Psychoneuroimmunology and Skin Diseases

Psychoneuroimmunology has emerged as a broad interdisciplinary field examining the interaction between the psychological state, the nervous system, the endocrine system, and the immune system. Psychodermatology or psychocutaneous medicine is an intersection of psychiatry, psychology and dermatology. There is a growing awareness of the connection between psychosocial stress and somatic illnesses, including dermatological diseases. Psychosomatic factors are considered significant in more than a third of people suffering from skin diseases. Communication between the psyche and the skin is a complex interaction of psychological, immunologic and endocrine factors with the skin, involving a number of neuropeptides, interleukins and immune system mediators. The skin, being the largest organ of the body, is equipped with metabolic and endocrinological capacities that facilitate homeostatic control between internal and external environments. In addition to psychosocial stress, factors relevant for a psychoneuroimmunological approach to skin diseases include nutrition, gut and skin microbiota, sleep and circadian rhythm, physical activity, and orthomolecular medicine. Knowledge of psychoneuroimmunological mechanisms and factors relevant for a holistic approach is very important for a better and broader understanding of skin diseases, and for better therapeutic outcomes for patients

THE ROLE OF IMMUNOTHERAPY IN THE PREVENTION OF ALLERGIC DISEASES

Imunoterapija uz ponavljanje davanja injekcija alergena uz povećanje doze (hiposenzibilizacija) je poznata već duže vrijeme s ciljem smanjenja težine alergijske reakcije tipa I ili čak njezinog kompletnog uklanjanja. Taj je oblik terapije osobito koristan kod alergije na otrov opnokrilaca, alergijskog rinokonjunktivitisa i alergijske astme, a provodi se nakon prethodno dokazana alergije na odgovorne alergene (insekti, pelud, grinje, dlaka životinja i dr.). Najčešće se primjenjuje supkutana imunoterapija koja uključuje niz injekcija specifičnih alergena (alergenskim vakcinama) u rastućim dozama primijenjenih supkutanim putem koje se daju tijekom 3-5 godina. Postoje i drugi oblici ove terapije (npr. sublingvalna imunoterapija) koji su ipak manje učinkoviti. Ponavljanje provođenja postupka hiposenzibilizacije u većine bolesnika dovodi do daljnjeg smanjenja težine alergijske bolesti. Ta je terapija osobito uspješna ako se daje djeci, s obzirom da se na taj način prevenira buduće alergijske simptome.Immunotherapy through repeated administration of allergens and augmentation of doses (hyposensibilization) with the purpose of decreasing the severity of type I allergic reactions or even its complete elimination is known already for a longer period of time. This type of therapy is especially beneficial in allergies to Hymenoptera venom, allergic rhinoconjunctivitis, allergic asthma and is implemented in patients with previously proven allergy to appropriate allergens (insects, pollen, house dust mite, pet dander and other). The most common form of therapy is subcutaneous immunotherapy which includes a series of injections containing specific allergens (allergy vaccines) with increasingly larger doses administered subcutaneously during a period of 3-5 years. There are also other forms of immunotherapy (for instance sublingual immunotherapy) although these are less effective. Repetition of the hyposensibilization procedure leads to further reduction in severity of allergy disease in the majority of patients. The efficacy of immunotherapy is also proven by a lower risk of allergic rhinitis patients developing asthma as well as by prevention of new sensibilizations

How to Cope with Psoriasis: Data from Patient Tests and Surveys

There are a limited number of studies that have addressed coping strategies in patients with psoriasis, so the aim of this study was to examine how patients with psoriasis cope with their illness. We included 122 participants in the study: 56 patients with psoriasis vulgaris and 66 healthy subjects. They filled out the Recent Life Changes Questionnaire (RLCQ), blinded to their stress and clinical status, and the Brief COPE questionnaire with 28 questions measuring 14 coping strategies that are either adaptive or maladaptive. We statistically analyzed the self-reported magnitude of each stressful event in the participants’ lives. Our results show patients with psoriasis most commonly used active coping, seeking emotional support, positive reframing, and acceptance, while their least used strategies were denial and substance use. Since patients with psoriasis often experience psychologically related problems/consequences, it is necessary to take into account their psychological state and try to provide appropriate help and support

Sindrom DRESS s blagim manifestacijama kao dijagnostički i terapijski problem: prikaz slučaja

