Betsy Bates

PARIS — Chronic cutaneous inflammation associated with psoriasis may trigger a cascade of metabolic events leading to serious systemic diseases, including diabetes and coronary heart disease, Enno Christophers, M.D., asserted at the European Congress on Psoriasis 2004.

A complex interaction of genetics, environmental factors, and age contributes to development of psoriasis and psoriatic flares, said Dr. Christophers, professor of dermatology at the University of Kiel (Germany).

Similarly, multifactorial causes are responsible for diseases found more commonly in people with psoriasis than those with other skin conditions or other adults. Obesity and alcoholism, both elevated in patients with psoriasis, may be environmental contributors.

But in some cases, the inflammatory connection is clear. For example, a recent study found that 30% of patients with psoriasis have evidence of arthritis.

“This is an extremely high figure that we need to memorize,” Dr. Christophers said.

Crohn's disease is seen seven times more frequently in psoriasis patients than in patients with other skin diseases.

Evidence is building that chronic inflammation may also lead to development of insulin resistance and Syndrome X, characterized by hypertension, diabetes, adiposity, dyslipidemia, and coronary heart disease.

Patients with psoriasis suffer disproportionately from these conditions. Recent studies have shown that patients with severe psoriasis have a significantly elevated mortality rate from cardiovascular diseases.

In recently completed research, Dr. Christophers and associates at the University of Kiel found that hospitalized psoriasis patients have almost double the body mass index of other skin disease patients or of community controls.

They have sharply increased rates of hypertension and higher rates of diabetes in patients who are in their 40s (comparative P less than .001) and those in their 70s (P less than .001, with a prevalence of about 25%, compared with about 5% in patients with other skin diseases).

Longstanding systemic inflammation has an impact on endothelial function and lipids, both of which contribute to serious disease, Dr. Christophers stressed. Longstanding cutaneous inflammation may well have the same consequences.

The T-helper 1 response associated with psoriasis activates autoreactive T-cells, and may be compounded by environmental factors and diseases (streptococcal tonsillitis).

Therapies that activate a T-helper 2 response, such as biologics and fumaric acid esters, may dampen inflammation over the long term and protect patients from serious diseases, such as diabetes and heart disease.

PARIS — Chronic cutaneous inflammation associated with psoriasis may trigger a cascade of metabolic events leading to serious systemic diseases, including diabetes and coronary heart disease, Enno Christophers, M.D., asserted at the European Congress on Psoriasis 2004.

A complex interaction of genetics, environmental factors, and age contributes to development of psoriasis and psoriatic flares, said Dr. Christophers, professor of dermatology at the University of Kiel (Germany).

Similarly, multifactorial causes are responsible for diseases found more commonly in people with psoriasis than those with other skin conditions or other adults. Obesity and alcoholism, both elevated in patients with psoriasis, may be environmental contributors.

But in some cases, the inflammatory connection is clear. For example, a recent study found that 30% of patients with psoriasis have evidence of arthritis.

“This is an extremely high figure that we need to memorize,” Dr. Christophers said.

Crohn's disease is seen seven times more frequently in psoriasis patients than in patients with other skin diseases.

Evidence is building that chronic inflammation may also lead to development of insulin resistance and Syndrome X, characterized by hypertension, diabetes, adiposity, dyslipidemia, and coronary heart disease.

Patients with psoriasis suffer disproportionately from these conditions. Recent studies have shown that patients with severe psoriasis have a significantly elevated mortality rate from cardiovascular diseases.

In recently completed research, Dr. Christophers and associates at the University of Kiel found that hospitalized psoriasis patients have almost double the body mass index of other skin disease patients or of community controls.

They have sharply increased rates of hypertension and higher rates of diabetes in patients who are in their 40s (comparative P less than .001) and those in their 70s (P less than .001, with a prevalence of about 25%, compared with about 5% in patients with other skin diseases).

Longstanding systemic inflammation has an impact on endothelial function and lipids, both of which contribute to serious disease, Dr. Christophers stressed. Longstanding cutaneous inflammation may well have the same consequences.

The T-helper 1 response associated with psoriasis activates autoreactive T-cells, and may be compounded by environmental factors and diseases (streptococcal tonsillitis).

Therapies that activate a T-helper 2 response, such as biologics and fumaric acid esters, may dampen inflammation over the long term and protect patients from serious diseases, such as diabetes and heart disease.

PARIS — Chronic cutaneous inflammation associated with psoriasis may trigger a cascade of metabolic events leading to serious systemic diseases, including diabetes and coronary heart disease, Enno Christophers, M.D., asserted at the European Congress on Psoriasis 2004.

A complex interaction of genetics, environmental factors, and age contributes to development of psoriasis and psoriatic flares, said Dr. Christophers, professor of dermatology at the University of Kiel (Germany).

Similarly, multifactorial causes are responsible for diseases found more commonly in people with psoriasis than those with other skin conditions or other adults. Obesity and alcoholism, both elevated in patients with psoriasis, may be environmental contributors.

But in some cases, the inflammatory connection is clear. For example, a recent study found that 30% of patients with psoriasis have evidence of arthritis.

“This is an extremely high figure that we need to memorize,” Dr. Christophers said.

Crohn's disease is seen seven times more frequently in psoriasis patients than in patients with other skin diseases.

Evidence is building that chronic inflammation may also lead to development of insulin resistance and Syndrome X, characterized by hypertension, diabetes, adiposity, dyslipidemia, and coronary heart disease.

Patients with psoriasis suffer disproportionately from these conditions. Recent studies have shown that patients with severe psoriasis have a significantly elevated mortality rate from cardiovascular diseases.

In recently completed research, Dr. Christophers and associates at the University of Kiel found that hospitalized psoriasis patients have almost double the body mass index of other skin disease patients or of community controls.

They have sharply increased rates of hypertension and higher rates of diabetes in patients who are in their 40s (comparative P less than .001) and those in their 70s (P less than .001, with a prevalence of about 25%, compared with about 5% in patients with other skin diseases).

Longstanding systemic inflammation has an impact on endothelial function and lipids, both of which contribute to serious disease, Dr. Christophers stressed. Longstanding cutaneous inflammation may well have the same consequences.

The T-helper 1 response associated with psoriasis activates autoreactive T-cells, and may be compounded by environmental factors and diseases (streptococcal tonsillitis).

Therapies that activate a T-helper 2 response, such as biologics and fumaric acid esters, may dampen inflammation over the long term and protect patients from serious diseases, such as diabetes and heart disease.

PARIS — Combining agents with complementary mechanisms and pharmacokinetic profiles may hold promise even for patients with severe psoriatic arthritis who have been failed by every other form of therapy.

German researchers used that approach, combining leflunomide (Arava) and etanercept (Enbrel) in two severely affected patients, with excellent results.

Jochen Schmitt, M.D., and Gottfried Wozel, M.D., of the department of dermatology at University Hospital Carl Gustav Carus of Dresden University of Technology presented their findings at the European Congress on Psoriasis 2004.

Confronted with patients who had severe swollen and tender joints, extensive psoriatic plaques, and profoundly affected quality of life and for whom an array of therapeutic options had failed, they decided to combine leflunomide and etanercept.

“The rationale of the combination is based on the predominant role of T cells and proinflammatory cytokines such as TNF-α in the pathogenesis of psoriasis,” they noted in a poster presentation.

“The active metabolite of leflunomide interferes with T-cell proliferation by inhibition of dihydroorotate dehydrogenase, a key enzyme of pyrimidine de novo synthesis,” and etanercept, a TNF-αreceptor, P75 fusion protein, blocks biologic activity to TNF-αaccording to the investigators.

Leflunomide was prescribed at an initial dosage of 100 mg for 3 days, then tapered to 20 mg and then to 10 mg. Patients received etanercept in 25-mg, twice-weekly subcutaneous injections.

The response was dramatic during the course of the 8-week study period and a follow-up period that extended 20 more weeks. The first patient went from 32 swollen and 30 tender joints, a Psoriasis Area and Severity Index (PASI) score of 52.6; and a Dermatology Life Quality Assessment score (DLQI) of 19, to 9 swollen and 8 tender joints, a PASI score of 1.8, and a DLQI score of 3.

The second patient was less severely affected at baseline but exhibited a complete remission. Specifically, she went from nine swollen and nine tender joints to zero; her PASI score dropped from 17.6 to 0, and her DLQI score declined from 3 to 0.

The researchers commented on the two drugs' complementary pharmacokinetic profiles.

“Leflunomide's active metabolite exhibits an extremely long half-life in vivo. Etanercept features an early onset of efficacy. Thus, in severe psoriasis, it might be reasonable to use leflunomide as a basic agent and to add etanercept when a relapse occurs,” Dr. Schmitt said.

PARIS — Combining agents with complementary mechanisms and pharmacokinetic profiles may hold promise even for patients with severe psoriatic arthritis who have been failed by every other form of therapy.

