Lymecycline vs. clindamycin plus rifampicin in hidradenitis suppurativa treatment: clinical and ultrasonography evaluation.

BACKGROUND: Antibiotic therapy remains the first-line treatment for hidradenitis suppurativa (HS). However, literature data on its comparative clinical efficacy and safety are limited. AIM: To investigate the efficacy of tetracycline (lymecycline 300 mg daily) vs. the combination therapy clindamycin and rifampicin (600 mg plus 600 mg daily) by evaluating and comparing the clinical response at the end of antibiotic treatment (10 weeks). METHODS: The study retrospectively analysed 52 patients divided in two groups of 26 patients: Group A received lymecycline and Group B received clindamycin plus rifampicin for 10 weeks. Subjects had mild, moderate and severe HS. The clinical and ultrasonography extent of disease was measured by the Hurley Score, Sonographic Score of Hidradenitis Suppurativa, International Hidradenitis Suppurativa Severity Score System (IHS4), pain visual analogue scale (pain VAS) and Dermatology Life Quality Index (DLQI). The primary outcome was the clinical response at the end of the antibiotic treatment period, according to the Hidradenitis Suppurativa Clinical Response measure. RESULTS: Both groups showed a significant improvement in IHS4, pain VAS and DLQI from baseline, but this was more marked in Group A. Reductions in nodule counts were similar between the two groups, whereas the number of abscesses and draining tunnels decreased more in Group B. Disease-free survival was similar between the two groups. CONCLUSION: Lymecycline monotherapy and clindamycin plus rifampicin combination are both effective treatments for patients with moderate-severe HS. Nodular-type HS seems to respond better to lymecycline, whereas the abscess/tunnel type seems to respond better to clindamycin plus rifampicin.

Ultrasonography in the pathway to an optimal standard of care of hidradenitis suppurativa: the Italian Ultrasound Working Group experience.

BACKGROUND: Ultrasound (US) is a real-time non-invasive technique that has been demonstrated to support an early diagnosis and a more precise assessment of hidradenitis suppurativa (HS). OBJECTIVES: To compare the clinical and US evaluation of a series of HS patients. METHODS: 434 HS patients (259 F, 175 M; mean age 33.82 ±13.31 years) observed across 19 Italian dermatology centres [members of the Italian Ultrasound Working Group (IUWG)] were enrolled in a retrospective study. Clinical staging was obtained by the Hidradenitis Suppurativa Physician's Global Assessment score (HS-PGA), while the ultrasonographic staging was determined by the US HS-PGA, based on the same scores as clinical HS-PGA but performed with the aid of US. RESULTS: At the end of the study, the mean clinical and US HS-PGA scores were 2.70 and 2.92, respectively. Direct comparison of clinical and ultrasonographic assessment revealed that a higher proportion of patients was classified as having moderate and very severe disease by US. In particular, 117 patients (26.96%) had a worse classification by US HS-PGA compared to clinical assessment. CONCLUSION: Our findings confirm that the use of clinical grading only to assess HS severity may underestimate the real disease severity. US examination can be considered an essential non-invasive imaging tool available to dermatologists for a more accurate diagnosis, staging, treatment planning and monitoring of HS and should be included in the pathway to an optimal standard of care of HS.

Hidradenitis suppurativa in a prepubertal case series: a call for specific guidelines.

Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory disease associated with a high physical and psychological burden. It is a disorder of the infundibular segment of the pilosebaceous unit, characterized by subcutaneous nodules, abscesses, sinus tracts and scar formation on the intertriginous and apocrine-bearing areas. HS is quite rare in young and prepubertal children. It usually begins after puberty, but several reports of prepubertal HS onset have been described. These cases are strongly linked to hormonal disorders and genetic susceptibility. Specific guidelines for prepubertal patients are still lacking, so further studies are warranted to better delineate a tailored approach. This paper aims to summarize the most significant aspects, as well as the most recent information about the epidemiology, pathogenesis, clinical features, diagnosis, comorbidities and treatment of paediatric HS. In addition, we report our clinical experience in managing HS in a group of eight prepubertal patients based on systemic antibiotics (azithromycin) and zinc oral supplementation.