The group of severe cutaneous drug reactions with systemic symptoms includes several syndromes: toxic epidermal necrolysis, Stevens-Johnson syndrome, acute generalized exanthematous pustulosis, and drug reaction with eosinophilia and systemic symptoms (DRESS). These reactions occur several days to six weeks after introducing the incriminating drug. The skin and internal organs (liver, kidneys, lungs, etc.) are usually involved. A great possibility of lethal outcome is a critical characteristic of these syndromes. A patient with pyelonephritis diagnosed during emergency room workup is described. Ciprofloxacin was prescribed and the patient was discharged. After ten days, the patient came back with worsening condition, general inflammatory response, skin changes, liver and kidney damage, and eosinophilia. DRESS syndrome was diagnosed based on clinical and other findings. The diagnosis and treatment of severe drug reactions with cutaneous and systemic symptoms pose a medical challenge.Teške oblike kožnih reakcija na lijekove povezanih sa sistemskim simptomima čini nekoliko sindroma: toksična epidermalna nekroliza, Stevens-Johnsonov sindrom, akutna generalizirana egzantematozna pustuloza te reakcija na lijekove s eozinofilijom i sistemskom reakcijom (DRESS). Kod takvih reakcija se nekoliko dana do 6 tjedana od uvođenja lijeka pojave promjene na koži, a često su zahvaćeni i unutarnji organi (jetra, bubrezi, pluća i dr.). Zbog toga je u ovakvim oblicima preosjetljivosti na lijekove velika smrtnost. Opisuje se slučaj bolesnice kojoj je ambulantno dijagnosticiran pijelonefritis, te je bila otpuštena kući uz preporuku terapije ciprofloksacinom. Deset dana kasnije bolesnica se vratila u ambulantu s pogoršanjem kliničke slike, lošeg općeg stanja, uz pojavu kožnih eflorescencija, oštećenje jetrene i bubrežne funkcije te s eozinofilijom. Na temelju kliničkih nalaza i ostale obrade postavljena je dijagnoza sindroma DRESS. Dijagnoza i terapija teških oblika reakcija na lijekove i u današnje vrijeme predstavljaju medicinski izazov

How to Cope with Psoriasis: Data from Patient Tests and Surveys

There are a limited number of studies that have addressed coping strategies in patients with psoriasis, so the aim of this study was to examine how patients with psoriasis cope with their illness. We included 122 participants in the study: 56 patients with psoriasis vulgaris and 66 healthy subjects. They filled out the Recent Life Changes Questionnaire (RLCQ), blinded to their stress and clinical status, and the Brief COPE questionnaire with 28 questions measuring 14 coping strategies that are either adaptive or maladaptive. We statistically analyzed the self-reported magnitude of each stressful event in the participants’ lives. Our results show patients with psoriasis most commonly used active coping, seeking emotional support, positive reframing, and acceptance, while their least used strategies were denial and substance use. Since patients with psoriasis often experience psychologically related problems/consequences, it is necessary to take into account their psychological state and try to provide appropriate help and support

FROM PITYRIASIS LICHENOIDES CHRONICA TO SYPHILIS AND HIV – A DETECTIVE’S APPROACH

Pityriasis lichenoides chronica (PLC) is a rare, non-infective dermatosis of unknown etiology characterized by reddish-brown papules with potential overlying mica-like scales, which sometimes progress to cutaneous T-cell lymphoma. Lesions mimicking PLC can (rarely) occur as a presentation of anunderlying infectious disease or as a paraneoplastic syndrom

Slučajevi bolesnika sa svrabom pogrešno dijagnosticiranih i liječenih kao alergijske bolesti: svrbež kao alarm

