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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Neutrophilic dermatoses &#40;ND&#41; encompass a heterogeneous set of skin diseases&#44; some of which have a chronic and recurrent course&#46; These diseases pose a therapeutic challenge&#59; many different drugs have been used to treat ND&#44; with variable results&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 51-year-old man with no past medical history of interest was in follow up for recurrent episodes of pyoderma gangrenosum &#40;PG&#41; triggered by trauma&#44; insect bites&#44; or infection &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; He reported no systemic symptoms nor any family history of skin disease&#46; Monoclonal immunoglobulin &#40;Ig&#41; A gammopathy of undetermined significance &#40;MGUS&#41; had been detected at the moment of diagnosis&#44; but had not required treatment&#46; PG flare-ups were treated with pulses of oral corticosteroids&#44; as well as topical and intralesional corticosteroids&#44; cyclosporine &#40;up to a maximum dose of 5&#8239;mg&#47;kg&#47;d&#41;&#44; and topical tacrolimus&#46; While the patient showed a good initial response to these treatments&#44; he experienced rapid recurrences affecting varying locations&#46; Later&#44; the patient developed new lesions in the form of flaccid pustules grouped on the edges of polycyclic erythematous plaques&#44; located on the trunk and armpits &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Culture did not reveal the presence of microorganisms&#46; Histology was compatible with a diagnosis of subcorneal pustular dermatosis &#40;SPD&#41;&#46; The patient began treatment with sulfone &#40;100&#8211;200&#8239;mg&#47;d&#41; and&#44; later&#44; with colchicine &#40;0&#46;5&#8211;1&#8239;mg&#47;d&#41;&#44; with little improvement&#46; He experienced 7 episodes of PG in 1&#8239;year&#44; despite various therapeutic attempts and avoidance of triggers&#46; Finally&#44; the patient began treatment with subcutaneous adalimumab &#40;induction dose&#44; 80&#8239;mg in wk 0 and 40&#8239;mg in wk 1&#59; maintenance dose&#44; 40&#8239;mg every 2 wk&#41;&#46; The SPD lesions disappeared after administration of the second dose of adalimumab&#44; and no recurrences were observed after 21 months of follow-up &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Episodes of PG were limited to a single new lesion that appeared 6 months after starting treatment and was easily controlled with topical corticosteroid therapy&#46; No further progression of the MGUS has been detected to date&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">ND is a group of skin diseases characterized by the presence on histology of a predominantly neutrophilic inflammatory infiltrate&#44; without evidence of infection&#46; Each of these entities can be considered part of the same spectrum of diseases &#40;and have overlapping clinical and histological characteristics&#41;&#44; and can occasionally appear simultaneously&#46; We have found only 13 published cases describing concomitant PG and SPD in a single patient&#44; most of which were associated with monoclonal IgA gammopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There are 3 main factors that contribute to the pathogenesis of ND&#58; abnormal expression of inflammatory molecules&#59; altered neutrophil function&#59; and genetic predisposition&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Some studies have demonstrated overexpression of tumor necrosis factor alpha &#40;TNF-&#945;&#41;&#44; interleukin 1 &#40;IL-1&#41; and its receptor&#44; IL-17&#44; and IL-8 in skin lesions in ND patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> TNF-&#945;&#44; IL-17&#44; and IL-8 induce the activation and migration of neutrophils and the synthesis of matrix metalloproteinases MMP-2 and MMP-9&#44; resulting in tissue damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Up to one third of ND patients do not respond to first-line treatment &#40;systemic corticosteroids combined with a corticosteroid-sparing agent&#41;&#46; A recent semi-systematic review reported an overall response rate of 87&#37; and a complete response rate of 67&#37; in PG patients treated with TNF-&#945; inhibitors&#44; and found no significant differences between infliximab&#44; adalimumab&#44; and etanercept&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Adalimumab is a therapeutic alternative for the treatment of PG associated with synovitis&#44; acne&#44; pustulosis&#44; hyperostosis&#44; osteitis &#40;SAPHO&#41; syndrome &#40;sometimes combined with low doses of methotrexate&#41;&#44; pyoderma