German researchers used that approach, combining leflunomide (Arava) and etanercept (Enbrel) in two severely affected patients, with excellent results.

Jochen Schmitt, M.D., and Gottfried Wozel, M.D., of the department of dermatology at University Hospital Carl Gustav Carus of Dresden University of Technology presented their findings at the European Congress on Psoriasis 2004.

Confronted with patients who had severe swollen and tender joints, extensive psoriatic plaques, and profoundly affected quality of life and for whom an array of therapeutic options had failed, they decided to combine leflunomide and etanercept.

“The rationale of the combination is based on the predominant role of T cells and proinflammatory cytokines such as TNF-α in the pathogenesis of psoriasis,” they noted in a poster presentation.

“The active metabolite of leflunomide interferes with T-cell proliferation by inhibition of dihydroorotate dehydrogenase, a key enzyme of pyrimidine de novo synthesis,” and etanercept, a TNF-αreceptor, P75 fusion protein, blocks biologic activity to TNF-αaccording to the investigators.

Leflunomide was prescribed at an initial dosage of 100 mg for 3 days, then tapered to 20 mg and then to 10 mg. Patients received etanercept in 25-mg, twice-weekly subcutaneous injections.

The response was dramatic during the course of the 8-week study period and a follow-up period that extended 20 more weeks. The first patient went from 32 swollen and 30 tender joints, a Psoriasis Area and Severity Index (PASI) score of 52.6; and a Dermatology Life Quality Assessment score (DLQI) of 19, to 9 swollen and 8 tender joints, a PASI score of 1.8, and a DLQI score of 3.

The second patient was less severely affected at baseline but exhibited a complete remission. Specifically, she went from nine swollen and nine tender joints to zero; her PASI score dropped from 17.6 to 0, and her DLQI score declined from 3 to 0.

The researchers commented on the two drugs' complementary pharmacokinetic profiles.

“Leflunomide's active metabolite exhibits an extremely long half-life in vivo. Etanercept features an early onset of efficacy. Thus, in severe psoriasis, it might be reasonable to use leflunomide as a basic agent and to add etanercept when a relapse occurs,” Dr. Schmitt said.

PARIS — Combining agents with complementary mechanisms and pharmacokinetic profiles may hold promise even for patients with severe psoriatic arthritis who have been failed by every other form of therapy.

German researchers used that approach, combining leflunomide (Arava) and etanercept (Enbrel) in two severely affected patients, with excellent results.

Jochen Schmitt, M.D., and Gottfried Wozel, M.D., of the department of dermatology at University Hospital Carl Gustav Carus of Dresden University of Technology presented their findings at the European Congress on Psoriasis 2004.

Confronted with patients who had severe swollen and tender joints, extensive psoriatic plaques, and profoundly affected quality of life and for whom an array of therapeutic options had failed, they decided to combine leflunomide and etanercept.

“The rationale of the combination is based on the predominant role of T cells and proinflammatory cytokines such as TNF-α in the pathogenesis of psoriasis,” they noted in a poster presentation.

“The active metabolite of leflunomide interferes with T-cell proliferation by inhibition of dihydroorotate dehydrogenase, a key enzyme of pyrimidine de novo synthesis,” and etanercept, a TNF-αreceptor, P75 fusion protein, blocks biologic activity to TNF-αaccording to the investigators.

Leflunomide was prescribed at an initial dosage of 100 mg for 3 days, then tapered to 20 mg and then to 10 mg. Patients received etanercept in 25-mg, twice-weekly subcutaneous injections.

The response was dramatic during the course of the 8-week study period and a follow-up period that extended 20 more weeks. The first patient went from 32 swollen and 30 tender joints, a Psoriasis Area and Severity Index (PASI) score of 52.6; and a Dermatology Life Quality Assessment score (DLQI) of 19, to 9 swollen and 8 tender joints, a PASI score of 1.8, and a DLQI score of 3.

The second patient was less severely affected at baseline but exhibited a complete remission. Specifically, she went from nine swollen and nine tender joints to zero; her PASI score dropped from 17.6 to 0, and her DLQI score declined from 3 to 0.

The researchers commented on the two drugs' complementary pharmacokinetic profiles.

“Leflunomide's active metabolite exhibits an extremely long half-life in vivo. Etanercept features an early onset of efficacy. Thus, in severe psoriasis, it might be reasonable to use leflunomide as a basic agent and to add etanercept when a relapse occurs,” Dr. Schmitt said.

FLORENCE, ITALY — A decade of remarkable progress in molecular genetics has brought new clarity to the diagnosis of skin diseases. DNA-based testing is providing important information to clinicians and offering families predictions about potentially lethal disorders in blastomere-stage embryos, even before implantation takes place.

“We can now recognize close to 300 different genes that harbor mutations in a manner that explains the clinical manifestations of these [dermatologic] conditions,” announced Jouni Uitto, M.D., professor and chair of dermatology and cutaneous biology at Jefferson Medical College in Philadelphia, at the 13th Congress of the European Academy of Dermatology and Venereology.

Putting genetic advances in perspective, Dr. Uitto noted that even a dozen years ago, inherited skin diseases mystified many community dermatologists and even confounded experts.

“Many of these conditions are evident at birth or shortly thereafter in the neonatal period, but the skin manifestations can be highly variable,” he said. Some resolve early or involve mainly cosmetic manifestations, whereas others are multisystemic and severe, even fatal.

“Genodermatoses have been and continue to be a diagnostic challenge for practitioners. Many of these are relatively rare conditions, so that practitioners are not familiar with [their] salient clinical features. Their classification schemes are very puzzling, riddled with eponyms that are not very informative at all.”

The completion of the Human Genome Project and concentrated effort by the dermatologic and genetic research communities have begun to change all that, offering clear insight into the differences and similarities of subtypes of disorders. This provides the opportunity for solid diagnoses in infancy, pregnancy, and prepregnancy.

To illustrate his point, Dr. Uitto reviewed 8 years of discoveries from his university's epidermolysis bullosa (EB) molecular diagnostics laboratory, which serves as a global diagnostic center and centralized mutation database for the blistering disease.

In 908 families, 783 distinct mutations have been identified on 10 different genes now associated with EB.

Genetic clues have led to a methodical classification of four distinct forms of EB, clarifying 30 subtypes historically identified by uninformative eponyms related to whichever physician first described them, Dr. Uitto said.

Improved diagnosis and classification provides better direction to physicians in terms of management and prognosis, and to families in terms of genetic risks to future children.

“This information certainly has profound consequences for genetic counseling,” he said.

DNA-based genetic tests have been sought out by 181 sets of parents, including 88 seeking information about the genetic status of a pregnancy at risk for junctional EB, which is usually lethal in the first year of life.

These tests can be conducted on embryos prior to implantation after in vitro fertilization, or can be conducted early in pregnancy.

Some families choose to terminate an affected pregnancy, if, for example, they have already lost a child to EB. Other families, however, want the information from this kind of genetic testing to help them plan a safe delivery in an appropriate medical setting with available access to a high-level neonatal intensive care unit.

At the Philadelphia program, the correct genetic phenotypic prediction was made in 155 of 181 pregnancies. In eight pregnancies, which occurred in the early years of the program when mutation detection was in its infancy, the result was inconclusive. The outcome is pending in 18 pregnancies.

The future of prenatal genetic diagnosis is even brighter than its recent past, according to Dr. Uitto.

Promising research is exploring genetic analysis of free fetal DNA within maternal blood samples as early as the seventh week of pregnancy.

Noninvasive diagnoses from maternal blood have already been successfully made in pregnancies at risk for a variety of inherited diseases such as β-thalassemia, sickle cell anemia, and lamellar ichthyosis, he said.

KEVIN FOLEY, RESEARCH

FLORENCE, ITALY — A decade of remarkable progress in molecular genetics has brought new clarity to the diagnosis of skin diseases. DNA-based testing is providing important information to clinicians and offering families predictions about potentially lethal disorders in blastomere-stage embryos, even before implantation takes place.

“We can now recognize close to 300 different genes that harbor mutations in a manner that explains the clinical manifestations of these [dermatologic] conditions,” announced Jouni Uitto, M.D., professor and chair of dermatology and cutaneous biology at Jefferson Medical College in Philadelphia, at the 13th Congress of the European Academy of Dermatology and Venereology.

Putting genetic advances in perspective, Dr. Uitto noted that even a dozen years ago, inherited skin diseases mystified many community dermatologists and even confounded experts.

“Many of these conditions are evident at birth or shortly thereafter in the neonatal period, but the skin manifestations can be highly variable,” he said. Some resolve early or involve mainly cosmetic manifestations, whereas others are multisystemic and severe, even fatal.

“Genodermatoses have been and continue to be a diagnostic challenge for practitioners. Many of these are relatively rare conditions, so that practitioners are not familiar with [their] salient clinical features. Their classification schemes are very puzzling, riddled with eponyms that are not very informative at all.”

