SAPHO: The Impossible Acronym

Edouard M. Grosshans, Clinique Dermatologique des Hôpitaux Universitaires, 1, Place de l’hôpital, F-7091 Strasbourg Cédex (France) The excellent paper of Brandsen et al. [1] dealing with this French-born new concept, the SAPHO [2], deserves some comments. This acronym – Syndrome – Acne – Pus-tulosis – Hyperostosis – Osteitis – emphasizes the occurrence simultaneous or not of cutaneous and osteoarticular disorders and the relationship of chronic, aseptic, neutro-philic, skin-limited, and painful rheumatic diseases. Behind this acronym, one may have the erroneous impression of discovering a ‘new disease’. It is in fact the imaginative creation of a new nosologic concept, which has drawn the attention of dermatologists, awaken their skepticism and will probably have some difficulties to make its way because of the choice of this acronymous effeminated denomination. The rheumatological counterpart is characterized by inflammatory aseptic changes of bones involving chiefly the sternocostoclavicular region, the spine and the sacroiliac joints; peripheral bones may also be involved. The radio-logic changes include osteitis (lytic lesions) and hyperostosis extending to the insertions of tendons and ligaments near the involved joints; they lead to progressive synostosis and ankylosis. The bone scan with 9‰Tc of these osteoarticular lesions discloses an increased uptake of the radioiso-tope. Slight nonspecific biological changes may be observed (increased WBC count and ESR, neither rheumatoid factor nor antinuclear antibodies). It has not yet been demonstrated if the structures primarily involved are the synovial membranes and the cartilages of the joints (arthritis), the bony tissue near the joints (osteitis) or the insertions of tendons, ligaments or capsules around the joints (enthesitis). These bone and/or joint lesions have their own specificity; but they are not necessarily associated with a skin disease or specifically related to a special type of skin disease. The dermatological counterpart is more ambiguous, at least for dermatologists. Palmoplantar pustulosis, a recurrent acrovesiculopustulosis unrelated to psoriasis, is one of the conditions which may be associated with osteoarticular lesions, chiefly of the anterior chest wall (Sonozaki syndrome). These recurrent pustules are aseptic, histologically unilocular and filled up with neutrophils in the mature stage; the bone and joint lesions are also aseptic, although Edlund et al. [3] found Propionibacterium acnes in some open biopsies of arthroosteitis: P. acnes are common anaerobic bacteria belonging to the microflora of seborrheic skin, and these findings deserve further controls. Acne is another condition that may be associated with osteoarticular involvement: the acne-associated rheumatism is especially observed in severe forms, such as acne conglobata or acne inversa; to this latter form belong some other conditions such as hidradenitis suppurativa, VerneuiΓs disease or dissecting cellulitis of the scalp, which are less common expressions of follicular occlusion [4], also described in association with aseptic arthroosteites.