'Food allergy / intolerance testing' in dermatology : science or hype?

Food allergies are becoming an increasingly recognized clinical problem and patients frequently ask if their health complaints are related to their diet. There has been a recent phenomenon of food allergy or intolerance testing leading to dietary alterations and restrictions. This article gives a brief overview of the latest evidence and current guidelines for proper diagnosis and management. A distinction between food allergies and food intolerance or sensitivity should be made. It focuses on the association of the common skin conditions: eczema, acne and urticaria, to food and whether dietary changes are indicated. The currently available tests and their appropriateness are also discussed.peer-reviewe

Treatment of psoriasis with biologic agents in Malta

Introduction: Biologic therapy has revolutionalised the treatment of moderate to severe psoriasis leading to improved clinical outcomes and quality of life scores. This study aims to determine current biologic use in psoriatic patients at our Dermatology department at Sir Paul Boffa hospital, Malta. Method: All patients who were administered biologic therapy for psoriasis in Malta until the end of 2014 were included. Data included demographic details, disease duration and severity, biologic use and duration, previously attempted treatments, side effects, early and late response to biologic using Psoriasis Area Severity Index (PASI) scores and Dermatology Life Quality index (DLQI) scores. Results: A total of 36 patients were started on a biologic between 2009 and 2014 for psoriasis (M:25, F:11) with a mean age of 46.9 years. These included etanercept (n=22), infliximab (n=8), adalimumab (n=4) and ustekinumab (n=2). Secondary failure was the main reason why biologics were stopped and switched. Most patients had an improvement in their PASI scores after 2 to 4 weeks of starting the biologic and had a PASI 90 score improvement. All patients had more than a 5 point improvement in DLQI score. Discussion: Biologic use in our department is on the increase. Our patients had considerable improvements in their PASI and DLQI scores. Secondary failures have occurred usually after 2 to 4 years and switching has yielded positive results. Biologics are expensive drugs and recently we have switched to cheaper biosimilars. Doctors should be aware of the treatment options available for psoriasis patients, their possible side effects and when to refer to our department. In most cases a satisfactory response can be achieved.peer-reviewe

Metastatic melanoma mortality in Malta

BACKGROUND: There are currently no studies looking specifically at the characteristics of the primary melanoma in patients who died of metastatic melanoma in Malta. This retrospective study looks at the demographics of these patients and the characteristics of their primary melanoma.METHOD: Mortality data secondary to metastatic melanoma between 2007 and 2016 was gathered from the Malta National Mortality Registry. All patients whose death certificates had metastatic melanoma as the cause of death were included. Further data on histology and imaging was gathered from the Malta National Cancer Registry and the hospital electronic database.RESULTS: There were 87 recorded deaths (45 male; 42 female) in Malta secondary to metastatic melanoma between 2007 and 2016, with an average age at diagnosis of the primary melanoma of 64.3 years (range 23-92 years), average age at death of 67.9 years (range 28-96 years) and an average duration of survival after diagnosis of primary melanoma of 34.7 months (range 1-180 months). The commonest histological subtype of the primary cutaneous melanoma was nodular. The commonest site for the primary cutaneous melanoma was the back. The mean Breslow thickness was 4.23mm (range 0.3-13mm). The commonest site of metastasis was to distant lymph nodes, followed by the skin, liver and lung.CONCLUSION: Mortality secondary to metastatic melanoma is prevalent in the over 60 age group, with the back being the commonest site of the primary melanoma. Identification of patients who are at higher risk of death from melanoma in Malta allows for their more effective targeting in local melanoma screening and education campaigns.peer-reviewe

Cutaneous melanoma more likely to be invasive in fairer skin phototypes : a retrospective observational study