The completion of the Human Genome Project and concentrated effort by the dermatologic and genetic research communities have begun to change all that, offering clear insight into the differences and similarities of subtypes of disorders. This provides the opportunity for solid diagnoses in infancy, pregnancy, and prepregnancy.

To illustrate his point, Dr. Uitto reviewed 8 years of discoveries from his university's epidermolysis bullosa (EB) molecular diagnostics laboratory, which serves as a global diagnostic center and centralized mutation database for the blistering disease.

In 908 families, 783 distinct mutations have been identified on 10 different genes now associated with EB.

Genetic clues have led to a methodical classification of four distinct forms of EB, clarifying 30 subtypes historically identified by uninformative eponyms related to whichever physician first described them, Dr. Uitto said.

Improved diagnosis and classification provides better direction to physicians in terms of management and prognosis, and to families in terms of genetic risks to future children.

“This information certainly has profound consequences for genetic counseling,” he said.

DNA-based genetic tests have been sought out by 181 sets of parents, including 88 seeking information about the genetic status of a pregnancy at risk for junctional EB, which is usually lethal in the first year of life.

These tests can be conducted on embryos prior to implantation after in vitro fertilization, or can be conducted early in pregnancy.

Some families choose to terminate an affected pregnancy, if, for example, they have already lost a child to EB. Other families, however, want the information from this kind of genetic testing to help them plan a safe delivery in an appropriate medical setting with available access to a high-level neonatal intensive care unit.

At the Philadelphia program, the correct genetic phenotypic prediction was made in 155 of 181 pregnancies. In eight pregnancies, which occurred in the early years of the program when mutation detection was in its infancy, the result was inconclusive. The outcome is pending in 18 pregnancies.

The future of prenatal genetic diagnosis is even brighter than its recent past, according to Dr. Uitto.

Promising research is exploring genetic analysis of free fetal DNA within maternal blood samples as early as the seventh week of pregnancy.

Noninvasive diagnoses from maternal blood have already been successfully made in pregnancies at risk for a variety of inherited diseases such as β-thalassemia, sickle cell anemia, and lamellar ichthyosis, he said.

KEVIN FOLEY, RESEARCH

FLORENCE, ITALY — A decade of remarkable progress in molecular genetics has brought new clarity to the diagnosis of skin diseases. DNA-based testing is providing important information to clinicians and offering families predictions about potentially lethal disorders in blastomere-stage embryos, even before implantation takes place.

“We can now recognize close to 300 different genes that harbor mutations in a manner that explains the clinical manifestations of these [dermatologic] conditions,” announced Jouni Uitto, M.D., professor and chair of dermatology and cutaneous biology at Jefferson Medical College in Philadelphia, at the 13th Congress of the European Academy of Dermatology and Venereology.

Putting genetic advances in perspective, Dr. Uitto noted that even a dozen years ago, inherited skin diseases mystified many community dermatologists and even confounded experts.

“Many of these conditions are evident at birth or shortly thereafter in the neonatal period, but the skin manifestations can be highly variable,” he said. Some resolve early or involve mainly cosmetic manifestations, whereas others are multisystemic and severe, even fatal.

“Genodermatoses have been and continue to be a diagnostic challenge for practitioners. Many of these are relatively rare conditions, so that practitioners are not familiar with [their] salient clinical features. Their classification schemes are very puzzling, riddled with eponyms that are not very informative at all.”

The completion of the Human Genome Project and concentrated effort by the dermatologic and genetic research communities have begun to change all that, offering clear insight into the differences and similarities of subtypes of disorders. This provides the opportunity for solid diagnoses in infancy, pregnancy, and prepregnancy.

To illustrate his point, Dr. Uitto reviewed 8 years of discoveries from his university's epidermolysis bullosa (EB) molecular diagnostics laboratory, which serves as a global diagnostic center and centralized mutation database for the blistering disease.

In 908 families, 783 distinct mutations have been identified on 10 different genes now associated with EB.

Genetic clues have led to a methodical classification of four distinct forms of EB, clarifying 30 subtypes historically identified by uninformative eponyms related to whichever physician first described them, Dr. Uitto said.

Improved diagnosis and classification provides better direction to physicians in terms of management and prognosis, and to families in terms of genetic risks to future children.

“This information certainly has profound consequences for genetic counseling,” he said.

DNA-based genetic tests have been sought out by 181 sets of parents, including 88 seeking information about the genetic status of a pregnancy at risk for junctional EB, which is usually lethal in the first year of life.

These tests can be conducted on embryos prior to implantation after in vitro fertilization, or can be conducted early in pregnancy.

Some families choose to terminate an affected pregnancy, if, for example, they have already lost a child to EB. Other families, however, want the information from this kind of genetic testing to help them plan a safe delivery in an appropriate medical setting with available access to a high-level neonatal intensive care unit.

At the Philadelphia program, the correct genetic phenotypic prediction was made in 155 of 181 pregnancies. In eight pregnancies, which occurred in the early years of the program when mutation detection was in its infancy, the result was inconclusive. The outcome is pending in 18 pregnancies.

The future of prenatal genetic diagnosis is even brighter than its recent past, according to Dr. Uitto.

Promising research is exploring genetic analysis of free fetal DNA within maternal blood samples as early as the seventh week of pregnancy.

Noninvasive diagnoses from maternal blood have already been successfully made in pregnancies at risk for a variety of inherited diseases such as β-thalassemia, sickle cell anemia, and lamellar ichthyosis, he said.

KEVIN FOLEY, RESEARCH

FLORENCE, ITALY — Unusually shaped or discolored nails may point to congenital abnormalities in children but rarely require surgical intervention, Bianca Maria Piraccini, M.D., noted at the 13th Congress of the European Academy of Dermatology and Venereology.

Diagnostic clues and management tips highlighted a symposium presentation by Dr. Piraccini, a dermatologist from the University of Bologna (Italy) who specializes in nail conditions.

Among the conditions she reviewed, all drawn from cases managed at her institution:

▸ Partial thumb polydactyly. An unusually wide nail with a bifid lunula should always be x-rayed if it is present at birth because this may reveal abnormal maturation of the distal phalanx.

“The nail follows the severity of the bone polydactyly,” Dr. Piraccini said.

A completely or partially duplicated nail may be an important sign of bone abnormalities that may be correctable with surgery.

▸ Congenital malalignment of the great toenail. This condition occurs when the major axis of the nail plate laterally deviates from the major axis of the digit, potentially causing the distal nail to become ingrown.

While this condition may resolve over time, it can be profoundly painful and difficult to manage when it occurs in infants.

Dr. Piraccini presented the case of a 45-day-old infant who was seen after a 14-day course of a low-potency topical steroid failed to relieve the painful inflammation of her lateral nail fold.

“We can have some problems managing this disease in very young children,” she explained, noting that the child's parents encountered a struggle whenever they tried to place socks on their baby's excruciatingly painful feet.

She recommended conservative therapy as described by a number of experts. The technique involves applying tape from the distal nail fold around the digit, with the aim of pulling down on the hypertrophic nail fold, relieving pressure, and redirecting growth of the nail.

▸ Subungual hemangioma. A nodule under the proximal nail, purplish-bluish discoloration, and possibly pseudoclubbing in an infant all point to this diagnosis. The diagnosis can be confirmed by vitropression, a technique popular in Europe in which pressure is applied under glass and the extent of subsequent skin-bleaching measured, Dr. Piraccini said.

Ultrasound is another favored diagnostic technique, as is magnetic resonance imaging, although the latter is difficult in nonsedated young children.

The condition is benign and will spontaneously resolve without intervention, Dr. Piraccini said.

▸ A darkening nail matrix nevus. Nail matrix nevi are not unusual in infancy. “We all see them. They are not rare,” she commented.

Many times such a nevus fades as the child ages, not because it regresses but because the nail matrix nevus cells reduce the production of melanin.

“What is unusual is to see darkening of pigmentation over time,” she declared.

Presented with two such cases in children, and concerned that the change might represent malignancy, Dr. Piraccini surgically removed the nail units of both children and performed dermoscopy, with reassuring results.

Both cases revealed junctional nevi, complicated in one child by postinflammatory hyperpigmentation following trauma. “Darkening [of nail matrix nevi] is not a sign of malignancy in children,” she said.

The subungual hemangioma on this child's finger is a benign condition that will resolve spontaneously.

This nail matrix nevus is unusual in that it has darkened over time. Photos courtesy Dr. Bianca Maria Piraccini

FLORENCE, ITALY — Unusually shaped or discolored nails may point to congenital abnormalities in children but rarely require surgical intervention, Bianca Maria Piraccini, M.D., noted at the 13th Congress of the European Academy of Dermatology and Venereology.

Diagnostic clues and management tips highlighted a symposium presentation by Dr. Piraccini, a dermatologist from the University of Bologna (Italy) who specializes in nail conditions.

