Systematic review of hematidrosis: Time for clinicians to recognize this entity

BACKGROUND

Hematidrosis is a sporadic disease, to a point where its existence is still denied up to date. It is also linked to stigmata, psychological roots, and religious beliefs, whih has strengthened clinicians' disbelief in hematidrosis.

AIM

To conduct a thorough review to classify the likelihood of hematidrosis cases.

METHODS

We searched PubMed, Science Direct, Medline, and Google Scholar, as well as four different preprint databases, including Medrxiv, Research Square, SSRN, and Biorxiv. We included studies from 1996 onwards, with no limitation on language. Hematidrosis was classified as "unlikely", "likely", and "highly likely".

RESULTS

There are 74 articles with 106 hematidrosis cases. India (n = 40) and China (n = 11) report the most cases. Patients are mostly female (76.5%) with a median age of 13 years. The head region is the most common bleeding site (n = 168/254). Headaches (26.9%) and abdominal pain (16.4%) are the most common prodromes. Beta-blockers (43%) and anxiolytic (23.2%) are the most commonly prescribed pharmacotherapy. Psychotherapy (37.5%) and counseling (32.5%) are the most utilized non-pharmacotherapy measures. Only 41.1% and 19.8% of all cases reach complete resolution and are highly likely to be hematidrosis, respectively.

CONCLUSION

Although hematidrosis is rare and the pathophysiology is still largely unknown, that does not mean hematidrosis does not exist. It is important to note that the most frequent trigger factors are either anxiety, fear, or excessive stress. Clinicians need to exclude other diagnoses and search for stressors to alleviate the bleeding.

Generalized prurigo nodularis with dramatic response to dupilumab treatment: A case report

BACKGROUND

Prurigo nodularis (PN) is a chronic condition characterized by a papulonodular pruriginous eruption of unknown aetiology. Currently, there are no medications for PN that the United States Food and Drug Administration has approved, which leads to very variable practices in the prescription of off-label treatments. Treatment of PN is based on clinical experience rather than controlled trials. We present our case of generalized PN, in which we had a dramatic response with dupilumab.

CASE SUMMARY

A 58-year-old female patient was admitted to our clinic with severe itchy, erythematous nodular lesions that were widespread all over her body, especially on the legs and back. It was learned that the patient's complaints started 4 years ago, and there was a significant increase in the lesions in the last period. Dermatological examination revealed diffuse firm erythematous excoriated nodular lesions all over the body. In the blood tests of the patient, serum Immunoglobulin E (IgE) was measured at 9330 IU/mL. The patient was diagnosed with generalized prurigo nodularis together with clinical and histopathological findings. Due to severe clinical findings and the presence of comorbidities, dupilumab treatment was planned for the patient. In the follow-up 4 mo later, it was observed that all nodular lesions healed with postinflammatory hypopigmentation. The IgE value decreased to 1500 IU/mL after 4 mo of dupilumab treatment.

CONCLUSION

Dupilumab treatment stands out as an effective and safe systemic treatment agent among existing systemic treatments.

Connection between dermatomyositis and montelukast sodium use: A case report

BACKGROUND

Montelukast or Singulair is a leukotriene receptor antagonist that reduces inflammation and relaxes the smooth muscles. It is known to be a safe and tolerable drug; nevertheless, it might be associated with several mild to severe adverse effects, one of which is dermatomyositis. Dermatomyositis is a rare acquired autoimmune myositis of unknown cause affecting adults and children. The literature has infrequently reported the association between dermatomyositis and montelukast use.

CASE SUMMARY

The current study reports a case of a 48-year-old black woman with a previous history of bronchial asthma and allergic rhinosinusitis who presented with typical signs and symptoms of dermatomyositis which were confirmed by investigations. Before developing dermatomyositis, the patient was prescribed montelukast for atopy and consumed the drug for five months. After administration of prednisolone, the patient had a significant improvement and is still being followed up.

CONCLUSION

Even though montelukast is widely used and believed to be a safe drug for managing several conditions, the present case report highlights the possibility of adverse effects of montelukast. Therefore, future studies with advanced study designs are highly recommended to investigate the association between dermatomyositis and montelukast use.

Platelet-rich plasma application in diabetic ulcers: A review

There are 422 million diabetic people in the world. 25% of these individuals are diagnosed with diabetic foot ulcer (DFU). 20% of patients with DFU will suffer amputation of the lower limbs. Following amputation procedures, the mortality rate of patients is over 70% in 5 years. Diabetes has no cure and, therefore, treatment aims to prevent and treat its complications. Autologous platelet-rich plasma (PRP) has been shown to be a therapeutic tool for many types of disorders, including the treatment of DFU. This manuscript aims to carry out a review to provide more knowledge about the efficacy and safety of autologous PRP for wound closure in patients with DFU. The majority of studies included in this review state that PRP promotes improvement of DFU lesions by accelerating tissue healing processes. However, many studies have a small sample size and thus require larger sample range in order to improve robustness of data in the literature.