The lack of scabies recognition by physicians is often caused by its similarity with other dermatoses and allergies such as eczema, urticaria, atopic dermatitis, allergic contact dermatitis, etc. The aim of this study was to present the most common misdiagnoses of scabies in physician’s work. With the aim of preventing future misdiagnoses in physicians’ work, we present 6 cases of patients (1 woman and 5 men, aged 23-82) who had been misdiagnosed prior to admission to our ward (tertiary care unit). In our patients, scabies was unrecognized for months during which time the patients were treated for allergic/immune diseases (nummular eczema, drug-induced reaction, allergic contact dermatitis, autoimmune skin disease). Additionally, none of our patients had lived in unhygienic conditions or were close to infected persons, but all had concomitant itch. Because of the similarity between scabies and pruritic allergic disorders, it is important to exclude scabies before diagnosing an allergy, based on patient history and skin examination. Early scabies recognition in practice is crucial for minimizing the disease societal impacts.Nedostatak prepoznavanja svraba od strane liječnika često je uzrokovan njegovom sličnošću s drugim dermatozama i alergijama poput ekcema, urtikarije, atopijskog dermatitisa, alergijskog kontaktnog dermatitisa itd. Cilj ove studije bio je prikazati najčešće pogreške u prepoznavanju svraba tijekom rada liječnika. Radi sprječavanja budućih pogrešnih dijagnoza u radu liječnika prikazujemo 6 slučajeva bolesnika (jedna žena i pet muškaraca u dobi od 23 do 82 godine) koji su bili pogrešno dijagnosticirani prije dolaska u našu kliniku (ustanovu tercijarne skrbi). U bolesnika koji su došli k nama svrab je prethodno mjesecima bio neprepoznat, a kožne promjene liječene su kao alergijske/imunosne bolesti (numularni ekcem, reakcija kože izazvana lijekovima, alergijski kontaktni dermatitis, autoimuna kožna bolest). Pritom nijedan od bolesnika s dokazanim svrabom nije živio u nehigijenskim uvjetima niti je bio u blizini zaraženih osoba, ali se u svih javljao izražen svrbež. Zbog sličnosti svraba i pruritičnih alergijskih bolesti važno je isključiti svrab prije dijagnosticiranja alergije temeljem anamneze i pregleda kože bolesnika. Rano prepoznavanje svraba u radu liječnika ključno je za minimiziranje negativnog utjecaja bolesti

Čimbenici koji doprinose regresiji kronične urtikarije /angioedema i numularnog dermatitisa - koji laboratorijski nalazi su ključni?

When working with dermatology patients, the question sometimes arises which diagnostic tests and tools should be used for workup, particularly in cases of chronic urticaria (CU) and discoid nummular eczema, where the treatment of associated systemic diseases and infections may be crucial for patient outcome. The aim was to investigate retrospectively the influence of associated diseases on skin disease outcomes based on medical records of CU and nummular eczema patients in comparison to controls. We included patients admitted to our Dermatology Department over a 6-year period and analyzed their laboratory findings, related factors and outcomes recorded after two years of workup and treatment. Compared to controls, CU patients had a significantly higher prevalence of positive Helicobacter (H.) pylori findings (p=0.020), confirmed allergies (p=0.006), increased IgE (p=0.011) and pathologic thyroid findings (p=0.049), whereas nummular eczema patients only had significantly higher positive H. pylori findings (p=0.046). Meaningful regression of both dermatoses was recorded after treatment of associated diseases, with significant benefit from H. pylori treatment. This indicated that the diagnosis of associated infections (particularly H. pylori and urogenital infections), confirmed allergies, endocrine disorders (particularly of thyroid gland in CU patients) and serum malignancy markers could play a crucial role, as their treatment may improve disease outcomes.Tijekom rada s dermatološkim bolesnicima javlja se pitanje koje dijagnostičke testove i postupke koristiti u obradi bolesnika, osobito kod slučajeva kronične urtikarije (KU) i numularnog ekcematoidog dermatitisa, bolesti kod kojih liječenje pratećih bolesti i infekcija može biti značajno za ishod liječenja bolesnika. U ovoj retrospektivnoj studiji istražili smo utjecaj pratećih bolesti na ishod bolesti kože, na temelju medicinske dokumentacije bolesnika s KU i ekcematoidnim dermatitisom koje smo usporedili s kontrolnom skupinom. Uključili smo bolesnike zaprimljene u našu dermatološku kliniku tijekom 6 godina te smo analizirali njihove laboratorijske nalaze, povezane čimbenike i ishode bolesti kože koji su zabilježeni nakon 2 godine praćenja i liječenja. U usporedbi s kontrolnim skupinama bolesnici s KU imali su značajno učestalije pozitivne nalaze na Helicobacter (H.) pylori (p=0,020), češće potvrđene alergije (p=0,006), češće povišen IgE (p=0,011) i češće patološke nalaze štitnjače (p=0,049), dok su bolesnici s ekcematoidnim dermatitisom imali značajno učestalije pozitivne nalaze H. pylori (p=0,046). Značajna regresija obiju dermatoza bolesti zabilježena je nakon provedenog liječenja pratećih, uz utvrđenu značajnu korist provedenog liječenja infekcije bakterijom H. pylori. To ukazuje na važnost dijagnostike pratećih infekcija (osobito H. pylori i urogenitalnih infekcija), potvrđenih alergija, endokrinih poremećaja (osobito štitnjače kod bolesnika s KU) i vrijednosti serumskih tumorskih biljega, kao i njihovog liječenja, što utječe na ishod ovih bolesti kože