Among the conditions she reviewed, all drawn from cases managed at her institution:

▸ Partial thumb polydactyly. An unusually wide nail with a bifid lunula should always be x-rayed if it is present at birth because this may reveal abnormal maturation of the distal phalanx.

“The nail follows the severity of the bone polydactyly,” Dr. Piraccini said.

A completely or partially duplicated nail may be an important sign of bone abnormalities that may be correctable with surgery.

▸ Congenital malalignment of the great toenail. This condition occurs when the major axis of the nail plate laterally deviates from the major axis of the digit, potentially causing the distal nail to become ingrown.

While this condition may resolve over time, it can be profoundly painful and difficult to manage when it occurs in infants.

Dr. Piraccini presented the case of a 45-day-old infant who was seen after a 14-day course of a low-potency topical steroid failed to relieve the painful inflammation of her lateral nail fold.

“We can have some problems managing this disease in very young children,” she explained, noting that the child's parents encountered a struggle whenever they tried to place socks on their baby's excruciatingly painful feet.

She recommended conservative therapy as described by a number of experts. The technique involves applying tape from the distal nail fold around the digit, with the aim of pulling down on the hypertrophic nail fold, relieving pressure, and redirecting growth of the nail.

▸ Subungual hemangioma. A nodule under the proximal nail, purplish-bluish discoloration, and possibly pseudoclubbing in an infant all point to this diagnosis. The diagnosis can be confirmed by vitropression, a technique popular in Europe in which pressure is applied under glass and the extent of subsequent skin-bleaching measured, Dr. Piraccini said.

Ultrasound is another favored diagnostic technique, as is magnetic resonance imaging, although the latter is difficult in nonsedated young children.

The condition is benign and will spontaneously resolve without intervention, Dr. Piraccini said.

▸ A darkening nail matrix nevus. Nail matrix nevi are not unusual in infancy. “We all see them. They are not rare,” she commented.

Many times such a nevus fades as the child ages, not because it regresses but because the nail matrix nevus cells reduce the production of melanin.

“What is unusual is to see darkening of pigmentation over time,” she declared.

Presented with two such cases in children, and concerned that the change might represent malignancy, Dr. Piraccini surgically removed the nail units of both children and performed dermoscopy, with reassuring results.

Both cases revealed junctional nevi, complicated in one child by postinflammatory hyperpigmentation following trauma. “Darkening [of nail matrix nevi] is not a sign of malignancy in children,” she said.

The subungual hemangioma on this child's finger is a benign condition that will resolve spontaneously.

This nail matrix nevus is unusual in that it has darkened over time. Photos courtesy Dr. Bianca Maria Piraccini

FLORENCE, ITALY — Unusually shaped or discolored nails may point to congenital abnormalities in children but rarely require surgical intervention, Bianca Maria Piraccini, M.D., noted at the 13th Congress of the European Academy of Dermatology and Venereology.

Diagnostic clues and management tips highlighted a symposium presentation by Dr. Piraccini, a dermatologist from the University of Bologna (Italy) who specializes in nail conditions.

Among the conditions she reviewed, all drawn from cases managed at her institution:

▸ Partial thumb polydactyly. An unusually wide nail with a bifid lunula should always be x-rayed if it is present at birth because this may reveal abnormal maturation of the distal phalanx.

“The nail follows the severity of the bone polydactyly,” Dr. Piraccini said.

A completely or partially duplicated nail may be an important sign of bone abnormalities that may be correctable with surgery.

▸ Congenital malalignment of the great toenail. This condition occurs when the major axis of the nail plate laterally deviates from the major axis of the digit, potentially causing the distal nail to become ingrown.

While this condition may resolve over time, it can be profoundly painful and difficult to manage when it occurs in infants.

Dr. Piraccini presented the case of a 45-day-old infant who was seen after a 14-day course of a low-potency topical steroid failed to relieve the painful inflammation of her lateral nail fold.

“We can have some problems managing this disease in very young children,” she explained, noting that the child's parents encountered a struggle whenever they tried to place socks on their baby's excruciatingly painful feet.

She recommended conservative therapy as described by a number of experts. The technique involves applying tape from the distal nail fold around the digit, with the aim of pulling down on the hypertrophic nail fold, relieving pressure, and redirecting growth of the nail.

▸ Subungual hemangioma. A nodule under the proximal nail, purplish-bluish discoloration, and possibly pseudoclubbing in an infant all point to this diagnosis. The diagnosis can be confirmed by vitropression, a technique popular in Europe in which pressure is applied under glass and the extent of subsequent skin-bleaching measured, Dr. Piraccini said.

Ultrasound is another favored diagnostic technique, as is magnetic resonance imaging, although the latter is difficult in nonsedated young children.

The condition is benign and will spontaneously resolve without intervention, Dr. Piraccini said.

▸ A darkening nail matrix nevus. Nail matrix nevi are not unusual in infancy. “We all see them. They are not rare,” she commented.

Many times such a nevus fades as the child ages, not because it regresses but because the nail matrix nevus cells reduce the production of melanin.

“What is unusual is to see darkening of pigmentation over time,” she declared.

Presented with two such cases in children, and concerned that the change might represent malignancy, Dr. Piraccini surgically removed the nail units of both children and performed dermoscopy, with reassuring results.

Both cases revealed junctional nevi, complicated in one child by postinflammatory hyperpigmentation following trauma. “Darkening [of nail matrix nevi] is not a sign of malignancy in children,” she said.

The subungual hemangioma on this child's finger is a benign condition that will resolve spontaneously.

This nail matrix nevus is unusual in that it has darkened over time. Photos courtesy Dr. Bianca Maria Piraccini

FLORENCE, ITALY — A brief series of cognitive-behavioral training sessions had a highly significant impact on scratching and profoundly improved the ability of patients with atopic dermatitis to cope with the itching that accompanies the disease, Andrea W.M. Evers, Ph.D., reported at the 13th congress of the European Academy of Dermatology and Venereology.

Dr. Evers and colleagues in the departments of dermatology and medical psychology at University Medical Center St. Radboud, in Nijmegen, the Netherlands, reported on the effect of four training sessions and a booster session among 34 adult patients with atopic dermatitis.

The study's control group was composed of 17 patients on a waiting list to begin the program.

The sessions were attended by five to eight adults who had self-described severe itching and were led by a medical psychologist and a nurse.

Training occurred in blocks, with some time periods being devoted to coping with itching and others to coping with scratching behavior.

Dr. Evers explained that the itch-scratch-itch cycle must be broken down into different behaviors, each with its own potential coping strategies.

“These patients have a long history of scratching,” she explained. “[They] scratch when they itch, but also scratch without itch, as a habitual response to stress, stimulation, and other triggers in the environment.

“It is frequently unconscious, and patients often feel quite helpless about it. They get the idea they have no control over it,” she said.

Sessions focused on coping with itching include education about skin care and compliance, suggestions on how to avoid itch triggers, and training in relaxation techniques and cognitive restructuring.

Sessions focused on scratching teach patients how to monitor their scratching over the course of 1 hour so they can track their progress.

They then learn scratch-reduction maneuvers, habit-reversal techniques, and tips on coping strategies for high-risk situations, including nighttime scratching.

In each session, patients set individual 2-week goals. For example, an attendee might write, “My goal in the next 2 weeks is to scratch not more than 10 times a day. To reach this goal, I will apply the following techniques:___. If I reach my goal, I will reward myself with:___.”

Session leaders help patients set concrete, realistic goals pertinent to their daily lives.

The leaders also reinforce the notion each week that the patient has become the expert on his or her own patterns of scratching and means of controlling the behavior, although the support of family and friends is encouraged.

Throughout the sessions, patients learn what to do if they relapse and learn how to help prevent further slips.

All patients enrolled in the sessions said they learned to cope better with itching, reduced their scratching, and improved the condition of their skin. Of the 34, 29 said the improvement in coping and reduction in scratching was profound.

Three-fourths of patients said their quality of life had improved.

A less subjective analysis of the patients' clinical skin status, coping ability, and scratching and itching behavior showed significant improvements on all measures, compared with patients in the control group, both at the conclusion of the sessions and when it was performed at a 3-month follow-up, Dr. Evers said.

A more detailed analysis of the results will be published, and a study is underway to see if the short-term training had long-lasting effects measurable over 1–2 years, she said.

She said the techniques used in the five-session program are being taught to teams in other hospitals and are now being applied to patients with other dermatologic conditions that involve pruritus, including psoriasis.

FLORENCE, ITALY — A brief series of cognitive-behavioral training sessions had a highly significant impact on scratching and profoundly improved the ability of patients with atopic dermatitis to cope with the itching that accompanies the disease, Andrea W.M. Evers, Ph.D., reported at the 13th congress of the European Academy of Dermatology and Venereology.

