Topical and Intralesional Therapies for Hidradenitis Suppurativa: A Systematic Literature Review.

BACKGROUND AND OBJECTIVE: Topical and intralesional (IL) treatments may be considered the first-line therapy in patients with hidradenitis suppurativa (HS); however, the evidence supporting their use is limited. The aim of our review is to evaluate the efficacy and safety profile of topical and IL treatments in patients with HS. MATERIALS AND METHODS: We designed a systematic review of the current medical literature available following the PICO(T) method. And including all types of studies (Study type [T]) of individuals with HS of any sex, age, and ethnicity (Population [P]) who received any topical or IL treatment for HS (Intervention [I]) compared to placebo, other treatments, or no treatment at all (Comparator [C]), and reported efficacy and/or safety outcomes (Outcomes [O]). Two outcomes were defined: quality of life and the no. of patients with, at least, one adverse event. The search was conducted in the Cochrane Library, MEDLINE, and EMBASE databases; study selection was performed based on pre-defined criteria. The risk of bias was determined in each study. RESULTS: We obtained a total of 11,363 references, 31 of which met the inclusion criteria. These studies included 1143 patients with HS, 62% of whom were women. A total of 10, 8, 6, 2, and 5 studies, respectively, evaluated the use of photodynamic therapy (PDT), glucocorticoids, resorcinol, topical antibiotics, and other interventions. Most articles were case series (n=25), with only five randomized clinical trials (RCTs) and one cohort study. RCTs showed improvement in disease activity with topical clindamycin and botulinum toxin (BTX) vs placebo, and PDT with methylene blue (MB) niosomal vs free MB; however, intralesional triamcinolone acetonide was not superior to placebo. The risk of bias was low in three RCTs and high in two RCTs. CONCLUSION: The quality of evidence supporting the use of topical, or IL treatments is low. However, it supports the use of topical clindamycin, PDT, and BTX. Well-designed RCTs with standardized outcomes and homogeneous populations of patients and lesions are needed to support decision-making in the routine clinical practice.

Prevalence of ankylosing spondylitis in Spain: EPISER2016 Study.

Objective: The aim of this study was to estimate the prevalence of ankylosing spondylitis (AS) in Spain.Method: This is a cross-sectional, population-based study of people aged 20 years or older in Spain. Randomly selected individuals were contacted by telephone and rheumatic disease screening was performed. If the first screening was positive, medical records were then reviewed and/or a telephone questionnaire was conducted by a rheumatologist, followed by an appointment if necessary. Cases had to fulfil the modified New York (mNY) criteria.Results: In total, 4916 individuals were included, of whom 355 had a positive screening result for AS. Of these, 11 were classified as AS. An additional individual who reported a prior diagnosis of rheumatoid arthritis had a diagnosis of AS confirmed on review of the medical records. Estimated prevalence was 0.26% (95% CI 0.14-0.49).Conclusion: EPISER2016 is the first population-based study to estimate the prevalence of AS in Spain, which has been estimated as being similar to that in other European countries.

European League Against Rheumatism recommendations for calcium pyrophosphate deposition. Part I: terminology and diagnosis.

OBJECTIVES: To agree terminology and to develop recommendations for the diagnosis of calcium pyrophosphate deposition (CPPD). METHODS: The European League Against Rheumatism (EULAR) CPPD Task Force, comprising 15 experts from 10 countries, agreed the terms and recommendations for diagnosis of CPPD using a Delphi consensus approach. Evidence was systematically reviewed and presented in terms of sensitivity, specificity and positive likelihood ratio (LR) to support diagnosis; ORs were used for association. Strength of recommendation (SOR) was assessed by the EULAR visual analogue scale. RESULTS: It was agreed that 'CPPD' should be the umbrella term that includes acute calcium pyrophosphate (CPP) crystal arthritis, osteoarthritis (OA) with CPPD and chronic CPP crystal inflammatory arthritis. Chondrocalcinosis (CC) defines cartilage calcification, most commonly due to CPPD and detected by imaging or histological examination. A total of 11 key recommendations were generated on the topics of clinical features, synovial fluid (SF) examination, imaging, comorbidities and risk factors. Definitive diagnosis of CPPD relies on identification of SF CPP crystals. Rapid onset inflammatory symptoms and signs are suggestive but not definitive for acute CPP crystal arthritis. Radiographic CC is not highly sensitive or specific, whereas ultrasonography appears more useful (LR=24.2, 95% CI 3.51 to 168.01) for peripheral joints. Recognised risk factors for CPPD include ageing, OA and metabolic conditions such as primary hyperparathyroidism, haemochromatosis and hypomagnesaemia; familial forms are rare. SORs varied from 53 to 99 (maximum 100). CONCLUSION: New terms for CPPD were agreed and 11 key recommendations for diagnosis of CPPD were developed using research evidence and expert consensus.

EULAR recommendations for calcium pyrophosphate deposition. Part II: management.

