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ABSTRACT: Human immunodeficiency virus (HIV)-related CD8+ cutaneous pseudolymphoma (CD8+ cytotoxic T cell skin infiltrative disease) is an inflammatory process resulting from a massive infiltration of the skin by activated, oligoclonal, HIV-specific, cytotoxic T lymphocytes. Usually, CD8+ cutaneous pseudolymphoma affects patients with a deep immunosuppression, and is rare in patients with mild immunosuppression. In deeply immunocompromised patients, highly active antiretroviral therapy (HAART) is considered as the first-line treatment. In contrast, the choice of therapy in moderately immunocompromised patients and/or patients already receiving HAART remains nonconsensual. We report a case of HIV-related CD8+ cutaneous pseudolymphoma in a moderately immunocompromised patient who was successfully and safely treated with methotrexate. We review the literature on HIV-related CD8+ pseudolymphoma and the use of methotrexate in HIV-positive patients.
Dermatology 01/2013; · 2.05 Impact Factor
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S Ingen-Housz-Oro,
J M Amici,
B Roy-Geffroy,
A Ostojic,
E Domergue Than Trong,
V Buffard,
S Lafaye,
J C Moreno,
S Goldszal,
A Mirkamali,
J L Plaquet,
D Thuillot,
J P Meningaud,
P Wolkenstein,
O Chosidow
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ABSTRACT: Background: Dermatosurgery (DS) is a growing sector in dermatology. Performance measurement is organized worldwide to improve the quality of health care. Clinical audit relies on self-assessment, comparison with guidelines, frames of references and implementation of improvement actions. Objective: To assess the efficiency of our DS department. Methods: A clinical audit focusing on the organization of the DS unit, patient routing, continuing medical education and training for students was conducted by two external auditors. After an initial evaluation, improvements were implemented and reassessed 1 year later by the same auditors. Results: The audit resulted in the implementation of preoperative consultation, improved pre- and postoperative information leaflets for patients, standardizing of surgery reports, earmarking of funds for materials, and patient satisfaction survey. The training of residents was organized. Conclusion: This audit was a driving force for communication among the medical and paramedical teams and helped improve patient care and training of residents in DS. It also highlighted areas needing further improvement.
Dermatology 11/2012; · 2.05 Impact Factor
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ABSTRACT: Official rules published in 2006 and 2010 concerning ambulatory care rates in France led to artificial redistribution of this activity from day-care hospitalization to consultations. In our dermatological day-care establishment, we compared the financial costs engendered for patients admitted for day-care hospitalization and those seen at consultations.
From 2011/01/10 to 2011/02/04, for each patient, we prospectively analyzed the following data: day-care hospitalization or consultation, age, sex, diagnosis, laboratory and radiological examination, non-dermatological consultations, time spent with the patient by doctors (interns, senior doctors) and nurses, with timing by a stop-watch. The hospital cost was the total for medical examinations (official nomenclature), non-dermatological consultations, physicians' and nurses' salaries and establishment overheads (216 €). The hospital revenue regarding the consultation group consisted of the sum of reimbursement for medical examination, dermatological and non-dermatological consultations, and regarding the day-care hospitalization group, the dermatology rate (670 €) or chemotherapy sessions (380 €). Results were compared using a Chi(2) test and a Student's t-test (P≤0.05).
One hundred and twenty-seven patients were included: 67 in the day-care hospitalization group and 60 in the consultation group. Patients in the day-care hospitalization group were older and had significantly more radiological examinations and non-dermatological consultations, but the number of laboratory examinations and skin biopsies did not differ between the two groups. The mean time spent by doctors was similar in both groups but the time spent by senior doctors without the help of interns was significantly greater and longer than the time for a standard consultation. Nurses spent a mean 72minutes with each hospitalized patient and 35minutes with consultation patients (P=0.007). Hospital costs were identical in both groups at around 415 €. The hospital showed a profit for day-care hospitalization patients (252 €) and a loss (244 €) for consultation patients.
Half of the patients studied were in day-care hospitalization and half were seen in consultations. The high number of bed-ridden patients with bullous pemphigoid accounts for the fact that day-care patients were older. The reasons for the significantly longer time spent by nurses with day-care hospitalized patients were administration and supervision of chemotherapy, skin care and nursing of bed-ridden patients. However, nurses spent 35min with each consultation patient, justifying the need to maintain the posts of these staff in such day-care units. The availability of physicians for patients with severe dermatoses and the organization of medical examinations in the same place in the same day underscore the need for medical structures like day-care hospitalization. At present, time spent on intellectual work involving reflection is regrettably not taken into account, which is detrimental to this specialty. The hospital was in profit for day hospitalizations while consultations resulted in losses, in particular because of the absence of social security reimbursement of the establishment's overheads.