Dr. Evers and colleagues in the departments of dermatology and medical psychology at University Medical Center St. Radboud, in Nijmegen, the Netherlands, reported on the effect of four training sessions and a booster session among 34 adult patients with atopic dermatitis.

The study's control group was composed of 17 patients on a waiting list to begin the program.

The sessions were attended by five to eight adults who had self-described severe itching and were led by a medical psychologist and a nurse.

Training occurred in blocks, with some time periods being devoted to coping with itching and others to coping with scratching behavior.

Dr. Evers explained that the itch-scratch-itch cycle must be broken down into different behaviors, each with its own potential coping strategies.

“These patients have a long history of scratching,” she explained. “[They] scratch when they itch, but also scratch without itch, as a habitual response to stress, stimulation, and other triggers in the environment.

“It is frequently unconscious, and patients often feel quite helpless about it. They get the idea they have no control over it,” she said.

Sessions focused on coping with itching include education about skin care and compliance, suggestions on how to avoid itch triggers, and training in relaxation techniques and cognitive restructuring.

Sessions focused on scratching teach patients how to monitor their scratching over the course of 1 hour so they can track their progress.

They then learn scratch-reduction maneuvers, habit-reversal techniques, and tips on coping strategies for high-risk situations, including nighttime scratching.

In each session, patients set individual 2-week goals. For example, an attendee might write, “My goal in the next 2 weeks is to scratch not more than 10 times a day. To reach this goal, I will apply the following techniques:___. If I reach my goal, I will reward myself with:___.”

Session leaders help patients set concrete, realistic goals pertinent to their daily lives.

The leaders also reinforce the notion each week that the patient has become the expert on his or her own patterns of scratching and means of controlling the behavior, although the support of family and friends is encouraged.

Throughout the sessions, patients learn what to do if they relapse and learn how to help prevent further slips.

All patients enrolled in the sessions said they learned to cope better with itching, reduced their scratching, and improved the condition of their skin. Of the 34, 29 said the improvement in coping and reduction in scratching was profound.

Three-fourths of patients said their quality of life had improved.

A less subjective analysis of the patients' clinical skin status, coping ability, and scratching and itching behavior showed significant improvements on all measures, compared with patients in the control group, both at the conclusion of the sessions and when it was performed at a 3-month follow-up, Dr. Evers said.

A more detailed analysis of the results will be published, and a study is underway to see if the short-term training had long-lasting effects measurable over 1–2 years, she said.

She said the techniques used in the five-session program are being taught to teams in other hospitals and are now being applied to patients with other dermatologic conditions that involve pruritus, including psoriasis.

FLORENCE, ITALY — A brief series of cognitive-behavioral training sessions had a highly significant impact on scratching and profoundly improved the ability of patients with atopic dermatitis to cope with the itching that accompanies the disease, Andrea W.M. Evers, Ph.D., reported at the 13th congress of the European Academy of Dermatology and Venereology.

Dr. Evers and colleagues in the departments of dermatology and medical psychology at University Medical Center St. Radboud, in Nijmegen, the Netherlands, reported on the effect of four training sessions and a booster session among 34 adult patients with atopic dermatitis.

The study's control group was composed of 17 patients on a waiting list to begin the program.

The sessions were attended by five to eight adults who had self-described severe itching and were led by a medical psychologist and a nurse.

Training occurred in blocks, with some time periods being devoted to coping with itching and others to coping with scratching behavior.

Dr. Evers explained that the itch-scratch-itch cycle must be broken down into different behaviors, each with its own potential coping strategies.

“These patients have a long history of scratching,” she explained. “[They] scratch when they itch, but also scratch without itch, as a habitual response to stress, stimulation, and other triggers in the environment.

“It is frequently unconscious, and patients often feel quite helpless about it. They get the idea they have no control over it,” she said.

Sessions focused on coping with itching include education about skin care and compliance, suggestions on how to avoid itch triggers, and training in relaxation techniques and cognitive restructuring.

Sessions focused on scratching teach patients how to monitor their scratching over the course of 1 hour so they can track their progress.

They then learn scratch-reduction maneuvers, habit-reversal techniques, and tips on coping strategies for high-risk situations, including nighttime scratching.

In each session, patients set individual 2-week goals. For example, an attendee might write, “My goal in the next 2 weeks is to scratch not more than 10 times a day. To reach this goal, I will apply the following techniques:___. If I reach my goal, I will reward myself with:___.”

Session leaders help patients set concrete, realistic goals pertinent to their daily lives.

The leaders also reinforce the notion each week that the patient has become the expert on his or her own patterns of scratching and means of controlling the behavior, although the support of family and friends is encouraged.

Throughout the sessions, patients learn what to do if they relapse and learn how to help prevent further slips.

All patients enrolled in the sessions said they learned to cope better with itching, reduced their scratching, and improved the condition of their skin. Of the 34, 29 said the improvement in coping and reduction in scratching was profound.

Three-fourths of patients said their quality of life had improved.

A less subjective analysis of the patients' clinical skin status, coping ability, and scratching and itching behavior showed significant improvements on all measures, compared with patients in the control group, both at the conclusion of the sessions and when it was performed at a 3-month follow-up, Dr. Evers said.

A more detailed analysis of the results will be published, and a study is underway to see if the short-term training had long-lasting effects measurable over 1–2 years, she said.

She said the techniques used in the five-session program are being taught to teams in other hospitals and are now being applied to patients with other dermatologic conditions that involve pruritus, including psoriasis.

PARIS — At least one abnormal biologic liver parameter was found in 20 of 22 patients with generalized pustular psoriasis, highlighting a previously underestimated connection between liver involvement and the disease, French researchers reported at the European Congress on Psoriasis 2004.

Extracutaneous manifestations of generalized pustular psoriasis are well recognized, and include arthritis and mucosal involvement.

Although liver abnormalities have been noted in isolated cases, the full extent of liver involvement has not been fully explored, noted Manuelle A. Viguier, M.D., of the department of dermatology at Saint-Louis Hospital in Paris.

Liver tests were performed on 22 consecutive patients admitted to the hospital for a flare of their generalized pustular psoriasis; tests were done at the time of the flare and several weeks later.

Patients with abnormal biologic tests (bilirubin, γ-glutamyl transferase, alkaline phosphatase, aspartate aminotransferase, or alanine aminotransferase serum counts) underwent a more extensive liver work-up, which included a drug intake analysis, serologic detection of hepatitis B virus and hepatitis C virus infections, abdominal ultrasound examination, liver histology, and endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography.

Abnormal biologic liver tests were a very common finding at the time of a psoriasis flare, occurring in nearly all patients.

Half of the 22 patients studied had pronounced abnormalities: jaundice in 4, γ-glutamyl transferase higher than four times the normal value in 10, alkaline phosphatase higher than twice the normal value in 7, and transaminases higher than three times the normal value in 7.

“These abnormalities returned to [the] normal range at the time of remission of pustular psoriasis and relapsed when new cutaneous attacks occurred,” Dr. Viguier and associates noted in their poster presentation.

Liver biopsies revealed neutrophilic cholangitis. Magnetic resonance studies showed features characteristic of sclerosing cholangitis in three of four patients who underwent such examinations.

“Biliary involvement related to neutrophilic cholangitis should be added to the spectrum of extracutaneous manifestations of this disease, and physicians should be aware of such complications in order to avoid both invasive liver investigations [that aren't useful] and withdrawal of drugs with potentially deleterious consequences on the course of the disease,” Dr. Viguier said.

Drug-induced liver toxicity was explored but ruled out as a cause of the sclerosing cholangitis-like changes that the investigators observed. Rather, the disease itself appears to be responsible.

The team is planning a study to test whether a sclerosing evolution of biliary involvement is present in patients with recurrent flares of generalized pustular psoriasis.

PARIS — At least one abnormal biologic liver parameter was found in 20 of 22 patients with generalized pustular psoriasis, highlighting a previously underestimated connection between liver involvement and the disease, French researchers reported at the European Congress on Psoriasis 2004.

Extracutaneous manifestations of generalized pustular psoriasis are well recognized, and include arthritis and mucosal involvement.

Although liver abnormalities have been noted in isolated cases, the full extent of liver involvement has not been fully explored, noted Manuelle A. Viguier, M.D., of the department of dermatology at Saint-Louis Hospital in Paris.

Liver tests were performed on 22 consecutive patients admitted to the hospital for a flare of their generalized pustular psoriasis; tests were done at the time of the flare and several weeks later.

Patients with abnormal biologic tests (bilirubin, γ-glutamyl transferase, alkaline phosphatase, aspartate aminotransferase, or alanine aminotransferase serum counts) underwent a more extensive liver work-up, which included a drug intake analysis, serologic detection of hepatitis B virus and hepatitis C virus infections, abdominal ultrasound examination, liver histology, and endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography.

Abnormal biologic liver tests were a very common finding at the time of a psoriasis flare, occurring in nearly all patients.