OBJECTIVES: To develop evidence-based recommendations for management of calcium pyrophosphate deposition (CPPD). METHODS: A multidisciplinary guideline development group of 15 experts, representing 10 European countries, generated key propositions for management of CPPD using a Delphi consensus approach. For each recommendation research evidence was searched systematically. Whenever possible, the effect size and number needed to treat for efficacy and RR or OR for side effects were calculated for individual treatment modalities. Strength of recommendation was assessed by the European League Against Rheumatism visual analogue scale. RESULTS: Nine key recommendations were generated, including topics for general management, treatment of acute attacks, prophylaxis against recurrent acute attacks and management of chronic symptoms. It was recommended that optimal treatment requires both non-pharmacological and pharmacological treatments. For acute CPP crystal arthritis, cool packs, temporary rest and joint aspiration combined with steroid injection are often sufficient. For prophylaxis or chronic inflammatory arthritis with CPPD, oral non-steroidal anti-inflammatory drugs with gastroprotective treatment and/or low-dose colchicine 0.5-1.0 mg daily may be used. Other recommendations included parenteral or oral corticosteroid for acute CPP arthritis in those unresponsive or unsuited to other measures, and low-dose corticosteroid, methotrexate or hydroxychloroquine for chronic inflammatory arthritis with CPPD. Asymptomatic CPPD requires no treatment. Strength of recommendations varies from 79% to 95%. CONCLUSION: Nine key recommendations for management of CPP crystal associated arthritis were developed using both research evidence and expert consensus. Strength of recommendations was provided to assist the application of these recommendations.

MRI and clinical findings in patients with ankylosing spondylitis eligible for anti-tumour necrosis factor therapy after a short course of etoricoxib.

OBJECTIVE: To describe and assess the response to short-term etoricoxib as shown by MRI and clinical variables in patients with ankylosing spondylitis (AS) selected for eligibility for anti-tumour necrosis factor therapy. METHODS: In a 6-week open-label study, 22 patients with AS and eligible for biological therapy were treated with 90 mg of etoricoxib daily. Clinical and laboratory parameters were obtained and MRI of the sacroiliac joints and the lower thoracic and lumbar spine performed at baseline and at week 6. The primary end point was the proportion of patients fulfilling the SpondyloArthritis international Society (ASAS) response criteria for biological therapies (ASASBIO) while secondary end points included the change in MRI-determined bone lesions. RESULTS: Eight of 20 completers improved enough to meet the ASASBIO response criteria and most clinical variables improved significantly. Fifteen patients had a total of 63 MRI-detectable lesions; overall, 13/60 lesions with paired scans either resolved completely or improved, while five lesions worsened or appeared during treatment. CONCLUSION: Etoricoxib is an effective symptomatic treatment for patients with AS; however, its effect on MRI-detected lesions is small. Further studies are needed to determine the effect of etoricoxib on MRI-determined bone oedema.

Severity of baseline magnetic resonance imaging-evident sacroiliitis and HLA-B27 status in early inflammatory back pain predict radiographically evident ankylosing spondylitis at eight years.

OBJECTIVE: Magnetic resonance imaging (MRI) is increasingly used to detect sacroiliitis earlier. This study was undertaken to investigate what proportion of patients with MRI-evident sacroiliitis develop ankylosing spondylitis (AS) in the long term and whether there are predictors of outcome. METHODS: Consecutive undiagnosed patients with early inflammatory back pain (IBP) (of <2 years' duration) were assessed clinically and radiologically. Baseline imaging assessments included fat-suppressed MRI sequences of the sacroiliac joints and lumbar spine that were scored for active bone marrow edema representative of acute inflammation, and anteroposterior radiographs of the pelvis and lateral radiographs of the lumbar spine, which were scored using the Stoke Ankylosing Spondylitis Spine Score. Patients were reassessed clinically and radiographically after 8 years. The primary outcome was the modified New York criteria for AS at followup. RESULTS: Fifty patients were assessed at the beginning of the study, and 40 patients were followed up after a mean of 7.7 years. Of these 40 patients, 58% were HLA-B27 positive, and 98% met the European Spondylarthropathy Study Group criteria. At baseline, 33 (83%) of the 40 patients followed up had MRI-evident sacroiliitis, and 6 (12%) had unequivocal AS according to the modified New York criteria. At followup, despite significant improvements in clinical outcomes, 13 of 39 patients (33.3%) had AS according to the modified New York criteria. The combination of severe sacroiliitis seen on MRI with HLA-B27 positivity was an excellent predictor of future AS (likelihood ratio [LR] 8.0, specificity 92%), while mild or no sacroiliitis, regardless of HLA-B27 status, was a predictor of not having AS (LR 0.4, specificity 38%). CONCLUSION: Our findings indicate that in patients with early IBP, a combination of severe sacroiliitis and HLA-B27 positivity has a high specificity for development of AS, compared with mild or no sacroiliitis, regardless of HLA-B27 status, which confers a low likelihood of developing AS. This has implications for the diagnosis of "early" AS and possibly for selection of more aggressive therapies.

First metatarsophalangeal joint aspiration using a 29-gauge needle.

OBJECTIVES: To asses the clinical feasibility of aspirating symptomatic and asymptomatic first metatarsophalangeal (MTP) joints with a 29-gauge needle in order to obtain a synovial fluid (SF) sample. METHODS: All consecutive aspirations of first MTP joints performed within our department were prospectively recorded. The procedure was considered successful if SF volume was enough to perform a crystal search. Crystals were identified using a polarised light microscope (magnification x400) with a first order red compensator. Pain was recorded on a 10-cm visual analogue scale (VAS). RESULTS: Aspirations were attempted in 33 first MTP joints in 31 patients. SF was drawn from 30 of the joints (91%), with little difference between asymptomatic (89%) and inflamed joints (93%). The technique was well tolerated (mean VAS 1.74). Urate monosodium crystals were identified in 22 samples (73%) and another sample contained calcium pyrophosphate dihydrate crystals. CONCLUSIONS: A 29-gauge needle allows easy aspiration of the first MTP joint with only modest discomfort for the patients, and generally yields a SF sample of sufficient volume for crystal detection and identification.