gangrenosum&#44; acne&#44; suppurative hidradenitis &#40;PASH&#41; syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> and PG refractory to conventional immunosuppressive therapies and other TNF-&#945; inhibitors&#46; Substitution of infliximab and etanercept with adalimumab has shown good results in the vast majority of patients&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> except for one who did not respond to either etanercept or adalimumab&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In complex cases&#44; intravenous immunoglobulins and ustekinumab have also been used with success &#40;overall response rate&#58; 66&#46;7 and 66&#46;6&#37;&#44; respectively&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We have found only 2 published cases of patients diagnosed with SPD who have been treated with adalimumab&#46; De Encarna&#231;&#227;o Roque Diamantino et al<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> reported a case in which the patient initially received topical and systemic corticosteroids&#44; sulfone&#44; sulfapyridine&#44; and acitretin&#44; without improvement&#46; Complete lesion clearance was achieved after 6 weeks of treatment with adalimumab &#40;40&#8239;mg every 2 wk&#41; and a tapering dose of deflazacort&#46; Versini et al<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> described the case of a patient with SPD and MGUS who was refractory to multiple treatments&#44; including infliximab and etanercept&#46; Complete lesion clearance was observed after 5 months of adalimumab therapy &#40;induction dose&#44; 80&#8239;mg at wk 0 and 40&#8239;mg at wk 1&#59; maintenance dose&#44; 40&#8239;mg every 2 wk&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">To our knowledge this is the first published report of a good response to adalimumab in a patient with concomitant PG and SPD&#46; This drug is a potential therapeutic alternative for the treatment of ND refractory to other agents&#44; and can provide rapid lesion improvement and control of recurrences&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letters
Recalcitrant Pyoderma Gangrenosum and Subcorneal Pustular Dermatosis Successfully Treated With Adalimumab
Pioderma gangrenoso y dermatosis pustulosa subcórnea refractarios tratados con éxito mediante adalimumab
M.C. García del Pozo-Martín de Hijas
Autor para correspondencia
magarciadel@sescam.jccm.es

Corresponding author.
, J.L. Agudo-Mena, M.E. Gómez-Sánchez, E. Escario-Travesedo
Servicio de Dermatología Médico-Quirúrgica y Venereología, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Neutrophilic dermatoses &#40;ND&#41; encompass a heterogeneous set of skin diseases&#44; some of which have a chronic and recurrent course&#46; These diseases pose a therapeutic challenge&#59; many different drugs have been used to treat ND&#44; with variable results&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 51-year-old man with no past medical history of interest was in follow up for recurrent episodes of pyoderma gangrenosum &#40;PG&#41; triggered by trauma&#44; insect bites&#44; or infection &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; He reported no systemic symptoms nor any family history of skin disease&#46; Monoclonal immunoglobulin &#40;Ig&#41; A gammopathy of undetermined significance &#40;MGUS&#41; had been detected at the moment of diagnosis&#44; but had not required treatment&#46; PG flare-ups were treated with pulses of oral corticosteroids&#44; as well as topical and intralesional corticosteroids&#44; cyclosporine &#40;up to a maximum dose of 5&#8239;mg&#47;kg&#47;d&#41;&#44; and topical tacrolimus&#46; While the patient showed a good initial response to these treatments&#44; he experienced rapid recurrences affecting varying locations&#46; Later&#44; the patient developed new lesions in the form of flaccid pustules grouped on the edges of polycyclic erythematous plaques&#44; located on the trunk and armpits &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Culture did not reveal the presence of microorganisms&#46; Histology was compatible with a diagnosis of subcorneal pustular dermatosis &#40;SPD&#41;&#46; The patient began treatment with sulfone &#40;100&#8211;200&#8239;mg&#47;d&#41; and&#44; later&#44; with colchicine &#40;0&#46;5&#8211;1&#8239;mg&#47;d&#41;&#44; with little improvement&#46; He experienced 7 episodes of PG in 1&#8239;year&#44; despite various therapeutic attempts and avoidance of triggers&#46; Finally&#44; the patient began treatment with subcutaneous adalimumab &#40;induction dose&#44; 80&#8239;mg in wk 0 and 40&#8239;mg in wk 1&#59; maintenance dose&#44; 40&#8239;mg