Clinicopathological features, MCPyV status and outcomes of Merkel cell carcinoma in solid-organ transplant recipients: a retrospective, multicentre cohort study

BACKGROUND

The proportion of Merkel cell carcinomas (MCCs) in solid-organ transplant recipients (SOTR) harbouring Merkel cell polyomavirus (MCPyV) is unknown, as are factors affecting their outcomes.

OBJECTIVE

To describe clinicopathological features of MCC in SOTR, investigate the tumoral MCPyV-status and identify factors associated with tumour outcomes.

METHODS

Retrospective, international, cohort-study. MCPyV-status was investigated by immunohistochemistry and polymerase chain reaction.

RESULTS

A total of 30 SOTR and 44 consecutive immunocompetent patients with MCC were enrolled. SOTR were younger at diagnosis (69 vs. 78 years, P < 0.001). Thirty-three percent of SOTR MCCs were MCPyV-positive vs. 91% of immunocompetent MCCs (P = 0.001). Solid-organ transplantation was associated with an increased cumulative incidence of progression (SHR: 3.35 [1.57-7.14], P = 0.002), MCC-specific mortality (SHR: 2.55 [1.07-6.06], P = 0.034) and overall mortality (HR: 3.26 [1.54-6.9], P = 0.002). MCPyV-positivity and switching to an mTOR inhibitor (mTORi) after MCC diagnosis were associated with an increased incidence of progression (SHR: 4.3 [1.5-13], P = 0.008 and SHR: 3.6 [1.1-12], P = 0.032 respectively) in SOTR.

LIMITATIONS

Retrospective design and heterogeneity of SOTR cohort.

CONCLUSIONS

MCPyV appears to play a less prominent role in the aetiopathogenesis of MCC in SOTR. SOTR have a worse prognosis than their immunocompetent counterparts and switching to an mTORi after the diagnosis of MCC does not improve progression.

Five-year efficacy and safety of tildrakizumab in patients with moderate-to-severe psoriasis who respond at week 28: pooled analyses of two randomized phase III clinical trials (reSURFACE 1 and reSURFACE 2)

BACKGROUND

The phase III reSURFACE 1 and reSURFACE 2 (NCT01722331/NCT01729754) trials of the anti-interleukin-23p19 monoclonal antibody tildrakizumab (TIL) for psoriasis treatment are complete.

OBJECTIVES

We present 5-year pooled data from reSURFACE 1 and reSURFACE 2.

METHODS

reSURFACE 1 and reSURFACE 2 were double-blind, randomized, controlled studies with optional long-term extensions. Adults with moderate-to-severe chronic plaque psoriasis were randomized 2 : 2 : 1 to TIL 100 mg (TIL 100) or 200 mg (TIL 200) or placebo at weeks 0 and 4, and every 12 weeks thereafter [reSURFACE 2 included an etanercept (ETN) arm]. Efficacy outcomes included proportions of patients achieving absolute and relative improvement from baseline Psoriasis Area and Severity Index (PASI) score through week 244 in TIL responders (≥ 75% improvement from baseline PASI; PASI 75 response) continuously receiving the same dose and ETN partial responders and nonresponders (PASI < 75 response) switched to TIL 200 at week 28. Safety was assessed from adverse events (AEs) in all patients as treated.

RESULTS

Efficacy analyses included 329 and 227 week 28 responders to TIL 100 and TIL 200, respectively, and 121 ETN partial responders/nonresponders switched to TIL 200 at week 28. Of TIL 100 or TIL 200 responders and ETN partial responders/nonresponders entering the extensions, 235/302, 176/213 and 85/107, respectively, were evaluated at week 244, and 88·7%, 92·5% and 81·3%, respectively, achieved PASI 75 response. Exposure-adjusted rates of serious AEs were 6·3 and 6·0 patients with events per 100 patient-years of TIL 100 and TIL 200, respectively.

CONCLUSIONS

TIL treatment provided sustained disease control over 5 years in week 28 TIL responders and ETN partial responders/nonresponders, with a reassuring safety profile.