Fecal microbiota transplant and dermatologic disorders: A retrospective cohort study assessing the gut microbiome’s role in skin disease

BACKGROUND

There is indication that fecal microbiota transplant (FMT) has the potential to alter the course of chronic skin disease, but few studies have investigated this phenomenon beyond case reports. Research with larger sample sizes is needed to provide a more thorough assessment of possible associations and to establish a broader foundation upon which to base hypotheses.

AIM

To identify associations between FMT and skin conditions, particularly infectious and inflammatory etiologies, and the role of dermatology post-FMT.

METHODS

We conducted a retrospective cohort study involving a chart review of all patients whom received FMT between January 2013 and December 2019 at a single academic medical center. Dermatologic follow-up was assessed for the two years after FMT or through March 2020 for more recent procedures. Dermatologic diagnoses and visits within the study time frame were recorded and assessed for trends. This study was exploratory in nature. Descriptive statistics were calculated, and the t-test, Pearson’s chi-squared test, and Fisher’s exact test were used to calculate P values.

RESULTS

Most patients were female (61.5%) and ethnically not Hispanic or Latino (93.6%). Median age was 38 (range, 17-90). In total, 109 patients who underwent 111 fecal microbiota transplant events were included. Twenty-six events (23.4%) involved a dermatology office visit post-procedure, and of these events, 20 out of the 26 (76.9%) had an infectious or inflammatory skin condition. The mean time to first visit was 10.0 (± 7.0) mo. The most common diagnoses were dermatophyte, wart(s), and dermatitis, though no specific diagnoses predominated in a way indicating FMT had a significant impact. More patients with a post-FMT skin disease diagnosis had a history of Crohn’s disease compared to those without (P = 0.022), but results could be affected by a small sample size.

CONCLUSION

Our study is limited by its retrospective nature, but the findings allow a glimpse at dermatologic conditions post-FMT. Few significant associations were found, but potential associations between FMT and skin disease should be further investigated, preferably in prospective studies, to identify how FMT might be of use for treating infectious and inflammatory skin diseases.

Fecal microbiota transplant for more than Clostridioides difficile: Dermatology a new frontier

Fecal microbiota transplant (FMT) has quickly become popular in research not only for recurrent Clostridioides difficile infections but for other chronic conditions as well. Recent, small dermatologic studies have reported improvements in inflammatory skin conditions in individuals treated with FMT, but larger studies are needed to clarify this possible relationship between the skin and the gut microbiome. We conducted a single-center, retrospective chart review to assess changes in acne, dermatitis herpetiformis and/or celiac disease, eczema, and psoriasis. Due to the retrospective nature of this study and the limitations of the current electronic medical record, we were unable to adequately assess cases of these diseases in relation to FMT. However, this study informs us that improvements in retrospective data are needed to formally evaluate this possible association. The better, but more cumbersome, study design would be a prospective, observational study. We encourage others to pursue further interdepartmental research on the influence of the gut microbiome on inflammatory skin diseases.

Rhinocerebral mucormycosis caused by Rhizopus oryzae in a patient with acute myeloid leukemia: A case report

BACKGROUND

Rhinocerebral mucormycosis (RCM) is a rare fatal fungal infection which is on the increase among immunocompromised hosts such as patients who have had hematological cancers, or have received immunosuppressive drugs, corticosteroids, or other T cell suppressing agents.

CASE SUMMARY

We report a case of RCM caused by Rhizopus oryzae, one of the most common opportunistic pathogens, in a patient suffering from a fourth relapse of acute myeloid leukemia. The patient developed RCM after he had received long-term antibiotic agents and corticosteroids. The pathogen was isolated three times from nasal secretions collected from the deep parts of the nasal cavity and was identified by morphology and internal transcribed spacer sequencing. Blood infection was excluded by droplet digital polymerase chain reaction and blood culture. The patient was empirically treated with caspofungin and voriconazole for several days while the lesions continued to progress. The patient was given amphotericin B in combination with caspofungin after RCM was suspected, and the lesions improved over the course of treatment, which lasted several days. However, the patient eventually died of the primary disease.

CONCLUSION

This case indicates that immunosuppressive drugs, including corticosteroids and antimetabolites in hematological tumor, do increase the risk of infections of this type. Early diagnosis, prompt and frequent surgical debridement, and treatment with amphotericin B without delay are all essential in combatting RCM.

Managing panniculitis in alpha-1 antitrypsin deficiency: Systematic review of evidence behind treatment

AIM

To systematically review literature for management of alpha-1 antitrypsin deficiency (AATD) panniculitis.

METHODS

Multiple databases were searched using combinations of pertinent terms. Articles were selected describing panniculitis treatment in patients with AAT < 11 μmol and/or PiZZ genotype, with no language limitation. All relevant articles were accessed in full text. Independent review of abstracts and full manuscripts was conducted by 2 reviewers, and quality assessment by one reviewer (checked by a second). Data extraction was conducted by one reviewer (checked by a second). Narrative synthesis only was conducted, as data were unsuitable for meta-analysis.