Sex-related differences of clinical features in hidradenitis suppurativa: analysis of an Italian-based cohort.

The clinical characteristics associated with hidradenitis suppurativa (HS) severity are poorly understood. In this study, 124 patients with HS from 6 Italian dermatology centres participated in this study. Disease severity was assessed using the Hidradenitis Suppurativa Physician's Global Assessment score (HS-PGA) and Hurley score. The impact of clinical characteristics on disease severity was assessed by logistic regression. Clinical characteristics were similar between men (n = 53) and women (n = 71). Disease severity was also similar; 75% of the patients had Hurley stage II or III disease, and > 60% had moderate, severe or very severe HS as judged by HS-PGA. Lesions were more frequent in the gluteal region in men (32.3% in men vs. 8.7% in women, P < 0.001) and more frequent on the breast in women (16.3% in women vs. 4.6% in men, P = 0.02). Obesity was associated with increased disease severity as measured by HS-PGA (OR: 3.28, 95% CI 1.55-6.95, P < 0.01) and Hurley classification (OR: 3.22, 95% CI 1.34-7.31, P < 0.01). Although severity of HS is similar between the sexes, the localization of lesions is different.

The effect of low-carbohydrates calorie-restricted diet on visceral adipose tissue and metabolic status in psoriasis patients receiving TNF-alpha inhibitors: results of an open label controlled, prospective, clinical study.

OBJECTIVE: TNF alpha inhibitors are usually associated with anthropometric changes over the time, however whether and how the visceral adipose tissue (VAT) is involved in this phenomenon, still remains unclear. Aim of the study is to evaluate if the increases in trunk fat percentage (TF%) and VAT are directly involved in anthropometric changes occurring during treatment, and whether and how a calorie restricted diet could prevent these changes. MATERIAL AND METHODS: Twenty patients receiving TNF-alpha inhibitors for psoriasis was evaluated at baseline (T0) and after 24 weeks of therapy (T24), and then compared with 25 patients receiving a combined treatment based on TNF alpha inhibitors and low-carbohydrates calorie-restricted diet. RESULTS: TNF-alpha inhibitors do not influence the VAT expression. The combined treatment is associated with a significant decrease in body weight (kg) (p < .0001), BMI (p = .0001), WC (cm) (p < .0001), TF% (p < .0001), VAT (p < .0001), serum levels of triglycerides (mg/dL) (p = .0018) and total cholesterol (mg/dL) (p = .0005). CONCLUSIONS: The administration of TNF-alpha inhibitors can induce anthropometric changes after 24 weeks, but it does not cause an increase in VAT. The association between low-carbohydrates calorie-restricted diet and anti-TNF-alpha therapy seems to be able to improve the anthropometric profile of psoriasis patients.

Ingenol mebutate in actinic keratosis: a clinical, videodermoscopic and immunohistochemical study.

BACKGROUND: Actinic keratosis (AK) is a cutaneous intraepithelial neoplasm that typically develops on sun-damaged skin. The incidence of AK is increasing worldwide, and it is accepted as the most frequent pre-malignant lesion in humans. OBJECTIVES: To demonstrate that ingenol mebutate gel is effective in the treatment of actinic keratoses because of its clinical, dermoscopic, capillaroscopic, histopathological and immunohistochemical treatment outcomes. METHODS: Sixty individuals with multiple non-hypertrophic AKs were enrolled into this non-randomized, open-label, prospective, trial. Acquisition of clinical, dermoscopic and capillaroscopic images at baseline (T0), immediately after treatment on 3rd (trunk and/or extremities) or 4th (scalp and/or face) day (T1), 14 days after the end of the treatment (T2) and at 60 days (T3). A subgroup of 20 patients received a cutaneous biopsy both at baseline and at T3 for histological and immunohistochemical evaluation. RESULTS: Clinical improvement was observed in 100% of cases: total clearance in 41 patients (68.3%); partial clearance in 19 patients (32.7%). After treatment, dermoscopic improvement of all non-pigmented and pigmented AK lesions was observed. Most of the dermoscopic features disappeared with treatment. Total disappearance of specific vascular structures or significant reduction in the number and calibre of new blood vessels was capillaroscopically observed in all patients analysed (P ≤ 0.001). The immunohistochemical expression of p63 (P = 0.002), Ki-67 (P = 0.015) and VEGF (P = 0.016) significantly decreased. CONCLUSIONS: The clinical efficacy of ingenol mebutate on AKs is confirmed by its effect on angiogenesis, stem cell activity and cell proliferation in vivo.