Rules are in need of modification in order to allow the treatment of patients with more complicated conditions.
Annales de Dermatologie et de Vénéréologie 11/2012; 139(11):701-9. · 0.72 Impact Factor
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ABSTRACT: The value of 230-kDa bullous pemphigoid antibody (BP230) enzyme-linked immunosorbent assay (ELISA) for the diagnosis of bullous pemphigoid (BP) was investigated, but in the immunological follow-up of the disease remains unknown.
Evaluation of BP230 ELISA for diagnosis, follow-up and prediction of relapse in BP.
Monocenter retrospective and prospective study. Patients with typical BP. Detection of autoantibodies by indirect immunofluorescence (IIF), BP180 and BP230 ELISA tests at diagnosis, during the treatment (disease control or failure) and at treatment stop (relapse or not 3 months after).
74 patients were included. At diagnosis, BP230 ELISA sensitivity was lower than IIF and BP180 ELISA. Combining both ELISA added a weak gain of sensitivity. Both tests paralleled the clinical evolution, especially in case of disease control. At the end of the treatment, BP230 ELISA was not different in patients with or without relapse.
In routine practice, BP230 ELISA does not seem to be a useful additional test in typical BP.
Dermatology 04/2012; 224(2):154-9. · 2.05 Impact Factor
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ABSTRACT: Background and objective Studies of dermatological emergencies (DE) are few. We evaluated the activity in our DE unit in a 1-month retrospective study and compared the results with a similar study performed in the same department in 2000. Methods We reviewed the charts of all outpatients seen in the DE unit in January 2010, collecting data on age, sex, place of residence, referral mode, day and hour of consultation, true emergency or non-emergency, diagnosis and follow-up. Results In January 2010, we serviced 605 patients (58% males, mean age 40 ± 21 years), 21% more than in 2000; 43.5% were seen during off-duty hours vs. 49% in 2000 (P = 0.066), 49% were considered true emergencies vs. 43% in 2000 (P = 0.046), and 14% were referred by a physician vs. 23% in 2000 (P = 0.0001). In total, 35.2% of cases were infectious dermatoses in 2010 vs. 29% in 2000 (P = 0.026). Other diagnoses were eczema, urticaria and drug-related eruptions. Follow-up was suggested to 53.3% of the patients. Conclusions Our DE unit satisfies a genuine need. Its activity increased over 10 years, most likely because of the decrease in the number of dermatologists in France. Although our results are close to those reported in the literature, comparison with previously published studies is difficult because of the heterogeneity of the definition of DE.
Journal of the European Academy of Dermatology and Venereology 01/2012; · 2.98 Impact Factor
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Annales de Dermatologie et de Vénéréologie 10/2011; 138(10):694-7; quiz 692-3, 698. · 0.72 Impact Factor
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A Du-Thanh,
S Merlet,
H Maillard,
P Bernard,
P Joly,
E Estève,
M A Richard,
C Pauwels, S Ingen-Housz-Oro,
B Guillot,
O Dereure
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ABSTRACT: The interest of long-term superpotent topical steroids (STS) in bullous pemphigoid (BP) has been supported by randomized controlled trials. However, inadequate compliance, poor cutaneous tolerance and nursing difficulties are potential drawbacks. Open-label studies on limited series of patients suggested that low-dose methotrexate (MTX) may be useful, permitting long-term maintenance of a clinical remission obtained by initial, short-term STS.
Open, clinical records-based retrospective analysis of a multicentre series of patients receiving a combined regimen of initial, short-term STS and MTX followed by long-term MTX alone. The primary objective was evaluation of the clinical efficiency of this strategy based on initial clinical remission and subsequent clinical maintenance. The secondary objective was evaluation of the tolerance (type and rating of adverse events) of this combined regimen.
Seventy patients with BP (mean age 82·7 years) were included. Treatment consisted of an initial combination of STS and MTX for a mean duration of 12·3 weeks followed by long-term MTX alone for a mean duration of 8·48 months with a mean and median MTX dosage of 10 mg per week.
One hundred per cent of the patients showed an initial, complete clinical remission after a mean time interval of 21·9 days. The overall rate of long-term disease control was 76%, whereas 24% of patients experienced at least one relapse during subsequent treatment with MTX alone. Drug-related adverse effects were mainly haematological and gastrointestinal and resulted in treatment discontinuation in 11 patients (16%). Six patients (9%) died during the follow-up period with one death (1%) most likely to be related to treatment.