Dermatologists and SARS-CoV-2: the impact of the pandemic on daily practice

Since the first case of 'pneumonia of unknown aetiology' was diagnosed at the Wuhan Jinyintan Hospital in China on 30 December 2019, what was recognized thereafter as 'severe acute respiratory syndrome coronavirus 2' (SARS-CoV-2) has spread over the four continents, causing the respiratory manifestations of coronavirus disease-19 (COVID-19) and satisfying the epidemiological criteria for a label of 'pandemic'. The ongoing SARS-CoV-2 pandemic is having a huge impact on dermatological practice including the marked reduction of face-to-face consultations in favour of teledermatology, the uncertainties concerning the outcome of COVID-19 infection in patients with common inflammatory disorders such as psoriasis or atopic dermatitis receiving immunosuppressive/immunomodulating systemic therapies; the direct involvement of dermatologists in COVID-19 care for patient assistance and new research needs to be addressed. It is not known yet if skin lesions and derangement of the skin barrier could make it easier for SARS-CoV-2 to transmit via indirect contact; it remains to be defined if specific mucosal or skin lesions are associated with SARS-CoV-2 infection, although some unpublished observations indicate the occurrence of a transient varicelliform exanthema during the early phase of the infection. SARS-CoV-2 is a new pathogen for humans that is highly contagious, can spread quickly, and is capable of causing enormous health, economic and societal impacts in any setting. The consequences may continue long after the pandemic resolves, and new management modalities for dermatology may originate from the COVID-19 disaster. Learning from experience may help to cope with future major societal changes.

SAT0412 ACCURACY OF AN INSTRUMENT FOR SCREENING PSORIATIC ARTHRITIS AMONG PSORIATIC PATIENTS: RESULTS FROM THE MULTICENTRE ITALIAN STUDY HERACLES (SCREENING STRATEGIES FOR RHEUMATOLOGICAL REFERRAL OF PSORIATIC SUBJECTS AIMED TO DISCLOSE PSORIATIC ARTHRITIS)

Background:

Identifying psoriatic arthritis (PsA) among people with psoriasis is often challenging due to low specificity of symptoms at early PsA stage and/or delayed referral to the rheumatologist. Screening instruments -assisting the dermatologist to decide when rheumatological assessment is beneficial- have potential to reduce the diagnostic delay.

Objectives:

To evaluate the accuracy of a dermatologist-filled-out questionnaire designed for screening PsA among psoriatic patients under dermatology care.

Methods:

HERACLES is a multicentre, cross-sectional study running at 9 Italian dermatology and rheumatology tertiary centres. All participants were under dermatology care for skin psoriasis. Previous diagnosis of PsA precluded eligibility. Dermatologists at each site assessed consecutive psoriatic subjects, filled in the specifically-designed HERACLES questionnaire (HQ, Figure 1) and finally referred the participants to rheumatologists for clinical evaluation. All participants filled in the ToPAS, PASE, PEST and EARP questionnaires. Rheumatologists assessed the participants regardless of the questionnaires’ scores. The gold standard applied to assess the instruments’ accuracy was the diagnosis of PsA as established by the rheumatologists. ROC curve analysis evaluated the performance of the scores associated with the clinical criteria listed in the HQ, estimating the sensitivity and specificity of different cut-off levels. Further exploratory ROC curve analysis compared HQ performance to that of the other four questionnaires tested.

Figure 1.

Results:

Out of 759 subjects enrolled, 524 (69%) attended rheumatology assessment. Rheumatologists diagnosed PsA in 73/524 patients (13.9%, Figure 2). Mean age was 53 (SD 16) years and 46% were female. Mean psoriasis duration was 20 (SD 19) years. The area under the ROC curve of HQ was 0.775. The HQ score cut-off value of 2 yielded a sensitivity of 92% and a specificity of 47%; a cut-off value of 3 yielded a sensitivity of 66% and a specificity of 75%. The comparison between the ROC curve of the HQ and those of the other four questionnaires evaluated did not show any significant difference (p=0.523 versus TOPAS; p=0.201 versus PASE; p=0.345 versus PEST and p=0.240 versus EARP).

Figure 2.

Conclusion:

The HERACLES questionnaire, a tool designed for dermatologists, showed good sensitivity and specificity in identifying PsA cases among subjects with cutaneous psoriasis.

Acknowledgments:

The HERACLES project was supported by a research grant from FIRA and Pfizer Italia SRL

Disclosure of Interests:

Gabriele De Marco: None declared, Maria Manara Consultant of: Consultant and/or speaker for Eli-Lilly, MSD, Sanofi-Genzyme, Novartis, Alfa Wasserman and Cellgene, Speakers bureau: Consultant and/or speaker for Eli-Lilly, MSD, Sanofi-Genzyme, Novartis, Alfa Wasserman and Cellgene, Paolo Gisondi: None declared, Luca Idolazzi: None declared, Roberta Ramonda Speakers bureau: Novartis, Celgene, Janssen, Pfizer, Abbvie, Lilly, Stefano Piaserico: None declared, Alberto Cauli: None declared, Marco Amedeo Cimmino: None declared, Veronica Tomatis: None declared, Carlo Salvarani: None declared, Rosanna Scrivo: None declared, Anna Zanetti: None declared, Greta Carrara: None declared, Carlo Alberto Scirè: None declared, Angelo Cattaneo: None declared, Antonio Marchesoni Speakers bureau: Abbvie, Pfizer, UCB, Novartis, Celgene, Eli Lilly