Half of the 22 patients studied had pronounced abnormalities: jaundice in 4, γ-glutamyl transferase higher than four times the normal value in 10, alkaline phosphatase higher than twice the normal value in 7, and transaminases higher than three times the normal value in 7.

“These abnormalities returned to [the] normal range at the time of remission of pustular psoriasis and relapsed when new cutaneous attacks occurred,” Dr. Viguier and associates noted in their poster presentation.

Liver biopsies revealed neutrophilic cholangitis. Magnetic resonance studies showed features characteristic of sclerosing cholangitis in three of four patients who underwent such examinations.

“Biliary involvement related to neutrophilic cholangitis should be added to the spectrum of extracutaneous manifestations of this disease, and physicians should be aware of such complications in order to avoid both invasive liver investigations [that aren't useful] and withdrawal of drugs with potentially deleterious consequences on the course of the disease,” Dr. Viguier said.

Drug-induced liver toxicity was explored but ruled out as a cause of the sclerosing cholangitis-like changes that the investigators observed. Rather, the disease itself appears to be responsible.

The team is planning a study to test whether a sclerosing evolution of biliary involvement is present in patients with recurrent flares of generalized pustular psoriasis.

PARIS — At least one abnormal biologic liver parameter was found in 20 of 22 patients with generalized pustular psoriasis, highlighting a previously underestimated connection between liver involvement and the disease, French researchers reported at the European Congress on Psoriasis 2004.

Extracutaneous manifestations of generalized pustular psoriasis are well recognized, and include arthritis and mucosal involvement.

Although liver abnormalities have been noted in isolated cases, the full extent of liver involvement has not been fully explored, noted Manuelle A. Viguier, M.D., of the department of dermatology at Saint-Louis Hospital in Paris.

Liver tests were performed on 22 consecutive patients admitted to the hospital for a flare of their generalized pustular psoriasis; tests were done at the time of the flare and several weeks later.

Patients with abnormal biologic tests (bilirubin, γ-glutamyl transferase, alkaline phosphatase, aspartate aminotransferase, or alanine aminotransferase serum counts) underwent a more extensive liver work-up, which included a drug intake analysis, serologic detection of hepatitis B virus and hepatitis C virus infections, abdominal ultrasound examination, liver histology, and endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography.

Abnormal biologic liver tests were a very common finding at the time of a psoriasis flare, occurring in nearly all patients.

Half of the 22 patients studied had pronounced abnormalities: jaundice in 4, γ-glutamyl transferase higher than four times the normal value in 10, alkaline phosphatase higher than twice the normal value in 7, and transaminases higher than three times the normal value in 7.

“These abnormalities returned to [the] normal range at the time of remission of pustular psoriasis and relapsed when new cutaneous attacks occurred,” Dr. Viguier and associates noted in their poster presentation.

Liver biopsies revealed neutrophilic cholangitis. Magnetic resonance studies showed features characteristic of sclerosing cholangitis in three of four patients who underwent such examinations.

“Biliary involvement related to neutrophilic cholangitis should be added to the spectrum of extracutaneous manifestations of this disease, and physicians should be aware of such complications in order to avoid both invasive liver investigations [that aren't useful] and withdrawal of drugs with potentially deleterious consequences on the course of the disease,” Dr. Viguier said.

Drug-induced liver toxicity was explored but ruled out as a cause of the sclerosing cholangitis-like changes that the investigators observed. Rather, the disease itself appears to be responsible.

The team is planning a study to test whether a sclerosing evolution of biliary involvement is present in patients with recurrent flares of generalized pustular psoriasis.

PARIS — Patients colonized with certain enterotoxic strains of Staphylococcus aureus had significantly worse Psoriasis Area and Severity Index scores than did patients not colonized with these bacterial strains, raising the possibility that antibiotics might have an adjunctive role in treatment, Austrian dermatologists reported at the European Congress on Psoriasis 2004.

Nordwig S. Tomi, M.D., and Elisabeth Aberer, M.D., of Karl Franzens University in Graz, Austria, theorized that enterotoxins might act as superantigens in stimulating dysfunction within T-cells and keratinocytes, triggering psoriasis.

To test the hypothesis, they took sample swabs from the lesional skin and nares of 25 patients with psoriasis for evidence of S. aureus colonization and identification of enterotoxins A, B, C, or D.

Samples from 15 of 25 patients grew positive cultures; these samples were from the nares alone in 1 patient, skin only in 4 patients, and skin and nares in 10. Sixty percent of the strains produced S. aureus enterotoxins.

Enterotoxin A was not detected in any patient, but four patients had enterotoxin B, two had enterotoxin C, one had D, and combinations of A plus D and B plus C were found in one patient each.

“The Psoriasis Area and Severity Index score was significantly higher (P = .001) in patients with enterotoxin-producing staphylococcal strains,” the investigators reported in a poster presentation at the meeting.

“Our results support the hypothesis that S. aureus enterotoxins can trigger psoriasis,” they concluded, noting that in patients with exacerbated psoriasis and a positive S. aureus enterotoxin profile, “antibiotics could be a supporting treatment tool.”

The dermatologists called for more research into the mechanisms by which superantigens may trigger psoriasis.

PARIS — Patients colonized with certain enterotoxic strains of Staphylococcus aureus had significantly worse Psoriasis Area and Severity Index scores than did patients not colonized with these bacterial strains, raising the possibility that antibiotics might have an adjunctive role in treatment, Austrian dermatologists reported at the European Congress on Psoriasis 2004.

Nordwig S. Tomi, M.D., and Elisabeth Aberer, M.D., of Karl Franzens University in Graz, Austria, theorized that enterotoxins might act as superantigens in stimulating dysfunction within T-cells and keratinocytes, triggering psoriasis.

To test the hypothesis, they took sample swabs from the lesional skin and nares of 25 patients with psoriasis for evidence of S. aureus colonization and identification of enterotoxins A, B, C, or D.

Samples from 15 of 25 patients grew positive cultures; these samples were from the nares alone in 1 patient, skin only in 4 patients, and skin and nares in 10. Sixty percent of the strains produced S. aureus enterotoxins.

Enterotoxin A was not detected in any patient, but four patients had enterotoxin B, two had enterotoxin C, one had D, and combinations of A plus D and B plus C were found in one patient each.

“The Psoriasis Area and Severity Index score was significantly higher (P = .001) in patients with enterotoxin-producing staphylococcal strains,” the investigators reported in a poster presentation at the meeting.

“Our results support the hypothesis that S. aureus enterotoxins can trigger psoriasis,” they concluded, noting that in patients with exacerbated psoriasis and a positive S. aureus enterotoxin profile, “antibiotics could be a supporting treatment tool.”

The dermatologists called for more research into the mechanisms by which superantigens may trigger psoriasis.

PARIS — Patients colonized with certain enterotoxic strains of Staphylococcus aureus had significantly worse Psoriasis Area and Severity Index scores than did patients not colonized with these bacterial strains, raising the possibility that antibiotics might have an adjunctive role in treatment, Austrian dermatologists reported at the European Congress on Psoriasis 2004.

Nordwig S. Tomi, M.D., and Elisabeth Aberer, M.D., of Karl Franzens University in Graz, Austria, theorized that enterotoxins might act as superantigens in stimulating dysfunction within T-cells and keratinocytes, triggering psoriasis.

To test the hypothesis, they took sample swabs from the lesional skin and nares of 25 patients with psoriasis for evidence of S. aureus colonization and identification of enterotoxins A, B, C, or D.

Samples from 15 of 25 patients grew positive cultures; these samples were from the nares alone in 1 patient, skin only in 4 patients, and skin and nares in 10. Sixty percent of the strains produced S. aureus enterotoxins.

Enterotoxin A was not detected in any patient, but four patients had enterotoxin B, two had enterotoxin C, one had D, and combinations of A plus D and B plus C were found in one patient each.

“The Psoriasis Area and Severity Index score was significantly higher (P = .001) in patients with enterotoxin-producing staphylococcal strains,” the investigators reported in a poster presentation at the meeting.

“Our results support the hypothesis that S. aureus enterotoxins can trigger psoriasis,” they concluded, noting that in patients with exacerbated psoriasis and a positive S. aureus enterotoxin profile, “antibiotics could be a supporting treatment tool.”

The dermatologists called for more research into the mechanisms by which superantigens may trigger psoriasis.

FLORENCE, ITALY — Complete remission of nearly 90% of keloids followed surgery and postoperative radiation, according to a report at the 13th Congress of the European Academy of Dermatology and Venereology.

With her colleagues, Monica Bellinvia, M.D., of the Institute of Dermatological Sciences of the University of Milan's Ospedale Maggiore, retrospectively analyzed the charts of 152 patients with 187 keloids treated with surgery and orthovoltage radiotherapy over the past 22 years (follow-up: 6 months to 18 years).