Biologic Therapy in Inflammatory and Immunomediated Skin Diseases: Safety Profile.

Biologic treatments have modified the therapeutic armamentarium in the treatment of many dermatological and non- dermatological diseases and data on literature have widely focused on the efficacy and safety of TNF-alpha inhibitors in psoriasis. Although the etiopathogenesis has not completely elucidated, inflammation appears the lait motif unifying the immune-pathogenesis of diverse skin disease, as atopic dermatitis, alopecia areata and hidradenitis suppurativa. Actually, data on the off-label use of biologics in cutaneous immune-mediated inflammatory diseases are scarce and restricted to anecdotal cases and case series. The present review aims to evidence the major off- label use of TNF-alpha inhibitors in dermatology.

Biologic Therapy in Immune Mediated Inflammatory Disease: Basic Science and Clinical Concepts.

During the last decades, the advent of biological therapies has revolutionized the management of several immune-mediated inflammatory disorders, as inflammatory bowel diseases, autoimmune arthritis and psoriasis, which significantly impact both quality of life and health care economics. Biological therapies currently available can be divided into two main categories: the tumor necrosis factor-α antagonists (infliximab, adalimumab, etanercept, golimumab, certolizumab pegol) and interleukin 12/23 monoclonal antibodies (ustekinumab). Biologics, reducing TNFα bioavailability or inhibiting proximal regulators of inflammatory cascade, represent an established therapeutic strategy of inflammatory autoimmune diseases, with remarkable efficacy and a safety profile that is extensively examined and monitored. The biology and the immunological effects of TNFα, IL-12, IL-23 and related signalling pathways are accurately summarized. The dosing regimens, methods of administration, pharmacodynamics profiles, and side effects of the currently licensed TNFα antagonists and IL12/IL23 inhibitor are discussed in detail.

Incarcerated uterine prolapse associated with a cul-de-sac abscess.

BACKGROUND: Incarceration is a rare complication of uterine prolapse and is usually associated with bladder calculi. We report a case of uterine incarceration associated with an abscess in the cul-de-sac. CASE: A 64-year-old woman presented with complaints of vaginal prolapse. Pelvic examination on admission revealed an edematous, prolapsed uterus and eversion of the vagina. The bladder was catheterized, and subsequent attempts to reduce the prolapse were unsuccessful. Conservative treatments were initiated including Trendelenburg positioning, estrogen cream, and moist soaks. Failure to reduce the prolapse under general anesthesia necessitated a vaginal hysterectomy and anteroposterior repair. When the cul-de-sac was entered, there was purulent material draining from an abscess behind the uterus. Postoperatively, the patient received antibiotics for 3 days and was sent home on day 4. CONCLUSIONS: Irreducible uterine prolapse is a rare condition and may be attributed to a narrowed introitus, bladder calculi, or pelvic abscesses. Historically, conservative management has attempted to alleviate the edema and restore the prolapse, to allow definitive surgery at a later date. We believe that the pelvic abscess in our case exemplifies a danger of delaying surgery. We recommended that when the patient is in stable condition, a hysterectomy and plastic repair be performed promptly.