Fitzpatrick skin phototype is one of the factors determining melanoma development, with fairer skin phototypes I and II known to be associated with a higher risk. This study aimed to identify any associations between skin phototype and the histologic subtype, Breslow's thickness, and the site of melanoma. Patients diagnosed with melanoma for over an 18-month period were included. Data were gathered from the Malta National Cancer Registry. There were 167 registered cutaneous melanoma patients, of which 135 were included in the study. Melanomas in patients with skin phototypes I and II were more likely to be invasive than in situ when compared to patients with skin phototypes III and IV (P = 0.00027). There was also an association between skin phototype and histologic type of melanoma (P = 0.005), with melanoma in situ being the most common subtype in patients with skin type III. This study confirms that fairer skin phototypes have an increased risk of melanoma. It also shows that in our population, melanoma in skin phototypes I and II is more likely to be invasive rather than in situ compared to melanoma in darker skin phototypes. Further studies are required to confirm these findings and identify possible reasons.peer-reviewe

Rituximab : a novel treatment for Pemphigus in Malta

Until recently, the main treatment for pemphigus has been systemic corticosteroids, usually administered at high doses with consequent side-effects. Lately, the biological agent rituximab has been introduced as an effective treatment for this condition. This article describes seven cases of pemphigus successfully treated with rituximab in Malta and discusses the benefits and drawbacks of this novel treatment modality.peer-reviewe

Pemphigus Vulgaris : case report

Case report on a 53yr old gentleman who initially presented to his family doctor with mouth ulcers, hoarseness and odynophagia. He was given various treatments including antibiotics, anti-virals, non-steroidal anti-inflammatory drugs (NSAIDs) and oral steroids with no effect. His condition worsened and was associated with a 5kg weight loss. He subsequently developed skin blisters and erosions and was referred to the dermatology department. A clinical diagnosis of pemphigus vulgaris was made and he was started on high dose oral steroids. A skin biopsy sent for histology and immunofluorescence confirmed the diagnosis. On confirmation he was admitted for rituximab therapy and started on azathioprine.peer-reviewe

A novel SPINK5 donor splice site variant in a child with Netherton syndrome

Abstract Background Netherton syndrome (NS) is a genodermatosis caused by loss‐of‐function mutations in SPINK5, resulting in aberrant LEKTI expression. Method Next‐generation sequencing of SPINK5 (NM_001127698.1) was carried out and functional studies were performed by immunofluorescence microscopy of a lesional skin biopsy using anti‐LEKTI antibodies. Results We describe a novel SPINK5 likely pathogenic donor splice site variant (NM_001127698.1:c.2015+5G>A) in a patient with NS and confirm its functional significance by demonstrating complete loss of LEKTI expression in lesional skin by immunofluorescence analysis. Conclusion The 2015+5G>A is a novel, likely pathogenic variant in NS. Herein we review and assimilate documented SPINK5 pathogenic variants and discuss possible genotype–phenotype associations in NS

Continuous Positive Airway Pressure: Is it a route for infection in those with Obstructive Sleep Apnoea?

Introduction: Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnoea (OSA), with limited data about the prevalence of respiratory infections and microbial colonization in these patients. Objectives: The aim of this study was to determine if CPAP use is associated with respiratory infections and to identify the organisms that colonize or infect these patients. Method: A retrospective, case-controlled study in patients diagnosed with OSA was carried out. 137 patients were recruited and interviewed using a questionnaire. A nasal swab was taken from each patient. Patients using CPAP machines had swabs taken from masks and humidifiers. Results: 66 (48.2%) patients received CPAP treatment with 60.6% of them having a heated humidifier. 78.8% were male, with the majority using a full face mask (63.6%). No significant difference was seen in the prevalence of rhinosinusitis, lower respiratory tract infections and hospital admissions for pneumonia between CPAP and non-CPAP treated patients. The presence of a humidifier did not influence the prevalence of infections. Commensal flora was predominantly cultured from nasal swabs from both patient groups. Coagulase Negative Staphylococci and Diphtheroids were the main organisms cultured from masks and humidifiers respectively. Conclusions: This study shows that the use of CPAP, choice of mask and humidifier have no significant impact on the prevalence of infections and micro-organisms isolated. This is very reassuring to the physician prescribing CPAP therapy and users