European Dermatology Forum guidelines on topical photodynamic therapy 2019 Part 1: treatment delivery and established indications - actinic keratoses, Bowen's disease and basal cell carcinomas

Topical photodynamic therapy (PDT) is a widely approved therapy for actinic keratoses, Bowen's disease (squamous cell carcinoma in situ), superficial and certain thin basal cell carcinomas. Recurrence rates when standard treatment protocols are used are typically equivalent to existing therapies, although inferior to surgery for nodular basal cell carcinoma. PDT can be used both as lesional and field therapies and has the potential to delay/reduce the development of new lesions. A protocol using daylight to treat actinic keratoses is widely practised, with conventional PDT using a red light after typically a 3-h period of occlusion employed for other superficial skin cancer indications as well as for actinic keratoses when daylight therapy is not feasible. PDT is a well-tolerated therapy although discomfort associated with conventional protocol may require pain-reduction measures. PDT using daylight is associated with no or minimal pain and preferred by patient. There is an emerging literature on enhancing conventional PDT protocols or combined PDT with another treatment to increase response rates. This guideline, published over two parts, considers all current approved and emerging indications for the use of topical PDT in dermatology, prepared by the PDT subgroup of the European Dermatology Forum guidelines committee. It presents consensual expert recommendations reflecting current published evidence.

Efficacy of secukinumab without the initial weekly loading dose in patients with chronic plaque psoriasis

BACKGROUND

Secukinumab is administered at the labelled dose of 300 mg at weeks 0, 1, 2, 3, 4 (loading dose) and every 4 weeks thereafter.

OBJECTIVES

To investigate the efficacy of secukinumab administered without the initial loading dose in patients with psoriasis.

METHODS

This was a retrospective observational study including adult patients with psoriasis (n = 156) treated with secukinumab 300 mg administered either according to the labelled dose (n = 75) or without the initial loading dose (n = 81). Efficacy was evaluated by comparing the Psoriasis Area and Severity Index (PASI) 75 and PASI 90 response rates at week 8, 12, 16, 32 and 48.

RESULTS

For patients who received the labelled dose vs. those who did not, PASI 75 response rates were achieved at week 8, 12, 16, 32 and 48 by 60% vs. 40% (P < 0·01), 72% vs. 61% (P < 0·01), 77% vs. 75%, 85% vs. 77% and 79% vs. 78%, respectively. PASI 90 responses were achieved at the same time points by 45% vs. 31% (P < 0·01), 49% vs. 40% (P < 0·01), 54% vs. 47%, 55% vs. 47% and 57% vs. 54% for those who received the labelled dose vs. those who did not, respectively. A greater proportion of patients receiving secukinumab without the loading dose discontinued treatment because of inefficacy (25% vs. 13%, P < 0·05), particularly those with body weight greater than 80 kg.

CONCLUSIONS

Secukinumab administered without the loading dose is associated with a higher proportion of primary inefficacy, and achieved inferior results compared with the labelled dose at week 8 and week 12, but showed similar efficacy thereafter. What's already known about this topic? Secukinumab is an interleukin (IL)-17A inhibitor for chronic plaque psoriasis administered by subcutaneous injections at the labelled dose of 300 mg at weeks 0, 1, 2, 3, 4 (loading dose) and every 4 weeks thereafter (maintenance dose). Dose adjustment is common in clinical practice, and can consist of dose reduction when a prolonged remission is obtained or a dose increase in order to improve efficacy. What does this study add? The efficacy of secukinumab administered without the initial weekly loading dose was significantly inferior compared with the labelled dose in the short term, but was similar after week 16 and up to week 48. A greater proportion of patients receiving secukinumab without the loading dose showed primary inefficacy, particularly those with body weight greater than 80 kg.

