Microsoft Word - DRM161BF


Editorial 

Dermatology 1993;186:161-162 

SAPHO: The Impossible Acronym 
E.M.  Grosshans 

Clinique Dermatologique des Hôpitaux Universitaires, Strasbourg, France 
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. 



Palmoplantar Pustulosis and Acne are two unrelated conditions. Their initials are 2 of the 5 
letters of the acronym SAPHO, but these two conditions never do occur together in a same 
patient suffering episodes of painful joint swelling. Can therefore the acronym and the syndrome 
survive if the constituent clinical and radiological items never occur together? 
I think that an ‘impossible’ acronym is not worth of acceptance; in the clinical practice, a 
diagnosis of the SAPHO cannot be relevant. On the contrary, the concept of a skin-related bone 
disease is a noticeable progress in the understanding and management of some chronic and 
recurrent painful arthroosteites with hyperostosis and functional impairment of joints. For this 
reason, the dermatologists ought to do homage to Chamot et al. [2] and to their 
 
© 1993 Karger AG, Basel 1018-8665/93/1863-0161 
$ 2.75/0 
outstanding achievement: like Christopher Columbus who rediscovered [5] the New World 
previously discovered by anonymous Vikings or Phoenicians, and made it known to Europe, 
they brought together their own experience and the dispersed data of literature and provided a 
new concept to the medical community. Christopher Columbus omitted 
to give a name to the new continent, and history has later been unfair to him in that respect. The 
French rheumatolo-gists baptized their discovery; the future will tell if the inaccuracy of the 
acronym will either impair or stimulate the diffusion of the concept and if misspelling may 
influence the fate of an idea. 
References 
Brandsen RE, Dekel S. Yaron M, Caspi D, Ophir J, Brenner S: SAPHO syndrome. Dermatology 
1993;186:176-180. Chamot AM, Benhamou CL, Kahn MF. Bera-nek L, Kaplan G, Prost A: Le 
syndrome acné-pustulose-hyperostose-ostéite (SAPHO). Ré-sultats d’une enquête nationale. 85 
observations. Rev Rhum 1987;54:187-196. 
Edlund E, Johnson U. Lidgren L, Pettersson H, Sturfelt G, Svensson B, Theander J, Willen H: 
Palmoplantar pustulosis and sternocostocla-vicular arthro-osteitis. Ann Rheum Dis 1988; 
47:809-815. 
Grosshans E, Bouffioux B. Toufik-Bellahcene M: Arguments en faveur de la nature follicu-laire 
de la maladie de Verneuil (‘hidrosadénites suppuratives chroniques’). Ann Dermatol Vénéréol 
1991;118:207-209. 
Grosshans E, Tomb R: 1492-1992 – II y a 500 ans Christophe Colomb redécouvrait ΓAméri-que. 
De la redécouverte des dermatoses dejà décrites. Ann Dermatol Vénéréol 1992;119: 
7-9. 
 
162 
Grosshans 
SAPHO