Letter: Human papilloma virus and molluscum contagiosum lesions related to infliximab therapy for psoriasis: a case series.

INTRODUCTION: Biological therapy for psoriasis exerts its action via an immunomodulatory and eventually immunosuppressive mode. Immunosuppression is linked to HPV flares. Our purpose is to investigate a possible relationship between infliximab therapy for psoriasis and human papilloma virus and molluscum (HPV/MC) infections. METHODS: We report a case series of three patients with psoriasis on infliximab, who developed HPV/MC lesions following their treatment. RESULTS: Our patients developed HPV/MC lesions within a few months after the initiation of infliximab infusions for psoriasis. DISCUSSION: Immunosuppresion is related to HPV/MC flares. Biological therapy and in particular infliximab treatment acts by immunomodulation and eventually a degree of immunosuppression. CONCLUSIONS: Anti-TNF treatment could be associated with HPV and/or MC flares. For this reason, we suggest the consideration of obtaining a routine cervical PAP smear before the commencement and during treatment with anti-TNF agents for psoriasis.

Pyoderma gangrenosum of the penis: a potentially dramatic skin disease.

We report the case of a 17-year-old boy who presented with penile ulceration and a urethral fistula that had failed to heal after plastic reconstructions with skin grafts. The patient had a history of pathergy, because the initial lesion was an ulcer that deteriorated and led to the development of the fistula after surgical interventions for its repair. On the basis of the patient's history and normal laboratory evaluation findings, the diagnosis of penile pyoderma gangrenosum was made, and the patient began corticosteroids and cyclosporine. Four months after treatment initiation, the penile area was free of inflammation and ulceration.

Pimecrolimus 1% cream in non-specific inflammatory recurrent balanitis.

BACKGROUND: Non-specific balanitis is a common inflammatory dermatosis with frequent relapses and considerable impact on male sexual life. OBJECTIVE: To evaluate the efficacy and safety of pimecrolimus 1% cream in recurrent non-specific balanitis. METHODS: Twenty-six patients with recurrent flares of non-specific balanitis were randomly assigned to 1 group applying pimecrolimus cream 1% and 1 group applying placebo on the glans twice daily for 7 days. The patients were assessed on day 14. They were instructed to continue applying the agent whenever symptoms initialized for the following 90 days and take account of the cumulative days with symptoms. RESULTS: Seven out of the 11 (63.6%) patients in the pimecrolimus group and 1 out of 11 (9%) in the control group were free of all symptoms and lesions after 14 days, 3 (27.3%) in both groups reported improvement, while 1 (9.1%) in the pimecrolimus and 7 (63.6%) in the control group remained unaffected. (chi(2) = 9.0, d.f. = 2, p = 0.011). Days with symptoms during the 90-day follow-up period were 7.50 +/- 3.02 for the pimecrolimus and 17.62 +/- 4.40 for the control group (p = 0.000064). CONCLUSIONS: Pimecrolimus 1% cream is promising in relieving symptoms and signs of non-specific balanitis during flares and controlling the disease during long-term follow-up.

Oral inosiplex in the treatment of cervical condylomata acuminata: a randomised placebo-controlled trial.

Conventional therapies for human papillomavirus infection aim to remove clinically apparent lesions, while latent infection may remain, representing a threat for transmission and carcinogenesis. The use of a systemic agent may more effectively control the virus. We conducted a randomised placebo-controlled study to investigate the efficacy and safety of oral inociplex in the treatment of cervical condylomata acuminata (CA) that had been resistant to conventional therapies. Thirty-eight white European women, aged 20-43 years, with genital warts of the cervix, refractory to at least one conventional therapy, were randomly assigned to receive either inosiplex, 50 mg/kg daily peros for 12 weeks (group 1), or placebo (group 2). Of the 17 evaluable group 1 women, 4 responded to the treatment completely, 7 responded partially and 6 did not respond. Of the 19 group 2 women, none responded to the treatment completely, 3 responded partially and 16 did not respond. The therapeutic difference between women receiving active and placebo therapy was statistically significant (chi(2)= 6.69, P < 0.01) and remained significant when an intention-to-treat analysis was performed (chi(2)= 7.69, P < 0.01). None of the complete responders experienced recurrence during the 12-month follow up. Adverse effects were mild and resolved upon completion of therapy. Compared with placebo, inosiplex showed considerable efficacy with insignificant and reversible adverse effects and without recurrences. Inosiplex may represent an efficacious and safe alternative systemic form of therapy for cervical genital warts.

Oral isotretinoin in the treatment of recalcitrant condylomata acuminata of the cervix: a randomised placebo controlled trial.

BACKGROUND: Conventional therapies for human papillomavirus (HPV) infection are often associated with unsatisfactory response rates and high recurrence rates. The use of a systemic agent may more effectively control the virus. OBJECTIVES: To investigate the efficacy and safety of low dose oral isotretinoin in recalcitrant condylomata acuminata (RCA) of the cervix. METHODS: Double blind placebo controlled clinical trial. 60 women, aged 21-43 years, with RCA of the cervix, refractory to at least one conventional therapy, were randomly assigned to receive either isotretinoin, 0.5 mg/kg daily for 12 weeks (group 1), or placebo (group 2). RESULTS: Of the 28 evaluable group 1 patients, nine (32.1%) responded to the treatment completely, 11 (39.2%) responded partially, and eight (28.5%) did not respond. Of the 25 group 2 patients, no one responded to the treatment completely, two (8%) responded partially, and 23 (92%) did not respond. The therapeutic difference between patients receiving active and placebo therapy was statistically significant (chi(2) = 19.35, p<0.001). Only one (11.1%) of the complete responders experienced recurrence during the 12 month follow up. Side effects were generally mild and resolved upon completion of therapy. CONCLUSIONS: Compared to placebo, low dose oral isotretinoin showed considerable efficacy with insignificant and reversible side effects and a low recurrence rate. Isotretinoin may represent an efficacious and safe alternative systemic form of therapy for RCA of the cervix.

