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Summary Background Acral naevi are a peculiar subtype of naevus with specific dermoscopic patterns. Little is known about congenital melanocytic naevi affecting acral volar skin in children. Objectives To determine the dermoscopic features of acquired and congenital acral melanocytic naevi in children and to assess their key differences in this age group. Methods This was a prospective observational controlled study conducted in two outpatient dermatology university hospitals in Nice, France. We recruited 24 children with 24 congenital acral melanocytic naevi (CAMNs) and 26 children with 33 acquired acral melanocytic naevi (AAMNs), and determined the clinical and dermoscopic features of both. Images were evaluated and compared by two dermatologists. Fourteen patients with CAMN were followed up. Results CAMNs were larger, and more asymmetrical and comma shaped than AAMNs. The parallel furrow pattern was predominant in CAMN (75%) and AAMN (79%). Globules were more frequent in CAMN (88%) than in AAMN (61%) (P = 0·026), often with a ‘pearl necklace’ distribution along skin markings. Central blue-grey pigmentation was present in 50% of CAMNs vs. 9% of AAMNs (P = 0·001). A new dermoscopic feature of central enlarged pink ridges was observed in 54% of CAMNs vs. 6% of AAMNs (P

Background A ready-to-use betamethasone valerate 0.1% (BMV) dressing was found to be superior to placebo dressing and a reference 0.1% BMV cream in the treatment of patients with chronic plaque psoriasis (CPP). Methods This multicentre, prospective, randomized, investigator-blinded, controlled, non-inferiority trial compared the efficacy and safety of the BMV dressing to the calcipotriol–betamethasone dipropionate (CBD) ointment during a 4-week treatment of patients with mild to moderate CPP. The primary efficacy endpoint was the 4-item psoriasis total severity score (TSS-4) at week 4, and the associated non-inferiority margin was 1 point. Secondary outcome measures included the psoriasis global assessment (PGA) score and patients’ quality of life (QoL). Safety was assessed through adverse events (AE) reporting in each treatment group. Results Of 325 screened patients, 324 were randomized to BMV (N = 165) or CBD (N = 159), and were considered evaluable for the safety and intention-to-treat (ITT) efficacy analyses. Per protocol (PP) populations included 133 and 131 patients in the BMV and CBD groups respectively. The mean adjusted TSS-4 significantly decreased through the study from baseline in both groups. The PP (primary) analysis of week 4 data revealed a −0.288 (95% CI: −0.610 to 0.034) not significant between-group difference in adjusted means, demonstrating non-inferiority of BMV to CBD. Non-inferiority was also demonstrated in the ITT analysis. The PGA and other secondary outcomes were significantly improved from baseline in both groups at week 4. The QoL score was slightly better in the CBD group at week 4, but no difference was observed at follow-up. No safety or tolerability concerns were observed in either group. Conclusions BMV dressing is non-inferior to CBD ointment in patients with mild to moderate CPP. Both treatments significantly improve patients’ psoriasis and QoL.

Background Blanching creams are used to depigment and to achieve uniform skin tone in widespread vitiligo.Length of the treatment and side-effects strongly limit their use in common practice.Objectives To assess the long-term efficacy and tolerance of Q-Switched (QS) lasers for depigmenting theremaining unaffected skin in vitiligo.Methods Retrospective study of vitiligo patients treated with QS lasers in the Department of Dermatology of theUniversity Hospital of Nice, France, from 2002 to 2011. Localizations and the percentage of body surface area oftreated lesions, the total number of sessions and the possible relapses and side-effects, were analysed. Globalsatisfaction of the patients was evaluated on a visual analogical scale.Results Sixteen areas of normally pigmented skin were treated in six patients. The median number of sessions toachieve a complete depigmentation was 2 (1–6). The mean duration of follow-up was 36 months (19–120). One thirdof the patients had no relapse. A complete repigmentation was observed after 21 months in one patient; a 50%repigmentation was noted in one patient, 7 months after the end of the treatment. Two patients showed a minimalrepigmentation (

Summary Background Certolizumab pegol (CZP) is a PEGylated antitumour necrosis factor agent. Objectives To evaluate the efficacy and safety of CZP in patients with plaque psoriasis. Methods In a randomized, placebo-controlled, double-blind study, 176 patients with moderate to severe psoriasis received placebo or CZP 400 mg at week 0 followed by placebo or CZP (200 or 400 mg) every other week until week 10. Co-primary endpoints were ≥ 75% improvement from baseline in Psoriasis Area and Severity Index (PASI 75) and a Physician’s Global Assessment (PGA) of clear-almost clear at week 12. A re-treatment extension study was conducted in 71 CZP PASI 75 responders who relapsed during a 12- to 24-week observation period without treatment. Results PASI 75 was achieved by 44/59 (75%), 48/58 (83%) and 4/59 (7%) patients in the CZP 200 mg, CZP 400 mg and placebo groups, respectively (P

Summary Background The treatment of vitiligo remains unsatisfactory. Objectives To assess in patients with vitiligo the effect of a laser dermabrasion in addition to the association of topical steroids and ultraviolet (UV) B in difficult-to-treat areas. Methods This was a single-centre prospective randomized trial including patients with nonsegmental vitiligo who had at least two symmetrical lesions located on bony prominences and/or extremities. An erbium laser-assisted dermabrasion was first performed on one side (randomly assigned). After 48 h, hydrocortisone 17-butyrate cream applied daily for three periods of 3 weeks followed by a 1-week steroid-free interval and narrowband UVB treatment was performed on both sides twice weekly for 12 weeks. The evaluation was performed on standardized pictures by two physicians blinded to the type of treatment received. The criterion of success was a repigmentation of at least 50%, 1 month after the end of the treatment. Results Eighteen patients were included (24 paired lesions treated). Two patients dropped out for personal reasons. Almost 50% of lesions achieved at least 50% repigmentation in the dermabrasion side while only 4·2% did so with topical steroids and UVB alone (P

Summary Background Infliximab is indicated for treatment of moderate-to-severe plaque psoriasis in adults whose disease cannot be controlled with other systemic therapies, including methotrexate (MTX). To date, no studies have directly compared the efficacy and safety of infliximab and MTX. Objectives To compare the efficacy and safety of infliximab vs. MTX in adults with moderate-to-severe plaque psoriasis. Methods MTX-naïve patients (n =868) were randomized 3 : 1 to receive infliximab 5 mg kg−1 at weeks 0, 2, 6, 14 and 22 or MTX 15 mg weekly with a dose increase to 20 mg weekly at week 6 if the Psoriasis Area and Severity Index (PASI) response was < 25%. At week 16, patients with < PASI 50 response could switch treatment groups. The primary efficacy endpoint was PASI 75 response at week 16. Major secondary efficacy endpoints were PASI 75 response at week 26, and the proportion of patients achieving a Physician’s Global Assessment (PGA) score of cleared (0) or minimal (1) at weeks 16 and 26. Others included Dermatology Life Quality Index, 36-Item Short Form Health Survey, and PGA, PASI 50, PASI 75 and PASI 90 responses over time. Results The primary endpoint was achieved by a significantly greater proportion of infliximab-treated patients (508/653, 78%) than MTX-treated patients (90/215, 42%; P Conclusions Infliximab was well tolerated and more efficacious than MTX in patients with moderate-to-severe plaque psoriasis. Infliximab also was efficacious in patients who failed MTX and switched to infliximab.