European Dermatology Forum guidelines on topical photodynamic therapy 2019 Part 2: emerging indications - field cancerization, photorejuvenation and inflammatory/infective dermatoses

In addition to approved indications in non-melanoma skin cancer in immunocompetent patients, topical photodynamic therapy (PDT) has also been studied for its place in the treatment of, as well as its potential to prevent, superficial skin cancers in immune-suppressed patients, although sustained clearance rates are lower than for immune-competent individuals. PDT using a nanoemulsion of ALA in a daylight or conventional PDT protocol has been approved for use in field cancerization, although evidence of the potential of the treatment to prevent new SCC remained limited. High-quality evidence supports a strong recommendation for the use of topical PDT in photorejuvenation as well as for acne, refractory warts, cutaneous leishmaniasis and in onychomycosis, although these indications currently lack approvals for use and protocols remain to be optimized, with more comparative evidence with established therapies required to establish its place in practice. Adverse events across all indications for PDT can be minimized through the use of modified and low-irradiance regimens, with a low risk of contact allergy to photosensitizer prodrugs, and no other significant documented longer-term risks with no current evidence of cumulative toxicity or photocarcinogenic risk. The literature on the pharmacoeconomics for using PDT is also reviewed, although accurate comparisons are difficult to establish in different healthcare settings, comparing hospital/office-based therapies of PDT and surgery with topical ointments, requiring inclusion of number of visits, real-world efficacy as well as considering the value to be placed on cosmetic outcome and patient preference. This guideline, published over two parts, considers all current approved and emerging indications for the use of topical photodynamic therapy in Dermatology prepared by the PDT subgroup of the European Dermatology Forum guidelines committee. It presents consensual expert recommendations reflecting current published evidence.

A case-control study of risk factors associated with Zoon balanitis in men

BACKGROUND

Zoon balanitis (ZB) is a chronic inflammatory benign mucositis. Its etiopathogenesis still remains hypothetical and speculative.

OBJECTIVES

To determine risk factors associated with genital ZB in men.

METHODS

This is a case-control study including 30 patients diagnosed with ZB and 54 patients with dermatological diseases other than ZB enrolled in the Dermatological Clinic of the University of Padova, Italy, from September 2015 to June 2018. Univariate and multivariate logistic regression analyses were used for analysis of data collected.

RESULTS

According to multivariate logistic regression analysis, risk factors for ZB were as follows: the mean daily cigarettes consumption (OR 1.065; 95% CI 1.8-11.4; P = 0.006) and the number of weekly foreskin retractions (OR 0.847; 95% CI 5.5-24.1; P = 0.003). There were no statistically significant differences between cases and controls according to age, presence of circumcision as well in number of sexual partners.

CONCLUSIONS

To our knowledge, this is the first case-control study showing that smoking and poor genital hygiene are associated with being affected by ZB.

Consensus on the management of patients with psoriatic arthritis in a dermatology setting

BACKGROUND

Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with psoriasis (PsO). Early diagnosis and prompt therapeutic intervention are crucial for limiting PsA progression and prevention of disability. Dermatologists are in a privileged position to detect early PsA. The management of patients with PsA in the dermatology setting is widely variable.

OBJECTIVE

To provide practical recommendations for the management of patients with PsA in the dermatology setting including early diagnosis and treatment.

METHODS

A consensus document was written by an expert panel composed by dermatologists (n = 12) and rheumatologists (n = 6). Eleven highly relevant questions were selected and elaborated with answers/statements based on a narrative literature review. The resulting document was discussed in a face-to-face meeting adopting a nominal group technique to reach consensus (i.e. 100% agreement) using the Delphi method.

RESULTS

A consensus was achieved in defining the following: the clinical characteristics differentiating inflammatory and non-inflammatory signs and symptoms of joint disease; the most important differential diagnoses of PsA in clinical practice; the most useful screening questionnaires, serum laboratory tests and imaging techniques for the detection of early PsA; the criteria for dermatologist to refer patients with PsO to rheumatologist; the criteria for the diagnosis of PsA; the selection of the indices that the dermatologist could use for measuring the activity and severity of PsA in clinical practice; when systemic steroids and/or intra-articular steroid injections are indicated in the treatment of PsA. Finally, systemic treatments including synthetic and biologic disease-modifying antirheumatic drugs to be considered for the treatment of PsA have been reported.

CONCLUSIONS

The implementations of these practical recommendations could be very helpful for the management of patients with PsA in the dermatology setting including early diagnosis and treatment.

Simulating the life course of psoriasis patients: the interplay between therapy intervention and marital status

BACKGROUND

Psoriasis, a chronic relapsing inflammatory disease affecting primarily the skin, shows multiple comorbidities including depression, cardiovascular diseases and other relevant conditions. Psoriasis patients experience social isolation, job loss, financial difficulties and partnership problems. Inversely, psychosocial impairments may negatively influence the disease course.