Complete remission occured in 166 lesions (89%), with a partial response in 21 lesions (11%). Relapses occurred in 17 lesions from 1 month to 6 years' post treatment, but the 5-year relapse-free rate was 85%, she said.

Excisional surgery was performed on all patients, with care taken to minimize tension at the wound site. Radiation followed within 48 hours in 48 lesions, within 3–7 days in 108 lesions, and within 8–23 days in 31 lesions. Surrounding tissues were protected from radiation.

Total radiation administered ranged from 15 Gy to 40 Gy, although a subanalysis of the data determined that the most therapeutic and cosmetically effective dose was between 25 Gy and 30 Gy.

FLORENCE, ITALY — Complete remission of nearly 90% of keloids followed surgery and postoperative radiation, according to a report at the 13th Congress of the European Academy of Dermatology and Venereology.

With her colleagues, Monica Bellinvia, M.D., of the Institute of Dermatological Sciences of the University of Milan's Ospedale Maggiore, retrospectively analyzed the charts of 152 patients with 187 keloids treated with surgery and orthovoltage radiotherapy over the past 22 years (follow-up: 6 months to 18 years).

Complete remission occured in 166 lesions (89%), with a partial response in 21 lesions (11%). Relapses occurred in 17 lesions from 1 month to 6 years' post treatment, but the 5-year relapse-free rate was 85%, she said.

Excisional surgery was performed on all patients, with care taken to minimize tension at the wound site. Radiation followed within 48 hours in 48 lesions, within 3–7 days in 108 lesions, and within 8–23 days in 31 lesions. Surrounding tissues were protected from radiation.

Total radiation administered ranged from 15 Gy to 40 Gy, although a subanalysis of the data determined that the most therapeutic and cosmetically effective dose was between 25 Gy and 30 Gy.

FLORENCE, ITALY — Complete remission of nearly 90% of keloids followed surgery and postoperative radiation, according to a report at the 13th Congress of the European Academy of Dermatology and Venereology.

With her colleagues, Monica Bellinvia, M.D., of the Institute of Dermatological Sciences of the University of Milan's Ospedale Maggiore, retrospectively analyzed the charts of 152 patients with 187 keloids treated with surgery and orthovoltage radiotherapy over the past 22 years (follow-up: 6 months to 18 years).

Complete remission occured in 166 lesions (89%), with a partial response in 21 lesions (11%). Relapses occurred in 17 lesions from 1 month to 6 years' post treatment, but the 5-year relapse-free rate was 85%, she said.

Excisional surgery was performed on all patients, with care taken to minimize tension at the wound site. Radiation followed within 48 hours in 48 lesions, within 3–7 days in 108 lesions, and within 8–23 days in 31 lesions. Surrounding tissues were protected from radiation.

Total radiation administered ranged from 15 Gy to 40 Gy, although a subanalysis of the data determined that the most therapeutic and cosmetically effective dose was between 25 Gy and 30 Gy.

FLORENCE, ITALY — An alternative to the classic, 150-year-old surgical technique for repairing ingrown toenails may be associated with fewer recurrences and a much-improved aesthetic result, two Swiss dermatologists reported at the 13th Congress of the European Academy of Dermatology and Venereology.

Bernard Noël, M.D., and his coauthor Renatto G. Panizzon, M.D., maintain that their new technique is superior to Emmert plasty, a procedure that consists of a rather superficial wedge excision of granulation tissue, as well as both the adjacent nail bed and the corresponding matrix.

To refine Emmert plasty, however, they first had to scrutinize its steps to understand why it has a recurrence rate as high as 10%–30%.

Dr. Noël and Dr. Panizzon, professor of dermatology at the University of Lausanne (Switzerland), theorized that recurrences may be related to the surgical target of Emmert plasty: the nail, which is narrowed by the radical surgery and sometimes left in a dystrophic state that may be vulnerable to the same pressure that led to the development of the ingrown nail initially.

Moreover, when a significant portion of the nail bed is sacrificed and the nail width is permanently reduced, aesthetic results are often "unsatisfactory," according to Dr. Noël, chief of dermatologic surgery and the wound healing clinic at Centre Hospitalier Universitaire Vaudois of the University of Lausanne.

By contrast, their approach preserves the nail apparatus while deeply targeting the granulation tissue and reducing the size of the toe itself.

"The breadth of the toe extremity is clearly reduced in a way that radically reduces the lateral pressure exerted by the shoes," Dr. Noël said.

"The great toe looks thinner, with a nail plate covering almost completely the distal phalange, reducing, therefore, the risk of recurrence," he noted.

The procedure is performed using a digital block and tourniquet at the toe base. Large, deep excisions remove granulation tissue before the wounds are closed in standard fashion.

Among 10 patients followed for a year or more, there has been a 100% success rate and no incidence of recurrence, Dr. Noël and Dr. Panizzon reported in their detailed poster presentation.

The authors believe their findings bode well for patients who are prone to develop ingrown toenails, which are the most common of all toenail disorders, believed to account for as many as 20% of foot-related physician visits.

Excessive pressures on the lateral toenail because of body weight, the wearing of ill-fitting shoes, or the practice of improperly cutting toenails all have been cited as contributors to the inflammation and the formation of granulation tissue that causes nails, usually of the great toe, to become ingrown.

When patient education and conservative therapy fail, repeated recurrences can lead to infections and extreme discomfort.

Granulation tissue is removed with large and deep excisions.

The toe extremity is narrowed but the nail appartatus is entirely preserved. Photos courtesy Dr. Bernard Noël

FLORENCE, ITALY — An alternative to the classic, 150-year-old surgical technique for repairing ingrown toenails may be associated with fewer recurrences and a much-improved aesthetic result, two Swiss dermatologists reported at the 13th Congress of the European Academy of Dermatology and Venereology.

Bernard Noël, M.D., and his coauthor Renatto G. Panizzon, M.D., maintain that their new technique is superior to Emmert plasty, a procedure that consists of a rather superficial wedge excision of granulation tissue, as well as both the adjacent nail bed and the corresponding matrix.

To refine Emmert plasty, however, they first had to scrutinize its steps to understand why it has a recurrence rate as high as 10%–30%.

Dr. Noël and Dr. Panizzon, professor of dermatology at the University of Lausanne (Switzerland), theorized that recurrences may be related to the surgical target of Emmert plasty: the nail, which is narrowed by the radical surgery and sometimes left in a dystrophic state that may be vulnerable to the same pressure that led to the development of the ingrown nail initially.

Moreover, when a significant portion of the nail bed is sacrificed and the nail width is permanently reduced, aesthetic results are often "unsatisfactory," according to Dr. Noël, chief of dermatologic surgery and the wound healing clinic at Centre Hospitalier Universitaire Vaudois of the University of Lausanne.

By contrast, their approach preserves the nail apparatus while deeply targeting the granulation tissue and reducing the size of the toe itself.

"The breadth of the toe extremity is clearly reduced in a way that radically reduces the lateral pressure exerted by the shoes," Dr. Noël said.

"The great toe looks thinner, with a nail plate covering almost completely the distal phalange, reducing, therefore, the risk of recurrence," he noted.

The procedure is performed using a digital block and tourniquet at the toe base. Large, deep excisions remove granulation tissue before the wounds are closed in standard fashion.

Among 10 patients followed for a year or more, there has been a 100% success rate and no incidence of recurrence, Dr. Noël and Dr. Panizzon reported in their detailed poster presentation.

The authors believe their findings bode well for patients who are prone to develop ingrown toenails, which are the most common of all toenail disorders, believed to account for as many as 20% of foot-related physician visits.

Excessive pressures on the lateral toenail because of body weight, the wearing of ill-fitting shoes, or the practice of improperly cutting toenails all have been cited as contributors to the inflammation and the formation of granulation tissue that causes nails, usually of the great toe, to become ingrown.

When patient education and conservative therapy fail, repeated recurrences can lead to infections and extreme discomfort.

Granulation tissue is removed with large and deep excisions.

The toe extremity is narrowed but the nail appartatus is entirely preserved. Photos courtesy Dr. Bernard Noël

FLORENCE, ITALY — An alternative to the classic, 150-year-old surgical technique for repairing ingrown toenails may be associated with fewer recurrences and a much-improved aesthetic result, two Swiss dermatologists reported at the 13th Congress of the European Academy of Dermatology and Venereology.

Bernard Noël, M.D., and his coauthor Renatto G. Panizzon, M.D., maintain that their new technique is superior to Emmert plasty, a procedure that consists of a rather superficial wedge excision of granulation tissue, as well as both the adjacent nail bed and the corresponding matrix.

To refine Emmert plasty, however, they first had to scrutinize its steps to understand why it has a recurrence rate as high as 10%–30%.

Dr. Noël and Dr. Panizzon, professor of dermatology at the University of Lausanne (Switzerland), theorized that recurrences may be related to the surgical target of Emmert plasty: the nail, which is narrowed by the radical surgery and sometimes left in a dystrophic state that may be vulnerable to the same pressure that led to the development of the ingrown nail initially.