Background Ustekinumab, a human anti-interleukin-12/23 monoclonal antibody, has been shown to effectively treat moderate-to-severe psoriasis which significantly affects health-related quality of life (HRQoL), including patients’ sexual lives. Objectives The aim of this study was to determine if sexual difficulties associated with psoriasis are related to disease severity and whether sexual difficulties improve with skin disease during ustekinumab treatment. Methods In phase III PHOENIX 1 and 2 trials, psoriasis patients were randomized to ustekinumab (n = 1334) at weeks 0 and 4 and q12 weeks thereafter or placebo (n = 662) at weeks 0 and 4 with crossover to ustekinumab at week 12. Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) were used to assess psoriasis severity and patient-reported HRQoL respectively. Based on DLQI Question #9, impaired sexual function was defined as ‘very much’ or ‘a lot’ of sexual difficulties. Results At baseline, mean DLQI was 12.0, indicating a very large negative effect on patients’ lives. Impaired sexual function was reported by 22.6% (women = 27.1%; men = 20.8%) and was significantly associated with increased psoriasis severity. At week 12, ustekinumab-treated patients had a greater mean improvement in DLQI (−9.13 vs. −0.53 with placebo, P

Background Few large clinical studies have evaluated whether switching tumour necrosis factor antagonists (anti-TNFs) is likely to improve psoriasis in patients with prior anti-TNF treatment. Objective The aim of this subanalysis of the BELIEVE study was to assess the efficacy and safety of adalimumab for psoriasis in patients with and without previous anti-TNF treatment. Methods The BELIEVE study enrolled patients with moderate to severe psoriasis and prior failure, intolerance or contraindication to ≥2 systemic therapies. In this 16-week, double-blind, randomized, controlled trial, patients received adalimumab (80 mg, week 0; 40 mg every other week, weeks 1–15) with either topical vehicle or topical calcipotriol/betamethasone dipropionate (C/B) applied once daily for 4 weeks, then as needed. The primary endpoint was ≥75% improvement from baseline in Psoriasis Area and Severity Index score (PASI 75) at week 16. This post hoc subanalysis evaluated the safety and efficacy of adalimumab, with and without topical therapy, in BELIEVE patients who had prior exposure to anti-TNFs. Results Of 730 patients enrolled, 282 (38.6%) had prior anti-TNFs and 448 (61.4%) were anti-TNF-naive. Combining topical vehicle and topical C/B study populations, 61.7% of patients with prior anti-TNFs achieved PASI 75 at week 16, compared with 71.7% of anti-TNF-naive patients (P = 0.095). Adalimumab resulted in clinically meaningful improvement regardless of which prior anti-TNF agent had been used, the number of prior anti-TNFs tried, or reasons for discontinuation of prior anti-TNF therapy. Adverse event incidences were similar between patients with and without prior anti-TNF therapy. Conclusion Adalimumab was effective and well-tolerated in patients with psoriasis previously treated with anti-TNF therapy.

Epidermolysis bullosa simplex (EBS) is an inherited skin disorder characterized by separation of the epidermis from the underlying dermis, with the cleavage plane lying within the basal-cell layer of the epithelium. The major clinical subtypes of EBS have a dominant inheritance and have been associated with genetic defects in specific domains of keratins K5 and K14 that result in abnormal organization of the keratin network and cell disruption. Autosomal recessive forms of EBS associated with extracutaneous manifestations, such as muscular dystrophy (MIM 226670) or pyloric atresia (MIM 612138), have been linked to genetic mutations in the gene for plectin (PLEC). PLEC mutations have also been found in 2 families with the rare dominant Ogna form of EBS. This article reviews current knowledge on EBS.

Summary Background The 308-nm excimer laser and 308-nm excimer lamp have both been shown to be effective in treating vitiligo but a direct comparison has never been performed. Objectives To test the equivalence of these two devices for treating nonsegmental vitiligo. Patients and methods A randomized monocentric study was undertaken. One lesion was treated with the 308-nm excimer laser and its counterpart with the 308-nm excimer lamp. Lesions were treated twice weekly with the same dose on both sides for a total of 24 sessions. The evaluation was done by two independent physicians blinded to the treatment on direct light and ultraviolet light photos. Results Twenty patients were included: 17 completed the study and 104 lesions were treated. The two treatments showed similar results in terms of efficacy for a repigmentation of at least 50% (P = 0·006). The lamp induced more erythema than the laser. Conclusions The 308-nm excimer lamp and laser showed a similar efficacy in treating vitiligo. For the same fluence, the lamp induced more erythema suggesting photobiological differences between the two devices.

Objective To assess patient-reported outcomes (PRO) in patients with moderate-to-severe plaque psoriasis receiving continuous or paused etanercept treatment. Methods In a multicentre European open-label study, one group (n = 352) received continuous therapy: 25 mg subcutaneously (SC) twice weekly (BIW) throughout 54-weeks. The other group (n = 359) received paused therapy: 50 mg SC BIW ( Results At baseline, mean DLQI for patients in the continuous (12.8) and paused group (13.8), indicated significant quality-of-life impairment; mean EQ-5D utility scores were 0.65 and 0.66 for continuous and paused patients, respectively; 30.0% of continuous and 37.0% of paused patients had at least mild symptoms of depression; 40.2% and 48.6%, respectively, had at least mild symptoms of anxiety. At week 54, both groups showed statistically significant (P Conclusions At baseline, patients exhibited significant quality-of-life impairment. Both continuous and paused etanercept treatment provided improvements in PRO measures. Either regimen could be considered and care should be individualized.