OBJECTIVE

To explore the feasibility of a model describing the interaction of psychosocial and clinical factors over the life course of patients.

METHODS

We considered only seven states for members of a hypothetical population: single and healthy, single and having a psoriasis flare, single and 'cured', coupled and healthy, coupled and having a psoriasis flare, coupled and 'cured', and dead. Transition probabilities between states were taken from the Norwegian Population Register for the healthy population and from epidemiological research articles. Clinical experience allowed adjustments on the assumed parameters.

RESULTS

Our macromodel, which simulates the effect of therapy intervention on patients' partnership status, yields a description of the transitions between the seven states. Treatment efficacy shows only a negligible effect on the chances of living with a partner.

CONCLUSIONS

Mathematical modelling of interactions between social and health variables is in principle feasible. However, complex models, comprising more variables (for instance: employment status, depression level, obesity etc.), are needed for more realistic simulations for the interactions studied. As increasing the number of variables leads to an exponential increase of the model's state space, switching to micromodelling (representing each individual separately) may be necessary.

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.

Adalimumab is a safe option for psoriasis patients with concomitant hepatitis B or C infection: a multicentre cohort study of 37 patients and review of the literature

BACKGROUND

Little data are available about the safety of TNF-α inhibitors in patients with HCV and HBV infection. In particular, data concerning the use of adalimumab in patients with psoriasis and concomitant viral hepatitis are lacking and little is known about the drug's real safety in this context.

OBJECTIVE

To assess the long-term safety of adalimumab in a group of 17 consecutive psoriatic patients affected by chronic HBV infection and 20 consecutive psoriatic patients affected by chronic HCV infection.

METHODS

Thirty-seven consecutive patients with psoriasis and concomitant HBV or HCV infection being treated with adalimumab at four Italian referral centres (Modena, Padova, Verona and Turin) were assessed before the treatment and at the end of follow-up. Viral load and radiological studies (echography, Fibroscan) were also carried out in some of the patients.

RESULTS

The patients responded well to treatment and did not show any HBV or HCV reactivation in a mean follow-up period of 27 and 40 months, respectively. The fibrosis score in eight HCV patients showed a slight reduction: pretreatment mean value 5.83 and post-treatment mean value 5.65.

CONCLUSION

The use of adalimumab seems to be safe in patients with severe psoriasis and HBV or HCV infection. Nevertheless, large-scale prospective studies will be able to provide vital information on the impact of anti-TNF treatment on hepatic function in patients with psoriasis and concomitant chronic HCV or HBV infection and appropriate monitoring scheduling.

Italian expert consensus for the management of actinic keratosis in immunocompetent patients

Actinic keratosis (AK) is a common skin disease which can potentially progress to invasive squamous cell carcinoma (iSCC). Given that mortality rates and health-care cost associated with iSCC are substantial, the management of AK represents an important public health issue. Several effective lesion-directed and field-directed treatments are available. Ablative procedures (e.g. cryosurgery, excision, laser ablation, curettage alone or with electrodessication) are considered cost-effective options for solitary lesions. Field-directed therapies (e.g. Ingenol Mebutate, imiquimod, PDT, 5-Fluorouracile, diclofenac 3%, 5-FU + Salicylic acid) can be used over large epidermal surfaces and are directed to treat both individual visible lesions and cancerization fields. In order to provide guidance for management choice in clinical practice, several guidelines concerning the diagnosis and treatment of AK have been published in the past decade. However, the introduction of novel therapeutic options requires continuous updates of recommendations and adaptation to national contexts. The present review summarizes the existing evidence and reports the results of a consensus workshop on the management of AK.

Biosimilar infliximab: an expert view

CT-P13, a biosimilar of infliximab, was the first biosimilar monoclonal antibody to be approved in both the European Union and Korea. As a monoclonal antibody, CT-P13 is a large molecule with a high molecular weight, and as such it differs from other biosimilars currently in the market. The comparability exercise for CT-P13, therefore, requires special consideration, as it was the first demonstration of biosimilarity between a biosimilar monoclonal antibody and its originator. This paper summarizes current regulations on the approval of biosimilars, describes the evidence leading to the approval of CT-P13, and discusses the potential role of this molecule in the Italian scenario on the basis of the view of a group of experts.

Quality of life in patients with scalp psoriasis

AIM

The aims of this study were to describe the quality of life (QoL) in patients suffering of scalp psoriasis and to assess the impact of the socio-demographic and clinical features of this condition on patients' health-related QoL, using general and specific QoL scales.

