissures were disinfected.

RESULTS

Cracks are a constant feature. Fissures were seen in 20 of the 33 cases of CBS with the site of predilection being large skinfolds. Morphine was necessary for pain relief in three cases. Pathogenic organisms were isolated in all cases of inflammatory fissures. Dissemination of septicaemia was confirmed in four cases and the offending organism was isolated from the inflammatory fissures in all cases. Candida albicans was present in all cases of fissures in the inguinal folds or between the buttocks. Keratotic adhesions occurred after healing of digital fissures and a surgical procedure was required in this event.

DISCUSSION

Fissures are lesions occurring secondarily to cracks and they were seen in 20 of the 33 cases of CBS. These secondary lesions are rarely mentioned in the literature and the reasons for this oversight are discussed. Fissures are potential complications in all states of CBS, particularly where the collodion is thick. Topical treatment does not prevent transformation of cracks to fissures in all cases. Where fissures are not inflammatory, routine prescription of oral antibiotics is not always necessary. Regular bacteriological monitoring at several different fissure sites allows selection of appropriate antibiotic therapy. The main therapeutic goal in CBS is to treat painful fissures and superinfection.

A role for T cell-derived interleukin 22 in psoriatic skin inflammation

Interleukin (IL)-22 is a T cell-derived cytokine that has been reported recently to induce cutaneous inflammation in an experimental murine model of psoriasis, and to induce in vitro an inflammatory-like phenotype. In the present study, we assessed the presence of IL-22 and the IL-22 receptor 1 (IL-22R1) in skin lesions, skin-derived T cells, as well as IL-22 levels in sera from patients with psoriasis. IL-22R1 and IL-10R2 transcripts are expressed at a similar level in psoriatic and healthy skin. In contrast, IL-22 mRNA expression was up-regulated in psoriatic skin lesions compared to normal skin, whereas IL-22 mRNA levels in peripheral blood mononuclear cells from psoriatic patients and normal subjects were similar. Circulating IL-22 levels were significantly higher in psoriatic patients than in normal subjects. T cells isolated from psoriatic skin produced higher levels of IL-22 in comparison to peripheral T cells isolated from the same patients. IL-10 was expressed at similar levels in skin biopsies and peripheral blood mononuclear cells of psoriatic patients and normal subjects. Finally, we show here that supernatants of lesional psoriatic skin-infiltrating T cells induce an inflammatory response by normal human epidermal keratinocytes, resembling that observed in psoriatic lesions. Taken together, the results reported in this study indicate that IL-22 is a cytokine produced by skin-infiltrating lymphocytes that is potentially involved in initiation and/or maintenance of the pathogenesis of psoriasis.

Bébé collodion révélant une trichothiodystrophie confondue avec un syndrome de Netherton : réévaluation d’une erreur de diagnostic

BACKGROUND

Reassessment of a previously published case report allowed correction of a misdiagnosis: a neonatal aspect of collodion baby with pilar dystrophy is evocative of trichothiodystrophy and not Netherton syndrome. Other than this published erroneous case report, there have been no other publications concerning Netherton syndrome mentioning this neonatal collodion baby status. It may be clearly stated that Netherton syndrome never begins with collodion baby status.

PATIENTS AND METHODS

The re-examined case concerned a girl with collodion baby syndrome presenting pilar dystrophy. At 2 years, an inaccurate diagnosis of Netherton syndrome was made despite the fact that the pilar dystrophy involved trichorrhexis nodosis with ichthyosis vulgaris. At 8 years, 13 years and 17 years, the diagnosis of trichothiodystrophy was posited in the presence of tiger-striping of the hair visible in polarised light together with low capillary cystine at only 51 p. 100 of the normal level. The phenotype obtained comprised ichthyosis, pilar dystrophy, low IQ and stunted growth of at least two standard deviations despite tall parents. There was no evidence of photosensitivity.

DISCUSSION

The state of baby collodion may or may not herald trichothiodystrophia. A review of 72 articles containing a clinical description of signs at the onset of trichothiodystrophy showed a relationship in 22 cases between this condition and collodion baby syndrome. The collodion baby phenotype is of moderate intensity with little or no facial dysmorphia. Microscopic examination of hair is alone able to orient diagnosis towards trichothiodystrophy. Microscopic examination of the hair with inspection under polarised light is essential to confirm an aetiological diagnosis of collodion baby. Collodion baby syndrome never leads to Netherton syndrome. In some cases, however, it may herald trichothiodystrophy.