Long-term low-dose MTX combined with short-term STS may result in protracted control of BP in carefully selected patients. These results should prompt randomized controlled trials comparing this treatment with the more usual regimen of long-term STS alone.
British Journal of Dermatology 07/2011; 165(6):1337-43. · 3.67 Impact Factor
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Annales de Dermatologie et de Vénéréologie 03/2011; 138(3):274-9. · 0.72 Impact Factor
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Annales de Dermatologie et de Vénéréologie 03/2011; 138(3):264-6. · 0.72 Impact Factor
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Annales de Dermatologie et de Vénéréologie 03/2011; 138(3):259-63. · 0.72 Impact Factor
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Annales de Dermatologie et de Vénéréologie 03/2011; 138(3):252-8. · 0.72 Impact Factor
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Annales de Dermatologie et de Vénéréologie 03/2011; 138(3):267-70. · 0.72 Impact Factor
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Annales de Dermatologie et de Vénéréologie 03/2011; 138(3):247-51. · 0.72 Impact Factor
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ABSTRACT: The efficacy of topical steroids in bullous pemphigoid (BP) was assessed by prospective therapeutic trials. Systemic corticosteroids and immunosuppressant agents are indicated in situations of failure or relapses.
To report our experience in the management of BP outside therapeutic trials focusing on the outcome of the patients at 6 and 12 months, compliance and follow-up difficulties.
Monocenter retrospective study with collection of clinical, therapeutic and follow-up data after 6 and 12 months.
Ninety-six patients, mean age 84 years, 65 females, 54% had neurological impairment. The initial dose of clobetasol propionate was 30 g/day, followed by a progressive decrease. In the first 6 months, 14% were lost to follow-up and 17.7% died; 62% were controlled with topical steroids alone, and 25% had adjunctive systemic treatment. Difficulties of compliance were mentioned in 34.4%, without significant difference between controlled and noncontrolled patients. After 12 months, 23% were lost to follow-up and 27.1% died. The mean duration of the treatment was 11.7 ± 8.4 months. After the stop, 18.9% of patients relapsed within 3 months.
We emphasize the frequent recourse to systemic treatments in the first few months, the difficulties of compliance and of follow-up in our day-to-day experience.
Dermatology 03/2011; 222(2):176-9. · 2.05 Impact Factor
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Annales de Dermatologie et de Vénéréologie 03/2011; 138(3):271-3. · 0.72 Impact Factor
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S Ingen-Housz-Oro
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ABSTRACT: Pemphigoid gestationis (PG) is a rare auto-immune bullous disease occurring in one pregnant woman over 20,000 to 50,000.
Review of literature about physiopathology, immunological diagnosis and treatment of PG.
Research on Medline and Embase database without any time limit until April 2010. Because of the lack of randomized therapeutic trials in PG, retrospective series and case reports have been analyzed.
PG is due to auto-antibodies directed against BP180 secondary to a mother-fetus immunological tolerance breaking. Blister formation results from a complex mechanism involving TH2 lymphocytes, cytokines and polymorphonuclear cells. Clinically, the disease is characterized by a pruritic, more or less extensive erythemato-papulous eruption. The presence of vesicles and/or blisters is inconstant but evocative. Recovery occurs generally in a few weeks after delivery but relapses are frequent in subsequent pregnancies. Combined oral contraception may also trigger flares of the disease. Diagnosis is confirmed by direct immunofluorescence showing linear C3±IgG deposits in the dermal-epidermal junction. ELISA BP180-NC16A method is very sensitive to detect circulating auto-antibodies. Fetal prognosis is good, but early onset in 1(st) or 2(nd) trimester and blister formation are risk factors for prematurity and low birth weight. Rarely the newborn may be affected by very transitory blisters. Efficiency of very potent topical corticosteroids has been showed in several studies, and they may be used as first-intent treatment in moderate forms of PG. Systemic corticosteroids are indicated in extensive forms. In very exceptional chronic or relapsing PG, immunosuppressant agents may be necessary.
In the absence of consensus between moderate and severe forms of the disease, precise modalities of the steroid treatment (topical or systemic, duration and rhythm of decrease) are not well defined.
Annales de Dermatologie et de Vénéréologie 03/2011; 138(3):209-13. · 0.72 Impact Factor
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S Ingen-Housz-Oro
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ABSTRACT: Linear IgA bullous dermatosis (LABD) is a rare auto-immune bullous disease occurring in adults or childhood.
Review of literature about physiopathology, triggering factors, clinical data and treatment of LABD.