METHODS

This research is a cross-sectional study. The study involved 55 patients attending their first examination at the Dermatology Clinic of Padua University over the course of one year (April 2010-March 2011). The outcome was quality of life analyzed by means Scalpdex and SF-36 questionnaire.

RESULTS

The sample's mean Scalpdex score was 43.60±17.52, while the mean SF-36 score was 68.28±20.32. The SF-36 identified statistically significant differences between the psoriasis patients and the Italian general population in two domains, i.e. general health (P=0.0075) and emotional role (P=0.0048). The severity of patients' scalp lesions emerged as a factor associated with a reduced QoL in these patients, irrespective of the severity of their disease as a whole. Sex, age, schooling and other socio-demographic factors also characterized patients' perceived QoL.

CONCLUSION

Patients with scalp psoriasis suffered from a lower QoL relating to the highly visible site of their psoriatic lesions. Specific supportive measures should be dedicated to these patients by health care workers.

Autochthonous Hookworm-Related Cutaneous Larva Migrans Disease in Northeastern Italy: A Case Report

Here we report the case of a 42-yr-old patient who presented himself to us with a serpiginous erythematous lesion from the wrist of the right forearm up the arm to the right shoulder A similar lesion of a smaller size was also present in the left forearm. On the basis of clinical manifestations and progression of the lesion, combined with previous treatments and different diagnostic investigations, hookworm-related cutaneous larva migrans (HrCLM) disease was hypothesized. Albendazole was employed as treatment and the resolution of the symptoms confirmed the diagnosis. The relevance of the reported case relies on 3 main aspects: the acquisition of the disease in Italy, the initial treatment with topical corticosteroids that sped up the progression of the cutaneous trail, and the uncommon location of the lesions. Furthermore, the anamnestic data and the laboratory/clinical investigations strongly suggested an occupational exposure to the etiological agent. As illustrated here, HrCLM might represent a challenge for Western physicians in terms of diagnosis, treatment, and ways of acquisition. Describing the clinical presentation and the treatment of cases of cutaneous larva migrans might contribute to early and correct diagnosis, to an increase of our knowledge on this disease, and to an update on its epidemiology.

Investigating psoriasis awareness among patients in Italy: validation of a questionnaire

OBJECTIVE

Psoriasis can have a profound impact on quality of life (QoL) and an awareness of the processes of the disease and its treatment is important in coping with symptoms. Patients do not always understand the potential consequences of their disease and the wide range of effective treatment strategies now available. We designed and validated a questionnaire to investigate patient awareness and understanding of psoriasis including pathogenesis, diagnosis, prognosis and treatment.

PATIENTS AND METHODS

This was a multicentre, cross-sectional investigation involving 14 psoriasis referral centres in Italy. The focus group technique was used by a panel of experts in psoriasis, to draw-up a list of questions exploring pathogenesis, diagnosis, prognosis, factors influencing clinical course of psoriasis as well as QoL issues and sources of information on their condition. Psychometric properties of the questionnaire were tested on a sample of 240 adult patients with psoriasis (including treatment-naïve and -experienced patients).

RESULTS

The mean age of patients was 50.3±14.9 years and 34.2% were female. The median time from diagnosis was 13.7 years (IQR 7.3-23.2). The Cronbach alpha was 0.77 and all items showed higher correlations within their own dimensions than to other dimensions. Each domain of awareness was well represented by a single dimension. Mean overall awareness was 59.7±13.1 on a 100-point scale.

CONCLUSIONS

Our questionnaire was valid in assessing patient awareness in five relevant areas of psoriasis, and can be useful in both the clinical setting and research studies to evaluate patients' knowledge of psoriasis better, with the final aim of reducing the burden of this chronic condition.