Background Medical skin care products are topical preparations with mainly moisturizing properties. A new line of medical skin products with an excellent tolerability profile and improved hydration for dry skin has been developed, but beneficial effects have not yet been investigated on damaged skin. Aim To investigate if these products maintain barrier function and hydration status, improve subjective symptoms due to irritant contact dermatitis and to prove their tolerability on damaged skin. Design and methods Single-centre, blinded, randomized, controlled study in 20 healthy Caucasian women. 5% sodium lauryl sulphate solution was used to induce skin irritation. Two sites on the inside surface of both forearms of each subject were treated daily for 5 days (irritation period). Lipo Cream, Lipo Milk (water-in-oil emulsions) and Lipo Ointment (water-free formulation) were applied twice daily to three of the four test sites on days 1–5. The fourth site was used as a control. Visual readings, subjective symptom assessments, transepidermal water loss (TEWL) and colorimetric measurements, corneometry and skin microrelief macrophotographies were done on days 1–6. Results On day 6, TEWL was increased vs baseline on all sites; however, TEWL with Lipo Cream or Lipo Ointment was significantly lower than control. At day 6, skin capacitance was 94%, 100% and 85% of baseline value for the cream, milk and ointment, respectively, versus 72% for control. All test products were well tolerated. Conclusions Lipo Line products showed both protective properties against epidermal dysfunction and significant hydrating effect.

Resume Introduction Le mycosis fongoide est un lymphome cutane T epidermotrope. Les stades precoces ont un bon pronostic mais posent des problemes therapeutiques par leur chronicite et les recidives frequentes. Nous avons realise une etude retrospective anatomo-clinique sur 10 malades atteints de mycosis fongoide afin d’evaluer l’efficacite du laser excimer a 308 nm dans cette indication. Methodes Dix malades dont le diagnostic de mycosis fongoide avait ete confirme histologiquement, ont ete inclus dans l’etude. Un traitement par laser excimer a 308 nm a ete realise sur un total de 29 lesions dont 25 lesions peu ou pas infiltrees, trois plaques infiltrees et un nodule. Apres determination de la dose erythemateuse minimale, les seances ont ete debutees au rythme de deux par semaine avec une augmentation progressive des doses en fonction de la tolerance. Un suivi clinique a ete ensuite realise. Des biopsies cutanees ont ete realisees, lorsque cela etait possible, avant, a la fin et a distance du traitement afin de realiser une etude histologique et immuno-histochimique. Resultats Quatre-vingt-six pour cent des lesions peu ou pas infiltrees ou en plaques etaient en remission complete a la fin du traitement et 14 p. 100 en remission partielle avec un taux global de reponse de 100 p. 100. Le nombre moyen de seances a ete de 15 (6 a 46 seances), soit une duree moyenne de traitement de 2 mois, et la dose cumulee de 5 J/cm2 (1,3 a 16,1 J/cm2). Dix-neuf lesions ont pu etre suivies a distance du traitement avec une duree mediane de suivi de 15 mois (8 a 26 mois). Une reponse complete s’est maintenue pour 13 lesions (12 lesions peu ou pas infiltrees et une plaque) sur 19, soit 68 p. 100. Une reponse partielle s’est maintenue pour trois lesions (une lesion peu ou pas infiltree et deux plaques) sur 19, soit 16 p. 100. Une rechute est survenue pour deux lesions (deux lesions peu ou pas infiltrees) sur 19, soit 11 p. 100. Ces deux rechutes ont toutes deux ete observees a 7 mois. Le seul nodule traite n’a pas repondu au traitement. Les resultats histologiques et immuno-histochimiques concordaient avec l’aspect clinique montrant une guerison histologique en cas de guerison clinique hormis un cas qui a montre la persistance de quelques cellules de type mycosis en exocytose alors que la lesion paraissait guerie cliniquement. Discussion Cette etude montre l’efficacite du laser excimer dans les mycosis fongoides au stade Ia. Compte tenu de la faible disponibilite de ce traitement et de son caractere onereux, le laser excimer a 308 nm reste indique en seconde intention apres echec ou recidive d’un traitement par dermocorticoides bien conduit.

Resume Introduction Le laser a colorant pulse (LCP) est une methode seduisante pour traiter les verrues. Cependant, les donnees concernant son efficacite reposent essentiellement sur des cas cliniques ou des series ouvertes avec des resultats tres variables d’une etude a l’autre. L’objectif de cette etude etait de comparer l’efficacite et la tolerance du laser a colorant pulse par rapport a un placebo dans le traitement d’un groupe homogene de malades ayant des verrues palmo-plantaires. Methodes Il s’agissait d’une etude prospective controlee contre placebo, randomisee, en simple insu menee de decembre 2004 a juillet 2005 chez des malades venant consulter dans le service de dermatologie du CHU de Nice pour des verrues palmo-plantaires. Les parametres de traitement par le laser a colorant pulse a 595 nm etaient : diametre du spot de 5 mm, duree d’impulsion de 0,45 ms, fluence de 9 J/cm 2 avec une repetition de cinq coups a une frequence de 1 Hz. Des impulsions de refroidissement (systeme integre a la machine) par spray de cryogene etaient utilisees avec une duree de 40 ms et un debit de 50 avant chaque tir laser. Chez les malades du groupe placebo, seules les impulsions de refroidissement etaient utilisees. Pour les verrues plantaires (dans les deux groupes) un decapage manuel au bistouri de l’hyperkeratose etait effectue avant chaque seance. Au maximum, trois seances, espacees de 3 semaines chacune, etaient realisees. Le type et le nombre de verrues etaient comptabilises et reportes sur un schema avant le debut du traitement, lors de chaque seance et 5 semaines apres la derniere seance. La tolerance globale du traitement etait evaluee sur une echelle visuelle analogique allant de 0 (intolerable) a 10 (tolerance parfaite). Resultats Dix-neuf malades ont ete retenus dans le groupe laser et 16 dans le groupe placebo. Soixante-quatre pour cent (48/75) des verrues du groupe laser ont totalement disparu versus 13 p. 100 (4/30) dans le groupe placebo (p Discussion Le laser a colorant pulse apparait comme un traitement efficace des verrues palmo-plantaires mais son efficacite semble equivalente a celle des traitements conventionnels (cryotherapie ou preparation a base d’acide salicylique). Sa tolerance est excellente et constitue l’un des principaux interets de cette technique. L’absence de superiorite prouvee, en terme d’efficacite, par rapport aux traitements conventionnels et son cout eleve incitent a utiliser le laser a colorant pulse comme un traitement de deuxieme intention chez des malades desireux de ne pas etre genes dans leur activite professionnelle.