Actinic Reticuloid – Photosensitivity or Pseudolymphoma? – A Review

Actinic reticuloid (AR) or chronic actinic dermatitis is considered a sunlight-induced pseudolymphoma (PSL) on light exposed areas of the skin, which primarily affects elderly males. The disease is a severe, chronic photosensitive dermatosis, first described by Ive et al. in 1969. PSL is a group of non-cancerous lymphocytic skin disorders that simulate malignant lymphomas, but the changes usually spontaneously regress. The clinical appearance of Actinic reticuloid is variable, usually characterized by an eczematous, pruritic eruption, predominantly present on the head and neck, or other sun exposed areas, but can involve any area of the body. Thereby, crucial characteristic is photosensitivity, whereat action spectrum involves UVB, UVA and visible light beyond 400 nm. The disease is considered as PSL which histologically resembles lymphoma with immunohistochemical analysis of the cutaneous infiltrate revealing presence of activated T cells, numerous histiocytes, macrophages and B cells. Moreover, the development of malignant (non-cutaneous) T cell lymphoma in the course of AR has been reported. As the disease has chronic character, it requires significant changes in the patient´s lifestyle and avoidance of provoking factors such as contact allergens or sources of intense light. Thus AR should be considered in every patient who presents with persistent, unclear, erythematous skin changes on the face and neck that are related to sun exposure

Sindrom DRESS s blagim manifestacijama kao dijagnostički i terapijski problem: prikaz slučaja

The group of severe cutaneous drug reactions with systemic symptoms includes several syndromes: toxic epidermal necrolysis, Stevens-Johnson syndrome, acute generalized exanthematous pustulosis, and drug reaction with eosinophilia and systemic symptoms (DRESS). These reactions occur several days to six weeks after introducing the incriminating drug. The skin and internal organs (liver, kidneys, lungs, etc.) are usually involved. A great possibility of lethal outcome is a critical characteristic of these syndromes. A patient with pyelonephritis diagnosed during emergency room workup is described. Ciprofloxacin was prescribed and the patient was discharged. After ten days, the patient came back with worsening condition, general inflammatory response, skin changes, liver and kidney damage, and eosinophilia. DRESS syndrome was diagnosed based on clinical and other findings. The diagnosis and treatment of severe drug reactions with cutaneous and systemic symptoms pose a medical challenge.Teške oblike kožnih reakcija na lijekove povezanih sa sistemskim simptomima čini nekoliko sindroma: toksična epidermalna nekroliza, Stevens-Johnsonov sindrom, akutna generalizirana egzantematozna pustuloza te reakcija na lijekove s eozinofilijom i sistemskom reakcijom (DRESS). Kod takvih reakcija se nekoliko dana do 6 tjedana od uvođenja lijeka pojave promjene na koži, a često su zahvaćeni i unutarnji organi (jetra, bubrezi, pluća i dr.). Zbog toga je u ovakvim oblicima preosjetljivosti na lijekove velika smrtnost. Opisuje se slučaj bolesnice kojoj je ambulantno dijagnosticiran pijelonefritis, te je bila otpuštena kući uz preporuku terapije ciprofloksacinom. Deset dana kasnije bolesnica se vratila u ambulantu s pogoršanjem kliničke slike, lošeg općeg stanja, uz pojavu kožnih eflorescencija, oštećenje jetrene i bubrežne funkcije te s eozinofilijom. Na temelju kliničkih nalaza i ostale obrade postavljena je dijagnoza sindroma DRESS. Dijagnoza i terapija teških oblika reakcija na lijekove i u današnje vrijeme predstavljaju medicinski izazov