Research on Medline and Embase database without any time limit until April 2010. Because of the lack of randomized therapeutic trials in LABD, retrospective series and case reports have been analyzed.
LABD is due to IgA auto-antibodies typically directed against a proteolytic fragment of BP180 antigen, a 97 or 120kD protein, and/or other components of dermal-epidermal junction. The disease may be either idiopathic or triggered by several medication, most often vancomycin, but also other antibiotics, non-steroid anti-inflammatory, anti-hypertensive and anti-epileptic drugs… Clinically, eruption is typical in childhood with cluster and herpetiform arrangement of blisters and involvement of evocative anatomical sites. In adults, eruption is polymorphic, very atypical presentations are described. Diagnosis is confirmed by direct immunofluorescence which shows linear IgA deposition on the basement membrane zone. Immunoblot and immunoelectron microscopy are evocative in case of diagnosis hesitation. LABD may be associated with some inflammatory bowel disorders. There is no increased risk of cancer or lymphoma. For drug-induced LABD, withdrawal of the medication is followed by a quick healing of the lesions. Dapsone is quickly efficient in idiopathic LABD. Colchicine, sulfapyridine and systemic corticosteroids are used in case of intolerance or inefficiency of dapsone. Some authors emphasize the efficiency of first-intent antibiotics in LABD of childhood.
A triggering drug should be always suspected and stopped. Dapsone is the reference treatment in idiopathic cases of LABD.
Annales de Dermatologie et de Vénéréologie 03/2011; 138(3):214-20. · 0.72 Impact Factor
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S Ingen-Housz-Oro
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ABSTRACT: Dermatitis herpetiformis (DH) is a rare auto-immune bullous disease characterized by its almost constant association to gluten sensitivity.
Review of literature about epidemiology, physiopathology, clinical data and treatment of DH.
Research on Medline and Embase database without any time limit until April 2010. Because of the lack of randomized therapeutic trials in DH, retrospective series and case reports have been analyzed.
DH is related to auto-antibodies against epidermal transglutaminase, which belongs to the same family as tissue transglutaminase, the auto-antigen of celiac disease. Physiopathology is complex, occurring in HLA DQ2 or DQ8 predisposed patients, and implies gluten, immunological reaction in the intestinal wall then in the skin. DH and celiac disease may be encountered in the same family. DH is characterized by a very pruritic microvesicular eruption typically located on elbows, knees and buttocks. Digestive manifestations of celiac disease occur in 15% of cases. Direct immunofluorescence is necessary to confirm the diagnosis, showing granular IgA±C3 deposits in the papillary dermis. Circulating IgA and IgG antiendomysium and antitransglutaminase antibodies are detected in almost all patients at the acute phase and follow the clinical course of the disease. Gastro-intestinal endoscopy with multiple duodenal biopsies shows partial or complete villous atrophy in two thirds of cases, intraepithelial lymphocyte infiltrate in the other cases. Other auto-immune diseases may be associated in 10-20% of cases. The main long-term risk is the occurrence of T or B nodal or intestinal tract lymphoma in 2% of cases (relative risk close to 6 in several studies, but not admitted by all authors), especially if adherence to gluten-free diet is not strict. Treatment is based on dapsone, which is quickly efficient on cutaneous manifestations, but not on the digestive involvement and on strict and definitive gluten-free diet, which cures villous atrophy and reduces the risk of lymphoma.
DH is associated to a gluten enteropathy and its physiopathology is better known. Even if the risk of secondary lymphoma seems little, most of the authors recommend a definitive gluten-free diet.
Annales de Dermatologie et de Vénéréologie 03/2011; 138(3):221-7. · 0.72 Impact Factor
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ABSTRACT: Linear IgA bullous dermatosis is a rare auto-immune bullous dermatitis characterized by linear IgA deposits in the basal membrane zone. Clinical diagnosis may be difficult due to the various clinical presentations mimicking bullous pemphigoid, pemphigus, erythema multiforme or toxic epidermal necrolysis. Linear IgA may be idiopathic or due to drugs, particularly vancomycin.
We describe a 91-year-old woman treated with verapamil for coronary disease who developed an eruption presenting as a toxic epidermal necrolysis, although the diagnosis was amended after direct immunofluorescence revealed IgA deposits in the basal membrane zone.
Ours appears to be the first reported case of verapamil-induced linear IgA bullous dermatosis.
Annales de Dermatologie et de Vénéréologie 01/2011; 138(4):302-6. · 0.72 Impact Factor
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Annales de Dermatologie et de Vénéréologie 12/2010; 137(12):819-20. · 0.72 Impact Factor