There have been very few well-conducted trials in melasma and this makes the process of comparing treatment outcome between trials difficult. The Pigmentary Disorders Academy has examined the issues relating to clinical trials on melasma, and has proposed recommendations on how they should be conducted. This covers all aspects including correct diagnosis of the condition, evaluation of efficacy and safety outcome, and overall clinical trial design. It is anticipated that the establishment of accepted guidelines on the conduct of clinical trials in melasma will greatly assist the dermatological community.

Contains fulltext : 50504.pdf (Publisher’s version ) (Closed access) BACKGROUND: Psoriasis is a chronic, inflammatory skin disorder that has a significant impact on quality of life and, particularly in moderate to severe cases, adversely affects the patient's overall health and well-being. Biological treatments, such as etanercept, are being widely adopted across Europe for treatment of moderate to severe psoriasis due to favourable safety and efficacy profiles. The increase in usage, combined with a growing body of clinical evidence, has identified a need to clarify the best use of etanercept within its current treatment label. OBJECTIVE: To prepare a series of recommendations agreed by an expert group of dermatologists, relating to the most effective use of etanercept for psoriasis in Europe, within the product license. METHODS: An expert panel of dermatologists from across Europe completed a Delphi survey to address the current use of etanercept in psoriasis in Europe. In June 2005 the results were presented to the expert panel at their nominal group meeting, and a consensus was agreed. RESULTS: It was recommended that, where possible, patients are initiated on the 50 mg twice-weekly (BIW) dose. Etanercept should be given until remission is achieved (maximum 24 weeks) and retreatment should be initiated according to the physician's judgement. Before commencing treatment, contraindications, such as infection or previous malignancy (within 5 years), should be ruled out. CONCLUSIONS: The consensus presented herein provides valuable clarification of use of etanercept according to the label, which may have wider implications relating to the use of all biological therapies in psoriasis.

Background and Objectives To determine the true efficacy of the 308-nm excimer laser for the treatment of vitiligo, while taking into account confounding factors such as anatomic site of treatment, age, sex, skin type, MED, and duration of evolution of the vitiligo. Study Design/Materials and Methods Thirty-five patients with vitiligo were included. Each lesion was treated twice a week by the 308-nm excimer laser for a maximum of 24 sessions. Efficacy was blindly evaluated by two independent physicians. Results Repigmentation was noted in 46 plaques/52 (88.5%). Repigmentation rate (75%) was obtained in 14 (26.9%). In “UV sensitive” areas (face, neck, trunk), 8/14 lesions (57.1%) had a repigmentation rate, 75% versus 6/38 (15.8%) in “UV resistant” areas (bony prominences and extremities) (P = 0.031). No relationship could be established between response to the treatment and the following variables: age, sex, skin type, MED, and duration of evolution of the vitiligo (respectively, P = 1, 0.666, 0.566, 0.628, 0.521). Conclusions An aesthetically reasonable result is achieved essentially in “UV sensitive” areas, thus appearing to be the appropriate places of choice for this treatment. Lasers Surg. Med. 35:152–156, 2004. © 2004 Wiley-Liss, Inc.

Background Recognition of psoriasis as a T-cell-mediated immune disease has led to the development of various therapeutic approaches directed against the pathogenic T cells. Alefacept, a novel and selective biological recombinant protein, binds CD2 on T cells to block T-cell activation and proliferation and interacts with FcγRIII receptors on accessory cells to produce selective T-cell apoptosis. Objective To demonstrate the efficacy and safety of once-weekly alefacept IM compared with placebo given for 12 weeks to patients with chronic plaque psoriasis. Methods Multicentre (63 sites in Europe, the USA, and Canada), randomized, double-blind, parallel-group study comparing 10 mg and 15 mg of alefacept and placebo administered IM once weekly for 12 weeks. Patients were followed for an additional 12 weeks after cessation of therapy. Patients were eligible for enrolment if they were ≥ 18 years of age, had chronic plaque psoriasis for ≥ 12 months involving ≥ 10% body surface area, and had CD4+ T-cell counts at or above the lower limit of normal. Results 507 patients were enrolled into three treatment groups, which were well balanced for demographic, baseline disease characteristics, and treatment history. A significantly greater percentage of patients treated with alefacept 15 mg IM achieved ≥ 75% PASI reduction from baseline 2 weeks after the last dose compared with placebo (21% vs. 5%, P

To establish the efficacy and duration of remission post-treatment of calcitriol 3 micro g/g ointment in comparison with betamethasone dipropionate 0.05% ointment.A randomized, multicentre trial was conducted in 258 adult patients with chronic plaque psoriasis. Calcitriol 3 microg/g ointment or betamethasone dipropionate 0.05% ointment was applied twice daily for 6 weeks or until complete clearance of lesions. Patients whose psoriasis cleared or were significantly improved and did not require treatment continuation at treatment endpoint were contacted over the following 8 weeks to determine whether relapse had occurred.Both treatments were efficacious; improvement in psoriasis or clearance of lesions (residual erythema was allowed) was recorded for 79% and 82% of patients receiving calcitriol or betamethasone dipropionate, respectively. Global improvement and global severity scores at treatment endpoint showed statistically significant differences in favour of betamethasone dipropionate (p0.05); however, the absolute reduction in mean PASI (psoriasis area and severity index) was comparable between the groups. A statistically significantly (p0.01) higher proportion of responders remained in remission (no worsening of the disease warranting new treatment) following calcitriol therapy (48%) than betamethasone therapy (25%). This is of potential importance to patients, physicians and healthcare suppliers.Twice-daily applications of either calcitriol 3 microg/g ointment or betamethasone dipropionate 0.05% ointment can be used to good effect in the treatment of chronic plaque psoriasis. However, the beneficial effect is likely to persist for longer following calcitriol treatment.