Moreover, when a significant portion of the nail bed is sacrificed and the nail width is permanently reduced, aesthetic results are often "unsatisfactory," according to Dr. Noël, chief of dermatologic surgery and the wound healing clinic at Centre Hospitalier Universitaire Vaudois of the University of Lausanne.

By contrast, their approach preserves the nail apparatus while deeply targeting the granulation tissue and reducing the size of the toe itself.

"The breadth of the toe extremity is clearly reduced in a way that radically reduces the lateral pressure exerted by the shoes," Dr. Noël said.

"The great toe looks thinner, with a nail plate covering almost completely the distal phalange, reducing, therefore, the risk of recurrence," he noted.

The procedure is performed using a digital block and tourniquet at the toe base. Large, deep excisions remove granulation tissue before the wounds are closed in standard fashion.

Among 10 patients followed for a year or more, there has been a 100% success rate and no incidence of recurrence, Dr. Noël and Dr. Panizzon reported in their detailed poster presentation.

The authors believe their findings bode well for patients who are prone to develop ingrown toenails, which are the most common of all toenail disorders, believed to account for as many as 20% of foot-related physician visits.

Excessive pressures on the lateral toenail because of body weight, the wearing of ill-fitting shoes, or the practice of improperly cutting toenails all have been cited as contributors to the inflammation and the formation of granulation tissue that causes nails, usually of the great toe, to become ingrown.

When patient education and conservative therapy fail, repeated recurrences can lead to infections and extreme discomfort.

Granulation tissue is removed with large and deep excisions.

The toe extremity is narrowed but the nail appartatus is entirely preserved. Photos courtesy Dr. Bernard Noël

NEW YORK — Tacrolimus proved to be more efficacious and no more irritating than pimecrolimus in the first large head-to-head comparison of the two topical immunomodulators in patients with atopic dermatitis, Dr. Alan B. Fleischer Jr. said at the American Academy of Dermatology's Academy 2004 meeting.

Previous studies had suggested “that tacrolimus ointment was much more effective than pimecrolimus cream, but the issue of tolerability—burning, stinging, redness—was quite unclear,” said Dr. Fleischer, professor and chair of dermatology at Wake Forest University, Winston-Salem, N.C.

As the result of these studies, he added, tacrolimus can be said to be not only more effective, but also equally well tolerated.

Dr. Fleischer directed the 6-week, randomized, investigator-blinded study of 1,056 patients with mild to severe atopic dermatitis (AD). Overall, 43% of patients who received tacrolimus were judged by the Investigator's Global Atopic Dermatitis Assessment to be “clear or almost clear,” compared with 31% of patients who received pimecrolimus, for a P value of less than .0001.

Only in children aged 2-15 years who had mild AD and were treated with 0.03% tacrolimus did the drug fail to show a statistically significant effect on this outcome variable. (See chart.)

On another measure—the 0- to 72-point Eczema Area and Severity Index (EASI)—the mean score of patients taking tacrolimus declined by 53 points, compared with a mean decline of 39 points for pimecrolimus patients, for a P value of less than .0001.

Itch scores showed a particularly profound decline among pediatric and adult patients with moderate to severe AD. Among such children, for example, the difference in itch scores reached a P value of .006 by the first week. Children with mild AD who were treated with the less potent concentration of tacrolimus also itched less than those treated with pimecrolimus, but the difference was not dramatic until day 43, when the P value reached .008.

Tolerability scores, which were first collected at the end of week 1 of therapy, never demonstrated a statistical difference between the two agents.

The study was sponsored by Fujisawa Healthcare Inc., which makes tacrolimus ointment.

Dr. Fleischer said a presumed tolerability advantage for pimecrolimus emerged from preapproval studies that did not involve patient groups with equally severe AD and used different criteria to judge side effects.

Some patients will still prefer a cream formulation to the ointment vehicle used for tacrolimus, and Dr. Fleischer said he personally believes there is a role for both medications.

“They're both safer than topical steroids used over the long term,” he said. “A young woman may not want to put an ointment on her face in the morning, but now we can give patients a choice.

NEW YORK — Tacrolimus proved to be more efficacious and no more irritating than pimecrolimus in the first large head-to-head comparison of the two topical immunomodulators in patients with atopic dermatitis, Dr. Alan B. Fleischer Jr. said at the American Academy of Dermatology's Academy 2004 meeting.

Previous studies had suggested “that tacrolimus ointment was much more effective than pimecrolimus cream, but the issue of tolerability—burning, stinging, redness—was quite unclear,” said Dr. Fleischer, professor and chair of dermatology at Wake Forest University, Winston-Salem, N.C.

As the result of these studies, he added, tacrolimus can be said to be not only more effective, but also equally well tolerated.

Dr. Fleischer directed the 6-week, randomized, investigator-blinded study of 1,056 patients with mild to severe atopic dermatitis (AD). Overall, 43% of patients who received tacrolimus were judged by the Investigator's Global Atopic Dermatitis Assessment to be “clear or almost clear,” compared with 31% of patients who received pimecrolimus, for a P value of less than .0001.

Only in children aged 2-15 years who had mild AD and were treated with 0.03% tacrolimus did the drug fail to show a statistically significant effect on this outcome variable. (See chart.)

On another measure—the 0- to 72-point Eczema Area and Severity Index (EASI)—the mean score of patients taking tacrolimus declined by 53 points, compared with a mean decline of 39 points for pimecrolimus patients, for a P value of less than .0001.

Itch scores showed a particularly profound decline among pediatric and adult patients with moderate to severe AD. Among such children, for example, the difference in itch scores reached a P value of .006 by the first week. Children with mild AD who were treated with the less potent concentration of tacrolimus also itched less than those treated with pimecrolimus, but the difference was not dramatic until day 43, when the P value reached .008.

Tolerability scores, which were first collected at the end of week 1 of therapy, never demonstrated a statistical difference between the two agents.

The study was sponsored by Fujisawa Healthcare Inc., which makes tacrolimus ointment.

Dr. Fleischer said a presumed tolerability advantage for pimecrolimus emerged from preapproval studies that did not involve patient groups with equally severe AD and used different criteria to judge side effects.

Some patients will still prefer a cream formulation to the ointment vehicle used for tacrolimus, and Dr. Fleischer said he personally believes there is a role for both medications.

“They're both safer than topical steroids used over the long term,” he said. “A young woman may not want to put an ointment on her face in the morning, but now we can give patients a choice.

NEW YORK — Tacrolimus proved to be more efficacious and no more irritating than pimecrolimus in the first large head-to-head comparison of the two topical immunomodulators in patients with atopic dermatitis, Dr. Alan B. Fleischer Jr. said at the American Academy of Dermatology's Academy 2004 meeting.

Previous studies had suggested “that tacrolimus ointment was much more effective than pimecrolimus cream, but the issue of tolerability—burning, stinging, redness—was quite unclear,” said Dr. Fleischer, professor and chair of dermatology at Wake Forest University, Winston-Salem, N.C.

As the result of these studies, he added, tacrolimus can be said to be not only more effective, but also equally well tolerated.

Dr. Fleischer directed the 6-week, randomized, investigator-blinded study of 1,056 patients with mild to severe atopic dermatitis (AD). Overall, 43% of patients who received tacrolimus were judged by the Investigator's Global Atopic Dermatitis Assessment to be “clear or almost clear,” compared with 31% of patients who received pimecrolimus, for a P value of less than .0001.

Only in children aged 2-15 years who had mild AD and were treated with 0.03% tacrolimus did the drug fail to show a statistically significant effect on this outcome variable. (See chart.)

On another measure—the 0- to 72-point Eczema Area and Severity Index (EASI)—the mean score of patients taking tacrolimus declined by 53 points, compared with a mean decline of 39 points for pimecrolimus patients, for a P value of less than .0001.

Itch scores showed a particularly profound decline among pediatric and adult patients with moderate to severe AD. Among such children, for example, the difference in itch scores reached a P value of .006 by the first week. Children with mild AD who were treated with the less potent concentration of tacrolimus also itched less than those treated with pimecrolimus, but the difference was not dramatic until day 43, when the P value reached .008.

Tolerability scores, which were first collected at the end of week 1 of therapy, never demonstrated a statistical difference between the two agents.

The study was sponsored by Fujisawa Healthcare Inc., which makes tacrolimus ointment.

Dr. Fleischer said a presumed tolerability advantage for pimecrolimus emerged from preapproval studies that did not involve patient groups with equally severe AD and used different criteria to judge side effects.

Some patients will still prefer a cream formulation to the ointment vehicle used for tacrolimus, and Dr. Fleischer said he personally believes there is a role for both medications.

“They're both safer than topical steroids used over the long term,” he said. “A young woman may not want to put an ointment on her face in the morning, but now we can give patients a choice.