every 2 wk&#41;&#46; The SPD lesions disappeared after administration of the second dose of adalimumab&#44; and no recurrences were observed after 21 months of follow-up &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Episodes of PG were limited to a single new lesion that appeared 6 months after starting treatment and was easily controlled with topical corticosteroid therapy&#46; No further progression of the MGUS has been detected to date&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">ND is a group of skin diseases characterized by the presence on histology of a predominantly neutrophilic inflammatory infiltrate&#44; without evidence of infection&#46; Each of these entities can be considered part of the same spectrum of diseases &#40;and have overlapping clinical and histological characteristics&#41;&#44; and can occasionally appear simultaneously&#46; We have found only 13 published cases describing concomitant PG and SPD in a single patient&#44; most of which were associated with monoclonal IgA gammopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There are 3 main factors that contribute to the pathogenesis of ND&#58; abnormal expression of inflammatory molecules&#59; altered neutrophil function&#59; and genetic predisposition&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Some studies have demonstrated overexpression of tumor necrosis factor alpha &#40;TNF-&#945;&#41;&#44; interleukin 1 &#40;IL-1&#41; and its receptor&#44; IL-17&#44; and IL-8 in skin lesions in ND patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> TNF-&#945;&#44; IL-17&#44; and IL-8 induce the activation and migration of neutrophils and the synthesis of matrix metalloproteinases MMP-2 and MMP-9&#44; resulting in tissue damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Up to one third of ND patients do not respond to first-line treatment &#40;systemic corticosteroids combined with a corticosteroid-sparing agent&#41;&#46; A recent semi-systematic review reported an overall response rate of 87&#37; and a complete response rate of 67&#37; in PG patients treated with TNF-&#945; inhibitors&#44; and found no significant differences between infliximab&#44; adalimumab&#44; and etanercept&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Adalimumab is a therapeutic alternative for the treatment of PG associated with synovitis&#44; acne&#44; pustulosis&#44; hyperostosis&#44; osteitis &#40;SAPHO&#41; syndrome &#40;sometimes combined with low doses of methotrexate&#41;&#44; pyoderma gangrenosum&#44; acne&#44; suppurative hidradenitis &#40;PASH&#41; syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> and PG refractory to conventional immunosuppressive therapies and other TNF-&#945; inhibitors&#46; Substitution of infliximab and etanercept with adalimumab has shown good results in the vast majority of patients&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> except for one who did not respond to either etanercept or adalimumab&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In complex cases&#44; intravenous immunoglobulins and ustekinumab have also been used with success &#40;overall response rate&#58; 66&#46;7 and 66&#46;6&#37;&#44; respectively&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We have found only 2 published cases of patients diagnosed with SPD who have been treated with adalimumab&#46; De Encarna&#231;&#227;o Roque Diamantino et al<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> reported a case in which the patient initially received topical and systemic corticosteroids&#44; sulfone&#44; sulfapyridine&#44; and acitretin&#44; without improvement&#46; Complete lesion clearance was achieved after 6 weeks of treatment with adalimumab &#40;40&#8239;mg every 2 wk&#41; and a tapering dose of deflazacort&#46; Versini et al<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> described the case of a patient with SPD and MGUS who was refractory to multiple treatments&#44; including infliximab and etanercept&#46; Complete lesion clearance was observed after 5 months of adalimumab therapy &#40;induction dose&#44; 80&#8239;mg at wk 0 and 40&#8239;mg at wk 1&#59; maintenance dose&#44; 40&#8239;mg every 2 wk&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">To our knowledge this is the first published report of a good response to adalimumab in a patient with concomitant PG and SPD&#46; This drug is a potential therapeutic alternative for the treatment of ND refractory to other agents&#44; and can provide rapid lesion improvement and control of recurrences&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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