Background: limited data exist on transitioning patients with psoriasis from conventional systemic agents to biologics. Objectives: the TRANSIT study aimed to assess the efficacy and safety of two methotrexate-to-ustekinumab transition strategies. Methods: patients with moderate-to-severe psoriasis and inadequate methotrexate response were randomized 1 : 1 to receive ustekinumab with immediate (arm 1) or 4-week gradual (arm 2) methotrexate withdrawal. Patients weighing ≤ 100 kg or > 100 kg received ustekinumab 45 mg or 90 mg, respectively. The primary endpoint was the frequency of adverse events (AEs) at week 12. Secondary endpoints included additional safety, efficacy and patient-reported outcomes. We report the 12-week efficacy and safety results. Results: overall, 244 patients in arm 1 and 245 in arm 2 were randomized and received ustekinumab. Four patients per arm discontinued the trial by week 12. At week 12 in arms 1 and 2, respectively, 61% and 65% of patients experienced an AE, 2·9% and 2·4% had a serious AE, and 1·2% and 0·4% had an AE leading to ustekinumab discontinuation. In arms 1 and 2, respectively, median Psoriasis Area and Severity Index (PASI) score decreased from 15·2 and 15·4 at baseline to 2·9 and 2·8 at week 12; 58% and 62% of patients achieved a 75% reduction from baseline in PASI score (PASI 75) at week 12; median baseline Dermatology Life Quality Index fell from 8 and 9 at baseline to 1 (both arms) at week 16. Conclusions: ustekinumab was well tolerated and effective in patients who had an inadequate response to methotrexate. Both transition strategies resulted in similar week 12 safety and efficacy outcomes.

Background: There are limited long-term, ‘real-world’ data on ustekinumab, or the effect of dose adjustment in suboptimal responders. Objectives: We describe 52-week data from TRANSIT, which initiated ustekinumab by licensed regimen and investigated exploratory dose adjustment. Methods: Patients with moderate-to-severe psoriasis and inadequate methotrexate response received ustekinumab, with immediate or gradual methotrexate withdrawal. Outcomes were similar between treatment arms at week 12 (primary endpoint), so week 52 data were pooled. Patients weighing ≤ 100 kg or > 100 kg were administered ustekinumab 45 or 90 mg, respectively. Patients weighing ≤ 100 kg without 75% improvement in Psoriasis Area and Severity Index (PASI 75) response at weeks 28 or 40 received a dose adjustment to 90 mg. The primary analysis used observed data. Results: Overall, 391 and 98 patients received ustekinumab 45 and 90 mg, respectively. Forty-four patients (9%) discontinued before week 52 (0·4% due to adverse events). At week 52 (in the overall population), 369 patients (83%) achieved a PASI score ≤ 5, and 341 patients (77%) achieved PASI 75; the median PASI score decreased from 15 at baseline to 1·8. At weeks 28 and 40, 84 and 31 patients, respectively, did not achieve PASI 75 and received a dose adjustment; by week 52, 35/82 (43%) and 15/31 (48%) of these patients, respectively, achieved PASI 75 (two discontinued between weeks 28 and 40). Conclusions: Ustekinumab showed sustained 1-year efficacy and was well tolerated when initially administered according to label. Adjusting the ustekinumab dose to 90 mg may result in clinically meaningful improvement in response in patients weighing ≤ 100 kg with suboptimal initial response.

Resume Introduction Nous rapportons un effet secondaire neuropsychiatrique inattendu de l’hydroxychloroquine (Plaquenil®) a type d’hallucinations cenesthesiques chez une malade traitee pour un lichen plan erosif plantaire. Observation Une femme de 75 ans etait hospitalisee pour un lichen erosif plantaire invalidant. Un traitement par hydroxychloroquine (400 mg par jour) etait debute, associe a des dermocorticoides et a une courte corticotherapie orale (methylprednisolone 0,5 mg/kg/j). Apres 10 jours de traitement, survenait un bref episode de desorientation temporo-spatiale, suivi d’une sensation de depersonnalisation et d’hallucinations cenesthesiques a type de sensations corporelles. Ces manifestations avaient ete precedees par la survenue de cauchemars. L’hydroxychloroquine etait arretee spontanement par la malade une semaine plus tard. Cet arret conduisait a une disparition progressive des hallucinations avec retour a un etat mental normal en un mois. Le recul de 2 ans et demi n’a pas montre de recidive des manifestations psychiatriques. Discussion Chloroquine et hydroxychloroquine peuvent etre a l’origine d’effets secondaires graves sur le plan psychiatrique, a type de psychose. Ces manifestations sont exceptionnelles, peu connues, et ont ete decrites essentiellement au cours du traitement du paludisme. La presentation clinique de la psychose aux antipaludeens de synthese est assez homogene d’une observation a l’autre : survenue chez un malade sans antecedents psychiatriques de manifestations a type de delire, hallucinations, episode maniaque, ou depression, apres un delai de quelques heures a 40 jours, cedant en moyenne une semaine apres l’arret des antipaludeens de synthese. Il n’y a pas de relation entre la dose d’antipaludeens de synthese administree et la survenue de troubles psychiatriques. Les mecanismes de survenue sont inconnus ; il semble s’agir d’une reaction idiosyncrasique. Notre observation permet d’attirer l’attention du dermatologue prescripteur sur la possibilite de survenue d’effets secondaires psychiatriques potentiellement graves.

Resume Introduction Les infections cutanees a Mycobacterium fortuitum ( M. fortuitum ) sont rares, le plus souvent iatrogenes. Nous rapportons un cas avec atteinte cervicale survenue apres une intervention pour lifting. Observation Une femme de 65 ans, sans antecedent, avait eu un lifting facial chirurgical bilateral. Il s’etait complique d’une necrose cutanee traitee par cicatrisation dirigee a domicile. Six semaines plus tard, apparaissaient un nodule abcede sous-maxillaire gauche, draine chirurgicalement, puis d’autres nodules inflammatoires pre-auriculaires et cervicaux gauches, sans adenopathie, ni fievre. Les prelevements bacteriologiques isolaient un M. fortuitum . L’antibiotherapie, initialement probabiliste par clarithromycine, secondairement adaptee par amikacine et ciprofloxacine puis amikacine et imipeneme, pour une duree totale de 3 mois, permettait d’obtenir une guerison clinique. Discussion M. fortuitum est une mycobacterie a croissance rapide, ubiquitaire, responsable d’infections nosocomiales chez les sujets immunocompetents, notamment apres chirurgie plastique. La contamination survient en un site de rupture de la barriere cutanee, par contact avec un vecteur (eau, materiel chirurgical, antiseptique…). Le traitement, mal codifie, consiste en l’association d’un traitement chirurgical et d’une antibiotherapie pendant plusieurs mois.