Cutaneous viral infections in organ transplant patients

Cutaneous infections might occur in up to 80% of organ transplant recipients (OTR) and viral infections are the most common them. The risk of different skin infection is among related to the intensity of immunosuppression. During the first post-transplant period, herpes viruses are most common. After some months following transplantation, human papilloma viruses represent the most significant infections among OTR. Reactivation of herpes simplex virus in OTR can become more invasive, takes longer to heal, and shows greater potential for dissemination to visceral organs compared to the general population. Specific immunosuppressive drugs (namely muromonab and mycophenolate mofetil) have been associated with an increased risk of herpes virus reactivation after transplantation. On the other hand, there is evidence that the mTOR inhibitors, such as everolimus, may be associated with a decreased incidence of herpesvirus infections in transplant recipients. The incidence of herpes zoster in OTR is 10 to 100 fold higher than the general population, ranging from 1% to 12%. The chronic immunosuppression performed in OTR may lead to persistent replication of herpesviruses, dissemination of the virus with multivisceral involvement (hepatitis, pneumonitis, myocarditis, encephalitis and disseminated intravascular coagulation) and eventually, the emergence of antiviral-drug resistance. Viral warts are the most common cutaneous infection occurring in OTR. The number of warts increases with the duration of immunosuppressive therapy. Since warts in organ recipients are frequently multiple and only rarely undergo spontaneous regression, the therapeutic management of warts in patients treated with immunosuppressive drugs might be challenging. Imiquimod, 1% cidofovir ointment, acitretin proved to be useful off-label strategies for recalcitrant cutaneous viral warts in OTR. Extensive and atypical presentation of molluscum contagiosum has been also reported in OTR, with a prevalence between 3% to 6.9%. Giant molluscum contagiosum is a clinical variant in which large nodule greater than 0.5-1 cm in diameter are observed.

Kaposi's sarcoma and other rare skin cancers in organ transplant patients

Kaposi's sarcoma and Merkel cell carcinoma represent potentially lethal cutaneous complications in organ transplanted patients. These neoplasms can severely complicate the clinical outcome of transplanted patient. Moreover, as the diagnosis is mainly clinical, a knowledge of these clinical entities may be fundamental in the daily management of this group of patients. In this review we will discuss these neoplasms in relation to the role of immunosuppression in their onset and progression.

Cutaneous melanoma in solid organ transplant patients

Solid organ transplant patients are at greatly increased risk of developing a wide variety of skin cancers, particularly epithelial skin cancers. On the other hand, it is well known that an intact immune system limits the development of benign melanocytic lesions. The eruptive nevi phenomenon, which we can observe in solid organ transplant recipients, is indicative of the relationship between melanocyte proliferation and immune system. Regression of melanocytic nevi after restoration of complete immune responsiveness is a further clinical example the role of immunosurveillance on melanocyte proliferation. However, melanoma incidence in organ transplant recipients appears only 2-3 folds higher than in general population. To this regard, organ transplant recipients who develop de novo melanomas thicker than 2mm seem to have a significantly worse outcome with a greatly increased risk of dying of metastatic melanoma, whereas those who develop a ≤2 mm thickness melanoma seem to have a prognosis similar to that of the general population. Furthermore, there is no evidence supporting an increased risk of melanoma recurrences after transplant in patients with a history of low-risk melanoma. Melanoma is also one of the most frequent and lethal donor-derived malignancies suggesting that a history of invasive melanoma should be considered an absolute contraindication to donation. The aim of this review is to investigate the relationship between immunosuppression and melanoma and to discuss its clinical implications for the management of transplant-associated melanoma.

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.

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.

Ustekinumab does not increase body mass index in patients with chronic plaque psoriasis: a prospective cohort study

BACKGROUND

Chronic plaque psoriasis is frequently associated with metabolic disorders including obesity. Antitumour necrosis factor α treatments can induce body-weight increase in patients with psoriasis. Information on the effect of ustekinumab on body weight is not available.

OBJECTIVES

To investigate whether therapy with ustekinumab is associated with changes in body mass index (BMI) in patients with chronic plaque psoriasis.

METHODS

A prospective, multicentre study comparing the changes in BMI in two closed cohorts of patients with psoriasis during 7-month treatment with ustekinumab (n = 79) or infliximab (n = 83).

RESULTS

Patients treated for 7 months with infliximab showed a significant (P < 0.001) increase in mean BMI (2.1 ± 4.5%) and body weight (2.5 ± 3.3 kg) compared with patients treated with ustekinumab (0.1 ± 3.3%; 0.6 ± 1.1 kg). Some 45% of patients treated with infliximab had a BMI increase > 2%, compared with only 11% of those receiving ustekinumab (P = 0.01). In the multivariate analysis, all other clinical parameters predicted the BMI increase, except for the use of infliximab. At month 7, 96% of patients treated with infliximab and 82% of patients treated with ustekinumab achieved at least a 50% improvement from their baseline psoriasis area and severity index (PASI 50), and 69% of the infliximab group compared with 58% of the ustekinumab group achieved at least PASI 75. There was no difference in the proportion of PASI 50 and PASI 75 responders between the two groups.