Pretibial myxedema as the initial manifestation of Graves' disease.

Pretibial myxedema (PM) is a localized thickening of the pretibial skin due to accumulation of acid mucopolysacharides (glycosaminoglycans). Its pathogenesis is still under investigation. Pretibial myxedema, exophthalmus and thyroid acropachy are the dassic extrathyroidal manifestations of Graves' disease. Almost invariably, PM follows the onset of ophthalmopathy, developing after the diagnosis and treatment of hyperthyroidism. Pretibial myxedema preceding Graves' ophthalmopathy is rare. We report the case of a 28-year-old Greek woman, who presented with multiple, asymptomatic nodules and plaques of the lower legs in the absence of other physical findings. Histopathologic examination revealed deposition of mucopolysacharides in the lower dermis. Laboratory investigation showed elevated serum T3 and T4 and depressed TSH levels. In our patient, pretibial myxedema was the earliest manifestation, leading to the diagnosis of Graves' disease.

Persistent pigmented purpuric eruption associated with mycosis fungoides: a case report and review of the literature.

A purpuric eruption may be an unusual early manifestation of mycosis fungoides (MF). On the other hand, persistent pigmented purpuric dermatoses (PPPD) may, occasionally, evolve to cutaneous T-cell lymphoma. Coexistence of these two conditions has been reported, but it is extremely rare. We present the case of an elderly woman with a long-standing pruritic, pigmented purpuric eruption. On 1-year follow-up, histological features suggesting early MF were observed and molecular analysis of the rearrangement of T-cell receptor genes revealed clonality. Our patient may represent a case of PPPD evolving to MF, a case of MF clinically featuring PPPD, or an intermediate condition in a nosological continuity extending from PPPD to MF. A persistent pigmented purpuric eruption may rarely be a harbinger of cutaneous T-cell lymphoma. Therefore, vigilant long-term follow-up of PPPD is highly recommended.

Increased density of Demodex folliculorum and evidence of delayed hypersensitivity reaction in subjects with papulopustular rosacea.

BACKGROUND: Rosacea is a common chronic dermatosis that evolves in stages. The mite Demodex folliculorum has been implicated in its obscure aetiopathogenesis. AIM: To evaluate the importance of D. folliculorum in the aetiology and course of rosacea. METHODS: We studied 92 consecutive cases of papulopustular rosacea and 92 age- and sex-matched controls. Prevalence and density of D. folliculorum were estimated by microscopic examination of the expressed follicular content. Histological examination and immunohistochemical study of the inflammatory infiltrate were performed in 10 subjects (five with positive D. folliculorum finding and five with negative finding). RESULTS: D. folliculorum was detected in 83 (90.2%) of the 92 rosacea subjects but only 11(11.9%) of the controls. The mean mite density was 2.03 mites/visual field in the rosacea group (range 0-5, SD = 1.2) and 0.16 mites/visual field (range 0-2, SD = 0.52) in the control group. The difference was statistically significant (P < 0.0001) for both mite prevalence and density. Hair follicle infestation was associated with intense perifollicular infiltrate of predominantly (90-95%) CD4 helper/inducer T cells. We observed an increased number of macrophages and Langerhans cells only in those subjects with a positive D. folliculorum finding. CONCLUSIONS: Although Demodex mites do not seem to be the cause of rosacea, they may represent an important cofactor, especially in papulopustular rosacea. Immunohistochemical findings suggest that a delayed hypersensitivity reaction, possibly triggered by antigens of follicular origin, probably related to D. folliculorum, may occur, stimulating progression of the affection to the papulopustular stage.

L-carnitine supplementation in patients with cystic acne on isotretinoin therapy.

BACKGROUND: Patients with cystic acne (CA) on Isotretinoin (Iso) therapy might present muscular symptoms as side effect of the drug. Myalgia, weakness, hypotension are also some of the main characteristics of carnitine (car) deficiency. METHODS: Two hundred and thirty (N = 230) patients with CA were treated with Isotretinoin (0.5 mg/kg per 24 h). All the patients were requested to visit our out-patient department at the onset of muscular symptoms. Laboratory tests including car (total, free, acylcarnitine) were determined in blood and urine before treatment, at the onset of muscular symptoms and after the end of a 45 day study. Fifty percent of the patients with muscular involvement received L-carnitine (100 mg/kg per 24 h per os) (group C) and 50% placebo (group P). RESULTS: Their laboratory tests showed the well known increases of their liver enzymes and lipids, whereas car blood levels were remarkably decreased at the onset of their muscular symptoms and or at the end of the study. Their supplementation with L-car, in patients of group C (N = 20) without Iso discontinuation or reduction, resulted in the disappearance of their muscular symptoms within 5-6 days and normalisation not only of the increased levels of their liver enzymes but also those of car, at the 45 day of their therapy. Additionally, the patients who received placebo (group P, N = 20) continued complaining for mualgias. The rest of the patients (group A, N = 190) did not experience any muscular symptoms, their laboratory tests showed elevation of liver enzymes and lipids and a decrease in car levels in the blood whereas a remarkable increase of car excretion was determined in their urine. CONCLUSIONS: Iso therapy decreases car blood levels in patients with CA. L-car supplementation might treat liver and muscular side effects of the drug. These hopeful preliminary results need further investigation.