In 1990, Anhalt et al described a newly autoimmune bullous disease: paraneoplastic pemphigus, in five patients. It was characterized by a distinct set of circulating autoantibodies from those in the sera of patients with pemphigus vulgaris and superficial pemphigus. We report a 71 year-old man with chronic lymphocytic leukemia of 4 years duration who developed a severe mucocutaneous eruption with clinical and immunofluorescence findings of pemphigus vulgaris evolving into an oral bullous lichen planus presentation. Evaluation of his serum confirmed the presence of autoantibodies specific for paraneoplastic pemphigus by indirect immunofluorescence on rat-bladder and immunoprecipitation. Subsequently, additional cases have been reported in the literature. All occurred in patients with various neoplastic conditions. These patients present with polymorphous skin lesions and severe erosive oral disease. Histologic examination shows interface dermatitis and keratinocyte necrosis in addition to acantolysis. Direct immunofluorescence may reveal deposition of immunoglobulin and/or complement at the basement membrane as well as deposition on epithelial cell surfaces. Circulating IgG anti-cell-surface antibodies are detectable with both stratified and stratified epithelia as substrates. These antibodies immunoprecipitate a complex of four desmosomal proteins, including desmoplakin I (250 kDa), the bullous pemphigoid antigen (230 kDa), desmoplakin II (210 kDa) and a 190 kDa antigen.

The occurrence of morphea-like changes during the course of eosinophilic fasciitis is considered to be rare. We observed such a case with simultaneous occurrence of both types of lesions. Histologically, fibrosis and inflammatory infiltrate were seen in the entire dermis, the subcutis and the fascia, suggesting that the same process might account for all skin changes. In addition, our patient had an antiphospholipid antibody, neurologic symptoms and livedo-like cutaneous lesions. However, whether the antiphospholipid antibody played a pathogenic role or not remains unclear. Corticosteroid treatment was successful.

P>Background Data are lacking on the use of topical therapies in combination with tumour necrosis factor blockers for the treatment of psoriasis. Objectives To assess the efficacy and safety of adalimumab (ADA) with topical calcipotriol/betamethasone (C/B) in patients with psoriasis resembling those treated in routine clinical practice. Methods A 16-week, randomized, vehicle-controlled trial was conducted in patients with moderate to severe psoriasis and previous failure, intolerance or contraindications to two or more systemic treatments. All patients received ADA (80 mg, week 0; 40 mg every other week, weeks 1-15) in addition to either topical C/B or drug-free vehicle applied once daily for 4 weeks, and as needed thereafter. The primary endpoint was 75% improvement from baseline in Psoriasis Area and Severity Index (PASI 75) at week 16. Results A total of 730 patients received either ADA + C/B (n = 366) or ADA + vehicle (n = 364). PASI 75 response was initially higher with the combination therapy [14 center dot 8% for ADA + C/B vs. 5 center dot 8% for ADA + vehicle at week 2 (P < 0 center dot 001); and 40 center dot 7% vs. 32 center dot 4%, respectively, at week 4 (P = 0 center dot 021)]. After week 4, the trend was towards a higher response with ADA monotherapy, with no statistical difference in the PASI 75 response at week 16 (64 center dot 8% for ADA + C/B vs. 70 center dot 9% for ADA monotherapy, P = 0 center dot 086). Safety findings were consistent with previous ADA trials. Conclusions ADA + C/B resulted in more rapid and higher efficacy within the first 4 weeks; thereafter, the trend was towards a higher response with ADA monotherapy. There was no statistical difference in the PASI 75 response at week 16. Both treatment regimens were well tolerated.

Objective/Aim To examine approaches to therapy for melasma in Latin Americans and to propose treatment algorithms for patients with mild, moderate and severe melasma. Background Melasma is prevalent in up to 10% of the Latin American population. It is found in all racial groups and is more common in subjects with darker skin phototypes. A number of topical treatments and procedures have been used for melasma. Topical treatments containing hydroquinone are the most popular. Care must be taken when treating melasma to avoid inducing post-inflammatory hyperpigmentation and ochronosis. Determination of the severity of melasma (using the Melasma Area Severity Index and/or Physician's Global Assessment) and choice of the most effective and suitable treatment and/or procedure for individual patients is therefore essential. Sun protection is mandatory for all melasma patients. Methods Thirty-one clinical studies of topical treatments, chemical peels and laser and other therapies used for treating melasma were assessed for the level and quality of clinical evidence, by the Latin American Pigmentary Disorders Academy. The results of this analysis were combined with differential diagnosis guidelines and methods for assessing treatment success to establish algorithms for treating mild and moderate-to-severe melasma. Results The most appropriate first-line treatment for mild melasma is hydroquinone 4%, triple combination cream containing hydroquinone 4%, tretinoin 0.05% and fluocinolone acetate 0.01%, double combination (e.g. 4% hydroquinone and 0.1% tretinoin) or non-phenolic therapy where there is an allergy to compounds. In moderate-to-severe melasma, triple combination cream is the recommended first-line treatment. Second-line treatment is double combination or hydroquinone 4% where triple therapy is not available or if allergic to compounds. Sun avoidance measures and broad spectrum sunscreens with high SPF are fundamental for the successful management of the disease.

Summary Background Patients with psoriasis experience remission and gradual reappearance of erythematous and scaly plaques and require individualized treatment over time. A goal of psoriasis treatment is to provide optimal efficacy with a flexible therapeutic regimen that may include treatment pauses. Objectives To determine whether patients receiving initial treatment with etanercept who then pause therapy would subsequently recapture response during re-treatment. Patients and methods A post-hoc analysis of 226 patients with moderate-to-severe psoriasis from a large multicentre trial was performed. Patients had received etanercept 50 mg twice weekly subcutaneously until a target clinical response had been achieved, then had paused treatment and eventually relapsed. They were then re-treated with etanercept 25 mg twice weekly. The number of patients recapturing a Physician Global Assessment (PGA) of psoriasis rating of ≤ 2 (clear, almost clear or mild) on first re-treatment was assessed. Patient satisfaction during the initial treatment and first re-treatment period was also determined. Results A total of 187 (83%) patients recaptured the target clinical response of a PGA of ≤ 2 after re-treatment. The majority of patients [219 of 226 (97%)] reported satisfaction with etanercept re-treatment. No new safety concerns emerged during re-treatment. Conclusions In this post-hoc analysis, patients with psoriasis who were re-treated with etanercept 25 mg twice weekly effectively recaptured clinical responses that patients found satisfactory. A flexible treatment option is available to dermatologists and patients for individualized care.

