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Apremilast is an oral small molecule approved for the treatment of psoriasis, psoriatic arthritis and oral ulcers associated with Behçet's disease. This research was conducted to describe the characteristics of patients who received treatment with apremilast for a skin disorder, either before, during, or after a biological treatment, with the aim of analyze the reasons that lead to start this drug in real clinical practice or suspend it for another. A total of 41 patients were enrolled: nine (22.0%) had received biological treatment prior to apremilast, seven (17.0%) both before and after apremilast and 25 (61.0%) after apremilast. One patient received concomitant treatment with adalimumab and apremilast. Most patients (85.4%) received apremilast as treatment for psoriasis. Reasons for starting apremilast were lack of efficacy with previous treatments (85.4%) and adverse effects or contraindication to previous treatments (14.6%), without statistically significant differences between patients who had received a previous biologic and those who had not. Drug survival was not influenced by previous biological treatment, but we found an increased risk of drug discontinuation in patients with chronic kidney disease (log-rank p = 0.028). The main reason of apremilast withdrawal was lack of adequate disease control (60.0%), most of whom required treatment with biologics. Therefore, despite the extensive development of new therapies for psoriasis and other dermatological conditions, apremilast is a widely used drug even in patients who are candidates for biologic treatment. Its initiation is more frequent due to poor disease control than because of other therapies contraindications.

We read with great interest the article by Piccolo et al1. describing chilblain‐like lesions (CLL) on feet and hands during the COVID‐19 Pandemic. They mention the rate of association to autoimmune conditions was very low, which led the to exclude a note autoimmune disorder as main cause of CLL. Here, we hypothesize the possible relationship between the development of these lesions and immune‐chained phenomena following viral infection in a certain group of patients.

To the Editor,We read with great interest Megna et al. (1) article, as we concur that discontinuation of psoriatic drugs may lead to higher disease burden and health-related costs. As authors claim...

Objective Raynaud’s phenomenon consists of vasospastic disease of the digital arteries after exposure to cold or stress. It causes an important reduction in the patient’s quality of life when severe. The available treatments do not always offer favorable results. Methods A 3-year retrospective study was presented. A total of 15 patients with severe Raynaud’s phenomenon who required infiltration with botulinum toxin type A participated in the study. In the first and follow-up visits (30 min, 7 days, 3 months, 6 months, and annual), the overall response by the patient was assessed as was the reduction in the number of weekly episodes of Raynaud’s phenomenon, improvement in pain by means of the Visual Analogue Scale, and resolution of ulcers and necrosis as efficacy variables. Results A total of 15 patients were included in the study. After 30 min of infiltration, the immediate results showed a very good perception of response in four patients. After 1 month of treatment, eight patients had obtained and maintained a very good response, persisting throughout the study. A statistically significant reduction in pain was obtained, as well as the number of weekly episodes of Raynaud’s phenomenon. Of the seven patients with basal ulcers, five were completely healed at 3 months. Of the patients, 64.3% showed an overall satisfaction level of >8 at the end of treatment. No serious adverse events were observed. Conclusion Botulinum toxin is a useful treatment for severe Raynaud’s phenomenon that is generally well tolerated. Its mechanism of action is not based exclusively on vasodilation. Further studies are necessary to define the ideal patient for this treatment, the most appropriate method of administration, and the number of units and frequency of the infiltrations.

Eccrine porocarcinoma is a rare, malignant cutaneous adnexal tumor that arises from the ducts of sweat glands. Found mainly in patients of advanced age, this tumor has diverse clinical presentations. Histology confirms the diagnosis, detects features relevant to prognosis, and guides treatment. Growth is slow, but the prognosis is poor if the tumor metastasizes to lymph nodes or visceral organs. We report 7 cases of eccrine porocarcinoma, describing patient characteristics, the clinical and histopathologic features of the tumors, and treatments used. Our observations were similar to those of other published case series. Given the lack of therapeutic algorithms or protocols for this carcinoma, we propose a decision-making schema based on our review of the literature and our experience with this case series. The algorithm centers on sentinel lymph node biopsy and histologic features.

Resumen El porocarcinoma ecrino es un tumor anexial cutaneo maligno poco frecuente, que deriva de la porcion ductal de las glandulas sudoriparas. Predomina en pacientes de edad avanzada, pudiendo adoptar diversas presentaciones clinicas. El estudio histologico confirma el diagnostico y establece factores pronosticos relevantes a la hora de decidir el tratamiento. El curso evolutivo es lento, pero su pronostico es sombrio cuando aparecen metastasis linfaticas o viscerales. Presentamos 7 pacientes diagnosticados de porocarcinoma ecrino, y describimos los aspectos epidemiologicos, clinicos, histopatologicos y los datos relacionados con el tratamiento de cada uno de ellos. Comparamos los datos obtenidos con las mayores series de casos publicadas, obteniendo similares resultados. Ante la ausencia de algoritmos terapeuticos protocolizados se propone un esquema de tratamiento basado en la literatura revisada y la experiencia personal con nuestra serie, que tiene como ejes centrales los factores pronosticos histologicos y la biopsia selectiva de ganglio centinela.

Resumen Introduccion El fenomeno de Raynaud severo ocasiona una reduccion importante de la calidad de vida de los pacientes. Los tratamientos disponibles no siempre ofrecen buenos resultados, siendo necesaria la busqueda de alternativas terapeuticas. Objetivos Describir los efectos de la toxina botulinica en una serie de pacientes con fenomeno de Raynaud severo. Material y metodos Presentamos una serie de 7 pacientes con fenomeno de Raynaud severo tratados con toxina botulinica entre diciembre de 2013 y marzo de 2014. Previamente a la infiltracion se descarta enfermedad obstructiva mediante ecodoppler y se realiza una capilaroscopia. Variables como el numero de episodios al dia, el dolor, el color, la existencia de ulceras o necrosis han sido evaluadas a nivel basal, a los 30 min, a la semana y al mes del tratamiento. Resultados A los 30 min, 3 pacientes no experimentaron ninguna mejoria, 2 ligera mejoria y 2 una importante mejoria. A la semana, una de las 3 pacientes que no habian respondido refiere una mejoria moderada, 2 continuan sin percibir cambios y el resto denota una importante mejoria. Al mes del tratamiento, las 2 pacientes que no han mejorado previamente continuan sin hacerlo y 4 experimentan una importante mejoria. La variable con respuesta mas llamativa ha sido el dolor. En cuanto a las ulceras, en 3 pacientes se han reepitelizado entre los meses 1 y 2. Conclusiones Tanto en nuestra serie como en otras publicadas previamente, se ha demostrado una respuesta positiva del fenomeno de Raynaud severo a la infiltracion con toxina botulinica con escasos efectos adversos.

Annular elastolytic giant cell granuloma (AEGCG) is a very infrequent granulomatous dermatitis characterized by elastolysis and elastophagocytosis. It usually appears in middle-aged Caucasian women and is normally located in sun-exposed areas. We present a case of a 73-year-old woman with hypertension and type II diabetes, who was admitted to the hospital for an ischemic cerebrovascular accident. She presented with annular and serpiginous skin lesions on her back and arms that had appeared seven months earlier; a clinical and histological diagnosis of elastophagocytic granuloma was made. Our patient exhibited a florid presentation and a self-limiting course.