CONCLUSIONS

In contrast to infliximab, ustekinumab does not increase BMI in patients with chronic plaque psoriasis. This difference could be taken into account in the selection of biologics when treating patients with psoriasis.

Consensus recommendations for the treatment of basal cell carcinomas in Gorlin syndrome with topical methylaminolaevulinate-photodynamic therapy

BACKGROUND

Patients with Gorlin syndrome develop multiple basal cell carcinomas (BCC), for which treatment is often difficult. Methylaminolevulinate-photodynamic therapy (MAL-PDT) is approved for the treatment of superficial and nodular BCCs in Canada and several European countries.

OBJECTIVES

To establish consensus recommendations for the use of MAL-PDT in patients with Gorlin syndrome.

METHODS

The Gorlin consensus panel was comprised of 7 dermatologists who had treated a total of 83 patients with Gorlin syndrome using MAL-PDT. Consensus was developed based on the personal experience of the expert and results of literature review (on PUBMED using the keywords 'MAL' and 'PDT' and 'Gorlin' or 'naevoid basal cell carcinoma syndrome').

RESULTS

Consensus was reached among the experts and the literature review identified 9 relevant reports. The experts considered MAL-PDT a generally effective and safe therapy for treatment of BCC in Gorlin syndrome. For superficial BCC (sBCC), all sizes can be treated, and in nodular BCC (nBCC), better efficacy can be achieved in thinner lesions (<2 mm in thickness). MAL-PDT treatment schedule should be performed according to labelling although in individual cases, it may be adapted and performed on a monthly basis based on clinical assessment. Follow-up should be related to frequency of recurrence, and severity, number and location of lesions. Multiple lesions and large areas may be treated during the same session; however, adequate pain management should be considered.

CONCLUSIONS

MAL-PDT is safe and effective in patients with Gorlin syndrome. Utilization of these recommendations may improve efficacy and clearance rates in this population.

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.

Photodynamic therapy for actinic keratosis in organ transplant patients

BACKGROUND

The incidence of actinic keratoses (AK) and non-melanoma skin cancer (NMSC) in organ transplant recipients (OTRs) is significantly higher than in immunocompetent patients. Rates of progression and recurrence following treatment are higher too, in part due to the effects of the immunosuppressant drugs. Conventional therapies for AK, using curettage, cryotherapy, surgical excision, topical therapies and photodynamic therapy (PDT), are often less effective, and may be inappropriate, for treating the greater numbers and extent of lesions in OTRs. Moreover, there are no specific protocols for treating this patient population that take into account the need for more frequent treatment and the increased pain associated with treating larger areas.

OBJECTIVES

Recently, a pan-European group of dermatologists with expertise in this area met to share current best practice in PDT for the treatment of AK in OTRs.

METHODS

The group identified areas where PDT currently is not meeting the needs of these patients and discussed how these gaps might be addressed.

RESULTS/CONCLUSIONS

This position article summarizes those discussions and makes recommendations concerning a standardized protocol for treating OTRs, for a large randomized controlled trial to provide robust data on safety, efficacy and optimal pain control, and to provide pharmaco-economics data that can be used to support extended reimbursement in this patient group. The authors also recommend a second clinical trial to further investigate induced immunosuppression with PDT in healthy volunteers.

Psodisk, a new visual method for assessing the burden of psoriasis on patients

BACKGROUND

The last decades have witnessed an increasing interest for the psychosocial aspects of chronic skin diseases, such as psoriasis. Nonetheless, systematic assessments of the impact of psoriasis on patients' lives are rarely done in daily clinical practice. The existing instruments are mostly meant to be completed by patients alone, and rarely comprise a graphical representation of the results.

OBJECTIVE

To develop a questionnaire allowing both a quick assessment of the impact of psoriasis on patients and, at the same time, an intuitive graphic visualization of the outcome of the test.

METHODS

A preliminary version of an Italian questionnaire aimed to assess the global impact of psoriasis on patients, meant to be filled in together by the patient and the dermatologist and to produce visual, intuitive results, was developed through focus groups. The instrument was then the object of a Delphi survey addressed to a panel of experts, to assess both the need of possible improvements of the questionnaire (in terms of the formulations of the questions and of the domains to be explored) and the usefulness of the questionnaire.

RESULTS

A 10-item questionnaire in Italian, taking into account different aspects of the burden of psoriasis on the patient, was developed. The answers are given on a 10-point visual analogue scale and graphically represented on a disc as a polygon.

CONCLUSIONS

A formal validation of the questionnaire and a study to assess potential clinical and psychological benefits of a systematic implementation of the instrument in daily practice are planned.