Contains fulltext : 80789.pdf (Publisher’s version ) (Closed access) Of the 131 studies on monotherapy or combination therapy assessed, 56 studies on the different forms of phototherapy fulfilled the criteria for inclusion in the guidelines. Approximately three-quarters of all patients treated with phototherapy attained at least a PASI 75 response after 4 to 6 weeks, and clearance was frequently achieved (levels of evidence 2 and 3). Phototherapy represents a safe and very effective treatment option for moderate to severe forms of psoriasis vulgaris. The onset of clinical effects occurs within 2 weeks. Of the unwanted side effects, UV erythema from overexposure is by far the most common and is observed frequently. With repeated or long-term use, the consequences of high, cumulative UV doses (such as premature aging of the skin) must be taken into consideration. In addition, carcinogenic risk is associated with oral PUVA and is probable for local PUVA and UVB. The practicability of the therapy is limited by spatial, financial, human, and time constraints on the part of the physician, as well as by the amount of time required by the patient. From the perspective of the cost-bearing institution, phototherapy has a good cost-benefit ratio. However, the potentially significant costs for, and time required of, the patient must be considered.

Background It has been generally believed that the four main causes of melasma are pregnancy, hormonal contraception, family history and sun exposure; however, there are few published comprehensive studies that confirm these assertions. The Pigmentary Disorders Academy - an international group of experts in pigmentary disorders - designed and conducted a global survey of women to investigate the effect of these factors on onset and chronicity of melasma and the course of the disease in order to gain a better understanding of the causative factors associated with this disorder, with a particular focus on hormonal factors and UV exposure in females. Methods A 40-item largely self-administered questionnaire was completed by 324 women being treated for melasma in nine clinics worldwide. Results The mean age at onset of melasma was 34 years, and 48% of subjects questioned had a family history of melasma (97% in a first-degree relative). Subjects with family history of melasma tended to have darker skin (90% types III-VI) compared to those without (77% types III-VI). The most common time of onset was after pregnancy (42%), often years after the last pregnancy, with 29% appearing pre-pregnancy and 26% during pregnancy. Onset was related to darker skin type post-pregnancy (P = 0.002). Risk of onset during pregnancy was associated with having spent more time outdoors (an extra 10 h per week spent working outside increases the odds of onset of melasma during pregnancy by approximately 27%) and an increased maternal age at pregnancy (increased by approximately 8% for each year of age at first pregnancy; P = 0.02). The odds of melasma occurring for the first time during a pregnancy were also increased with multiple pregnancies (twice the odds if 2 vs. 1 pregnancies, three times higher if 3 or more vs. 1 pregnancy). Of the women, 25% who had used hormonal contraception claimed that melasma appeared for the first time after its use, the rate being higher for those without vs. with a family history. Conclusions The results suggest that, whilst accepted causes do affect onset of melasma, a combination of these factors often triggers this disorder. These factors may provide further insights into how physicians can manage individual melasma cases, support recommendation of preventative measures and even anticipate treatment results and recurrence.

Activation of PPARgamma by synthetic ligands, thiazolidinediones, inhibits the proliferation of cancer cells. In this report, focusing our attention on ciglitazone, we show that ciglitazone inhibits melanoma growth by inducing apoptosis and cell-cycle arrest, whereas normal melanocytes are resistant to ciglitazone. In melanoma cells, ciglitazone-induced apoptosis is associated with caspase activations and a loss of mitochondrial membrane potential. Induction of cell-cycle arrest by ciglitazone is associated with changes in expression of key cell-cycle regulators such as p21, cyclin D1, and pRB hypophosphorylation. Cell-cycle arrest occurs at low ciglitazone concentrations and through a PPARgamma-dependent pathway, whereas the induction of apoptosis is caused by higher ciglitazone concentrations and independently of PPARgamma. These results allow an effective molecular dissociation between proapoptotic effects and growth inhibition evoked by ciglitazone in melanoma cells. Finally, we show that in vivo treatment of nude mice by ciglitazone dramatically inhibits human melanoma xenograft development. The data presented suggest that ciglitazone might be a better candidate for clinical trials in melanoma treatment than the thiazolidinediones currently used in the treatment of type 2 diabetes, such as rosiglitazone, which is devoid of a proapoptotic PPARgamma-independent function.

Background: Appropriate use of prebiotics and optimal combinations of probiotics and prebiotics (synbiotics) could allow significantly better results to be obtained in the treatment of atopic dermatitis (AD). Objective: To evaluate the efficiency of synbiotics when compared with prebiotics alone (control group) in the treatment of moderate and severe AD in children aged 2 years and over. Methods: Double-blind prospective randomized study performed on children aged at least 2 years presenting AD with a minimum SCORing Atopic Dermatitis (SCORAD) score of 15. A dose of 1.2 × 109 colony-forming units Lactobacillus rhamnosus Lcr35 plus prebiotic preparation or an identically appearing prebiotic preparation alone was given three times a day for 3 months. Patients’ diet and usual treatment for AD remained unchanged during the study period. Efficiency was evaluated using the SCORAD score. Use of topical drugs was noted. Results: A total of 48 patients were originally enrolled; nine did not complete the study. In synbiotic group, the mean values of the total SCORAD score was 39.1 before treatment vs 20.7 after 3 months of treatment (P

Contains fulltext : 49726.pdf (Publisher’s version ) (Open Access) The efficacy and safety of 0.3% tacrolimus gel and 0.5% tacrolimus cream compared with calcipotriol ointment were evaluated in adults (n = 124) with mild to moderate plaque psoriasis. Treatment was twice daily for a maximum of 12 weeks. Clinical efficacy was assessed by the percentage change in the local psoriasis severity index of a target lesion between baseline and week 12. By week 12, the median percentage changes in local psoriasis severity index of the target lesions in the tacrolimus gel, tacrolimus cream and calcipotriol groups were 55.6%, 50.0% and 58.6%, respectively (no statistically significant differences). Clinical improvement was observed after one week and increased throughout the study. Tacrolimus-treated patients experienced more application site skin burning (tacrolimus gel and cream both 31.0% versus 7.5% for calcipotriol; p = 0.011). Skin burning was mostly mild in intensity and decreased substantially after 1 week of treatment. There were no differences in the nature and incidence of infections and no clinically relevant changes in laboratory values.

We report 2 cases of localized B-cell non-Hodgkin lymphoma occurring on the face in AIDS patients. The tumors were limited to the skin and bone, without other involvement. They were characterized by an aggressive local behavior that caused infectious and compressive complications and resulted in fatal outcome. Knowledge of the possibility that lymphoma may remain localized in AIDS patients should prompt clinicians to perform a biopsy as soon as possible, regardless of the CD4 count. Indeed, early diagnosis might increase the efficacity of treatment and might avoid disastrous local complications.

Summary Background Early detection of melanomas by means of diverse screening campaigns is an important step towards a reduction in mortality. Computer-aided analysis of digital images obtained by dermoscopy has been reported to be an accurate, practical and time-saving tool for the evaluation of pigmented skin lesions (PSLs). A prototype for the computer-aided diagnosis of PSLs using artificial neural networks (NNs) has recently been developed: diagnostic and neural analysis of skin cancer (DANAOS). Objectives To demonstrate the accuracy of PSL diagnosis by the DANAOS expert system, a multicentre study on a diverse multinational population was conducted. Methods A calibrated camera system was developed and used to collect images of PSLs in a multicentre study in 13 dermatology centres in nine European countries. The dataset was used to train an NN expert system for the computer-aided diagnosis of melanoma. We analysed different aspects of the data collection and its influence on the performance of the expert system. The NN expert system was trained with a dataset of 2218 dermoscopic images of PSLs. Results The resulting expert system showed a performance similar to that of dermatologists as published in the literature. The performance depended on the size and quality of the database and its selection. Conclusions The need for a large database, the usefulness of multicentre data collection, as well as the benefit of a representative collection of cases from clinical practice, were demonstrated in this trial. Images that were difficult to classify using the NN expert system were not identical to those found difficult to classify by clinicians. We suggest therefore that the combination of clinician and computer may potentially increase the accuracy of PSL diagnosis. This may result in improved detection of melanoma and a reduction in unnecessary excisions.

BACKGROUND Psoriasis involving sensitive skin areas remains difficult to treat because of the side-effects of topical corticosteroids and the irritancy potential of vitamin D3 derivatives. Several clinical trials have demonstrated that calcitriol, the naturally occurring and hormonally active form of vitamin D3, is effective and safe at the dose of 3 microg g(-1) for the treatment of psoriasis affecting the trunk and limbs. METHODS We compared the safety and efficacy of calcitriol 3 microg g(-1) ointment and calcipotriol 50 microg g(-1) ointment in a multicentre, randomized, investigator-blinded, left-right comparison in mild to moderate chronic plaque psoriasis affecting sensitive areas, defined as being the face, hairline, retroauricular and flexural areas. One pair of symmetrical and bilateral target lesions was selected from each area and assessed for perilesional erythema, oedema, and stinging/burning. Global assessment of local tolerability and global improvement were rated by the investigator, and the subjects were asked to evaluate the tolerability and efficacy of each product and to express their global preference. RESULTS In the 75 subjects, calcitriol and calcipotriol both led to clearing of at least one target lesion in 21 (28%) of the subjects each. Perilesional erythema (P < 0.001), perilesional oedema (P < 0.02) and stinging/burning (P < 0.001) were all significantly less severe with calcitriol than with calcipotriol. The subjects' evaluation of local tolerability was significantly (P < 0.0001) in favour of calcitriol. Ten treatment-related dermatological events occurred in eight subjects, including one subject who experienced skin discomfort on both sides. All other events occurred only on the calcipotriol-treated side (irritant dermatitis, six subjects; contact dermatitis, one subject). Global assessment of improvement from baseline by the investigators was significantly greater for the calcitriol-treated lesions (P < 0.02). The subjects' global preference was significantly in favour of calcitriol (P < 0.02). CONCLUSIONS In the present study, calcitriol ointment was found to be better tolerated and would appear to be more effective than calcipotriol ointment in the treatment of psoriasis in sensitive areas.

In this study, we compared a new combination ointment containing both calcipotriol and betamethasone dipropionate with betamethasone dipropionate ointment (Diprosone) and calcipotriol ointment (Daivonex) in patients with psoriasis vulgaris; 1106 patients were randomized to twice daily double-blind treatment with combination, betamethasone dipropionate or calcipotriol for 4 weeks. Patients then received twice daily calcipotriol, unblinded, for a further 4 weeks. Mean percentage change in PASI at end of the double-blind phase was -74.4 (combination group), -61.3 (betamethasone group) and -55.3 (calcipotriol group). Mean difference (95% Cl) combination-betamethasone was -13.1 (-16.9 to -9.3, p < 0.001) and for combination-calcipotriol -19.0 (-22.8 to -15.2, p

We have studied the prevalence of hepatitis C virus antibodies (anti-HCV) in 13 patients suffering from sporadic porphyria cutanea tarda. The sera were tested by Abbott second-generation enzyme immunoassay; seropositivity was confirmed by Ortho second-generation recombinant immunoblot assay. Ten cases (76.1%) were anti-HCV positive; one patient was also seropositive for HIV. This preliminary study suggests that HCV could be a frequent triggering factor for sporadic porphyria cutanea tarda.

We report a new case of Ofuji papuloerythroderma. There was no obvious sign of lymphoma or underlying malignancy. This is the 7th European case of papuloerythroderma. This recently described clinical entity is characterized by a pruritic eruption of widespread red-brown flat papules sparing the skin folds, with eosinophilia. The recognition, report and follow-up of further cases are necessary to clarify its relationship with paraneoplastic syndromes, hypereosinophilic syndrome, or prelymphoma skin eruptions.

Constriction band of the trunk is a rare congenital malformation. A 2-year-old girl with a congenital circumferential constriction band around the waist is described. Six other cases of congenital constriction band of the trunk are reviewed. Like constriction band of the limbs, this malformation is probably related to the amniotic band syndrome. Surgical correction should be considered carefully because natural evolution is usually benign and the postoperative esthetic benefit may be questionable. There is no evidence of any risk of familial recurrence.

A 15-month-old girl developed acute lymphoblastic leukemia. Chemotherapy had induced a complete remission and she was continued on maintenance therapy. At 3 years of age, she developed an eruption consisting of excoriated papules and pustules on the face. Demodex folliculorum seemed to be the cause. Topical treatment with metronidazole applied twice a day over a period of 2 weeks resulted in partial improvement. The dermatosis finally cleared gradually with oral erythromycin therapy and one overnight application of 1% lindane cream per week for 2 successive weeks.

A 39-year-old HIV-infected man had manifested a typical varicella successfully treated with intravenous acyclovir. Despite oral acyclovir, he developed 10 days later a widespread eruption of pinpoint-sized erythematous papular lesions. Histologic examination and viral culture showed a persistent varicella-zoster virus (VZV) infection. Intravenous acyclovir and foscarnet were both efficient. However, each withdrawal of intravenously administered treatment resulted in a rapid relapse. Among the atypical forms of chronic varicella, this eruption appears to be unique. As in our case, chronic VZV infection appears often to be a difficult therapeutic challenge.