RESULTS

Thirty-two case reports and 4 case series were found. Augmentation therapy (infusions of plasma-derived AAT) was the most successful, with complete resolution of symptoms in all patients. Dapsone is a less expensive option, and it achieved clinical resolution in 62% of patients, but it is very poorly tolerated. Among other single-agent antibiotics, doxycycline was the most successful with complete clinical resolution seen in 33% of patients. Immunosuppressants were largely unsuccessful; 80% of patients exhibited no response. Liver transplantation and therapeutic plasma exchange displayed complete resolution in 66% of patients. Other strategies, such as non-steroidal anti-inflammatory drugs or antibiotics other than dapsone did not show sufficient response rates to recommend their use. Authors note the risk of bias imposed by the type of evidence (case reports, case series) available in this field.

CONCLUSION

Dapsone is the recommended first line therapy for AATD panniculitis, followed by augmentation therapy. Plasma exchange may be an alternative in the setting of rapidly progressive disease.

Pleomorphic cutaneous xanthomas disclosing homozygous familial hypercholesterolemia

Homoxygous Familial Hypercholesterolemia is characterized by a presence of several types of cutaneous xanthomas with an abnormal lipid profile. Some of these could be pathognomonic. Although these could be initially interpreted as isolated and localized benign disorders and offered surgical treatment, it has become increasingly clear that they could be a part of a systemic pathology. Here we describe a case of this rare disorder in a 19 years old non-obese young man who presented multiple, intertriginous, tuberous and tendinous xanthomas and had an associated abnormal lipid profile with elevated low-density lipoprotein cholesterol levels. A detailed history with clinical assessment in the differential diagnosis and laboratory investigations led to a precise diagnosis.

Skin-gut axis: The relationship between intestinal bacteria and skin health

The gut microbiome is an emerging area of interest in medicine. Imbalances in the gut microbiome have been linked to a number of disease states such as obesity and type 2 diabetes. The relationship between normally residing intestinal bacteria (the gut microbiota) and their potential role in the pathogenesis of skin diseases is an area of research for which we are only beginning to understand. Small studies have demonstrated underlying changes in the gut microbiome of patients with certain dermatological diseases. Interestingly, studies suggest that probiotics may have a role in the treatment of atopic dermatitis. However, the concept of the “skin-gut axis” is a newly emerging and important avenue of investigation, still lacking in pathobiological explanations. This review will introduce and describe the intestinal microbiome as it relates to skin health in a complex communication network between the immune system, endocrine system, metabolic system, and nervous system.

Atopic eczema treatment now and in the future: Targeting the skin barrier and key immune mechanisms in human skin

The skin facilitates a number of key roles but its functioning can be impaired by disease. Atopic eczema is a chronic inflammatory disease where the skin barrier has become leaky, and inflammation occurs. It affects up to 20% of children and 3% of adults worldwide, manifesting as red itchy patches of skin with varying severity. This review aims to investigate the leaky skin barrier and immune mechanisms from the perspective of potential novel treatments. The complexity of atopic eczema as a disease is what makes it difficult to treat. Genome-wide association studies have highlighted possible genetic variations associated with atopic eczema, however in some cases, individuals develop the disease without these genetic risk factors. Loss of function mutations in the filaggrin gene are one of these associations and this is plausible due to its key role in barrier function. The Th2 immune response is the link with regards to the immune mechanisms as atopic inflammation often occurs through increased levels of interleukin (IL)-4 and IL-13. Eczematous inflammation also creates susceptibility to colonisation and damage by bacteria such as Staphylococcus aureus. Potential novel treatments are becoming ever more specific, offering the hope of fewer side effects and better disease control. The best new treatments highlighted in this review target the immune response with human beta defensin 2, phosphodiesterase-4 inhibitors and monoclonal antibodies all showing promise.

Use of a selective enzymatic debridement agent (Nexobrid®) for wound management: Learning curve

AIM

To evaluate the efficacy of Nexobrid^® in the initial management of burns and lessons learned with the procedure.

METHODS

From January 27^th 2015 until January 25^th 2016, 25 patients aged between 18-94 years old with deep partial and full thickness burns were treated with Nexobrid^® covering 1%-30% of their total body surface area (TBSA). The debridement was applied in the first 96 h post-injury following the protocol suggested for Nexobrid^®. In patients with burns of more than 15% TBSA a second application of Nexobrid^® was performed. After the removal of the product - 4 h post application and after a 2 h period of wet dressing - we used several products to cover the wound like Suprathel^®, Biobrane^®, Mepitel^® with wet dressing, silver sulphadiazine 1% cream, and in some cases even autografts. We treated patients with inhalation injury as well. All the procedures were done under deep sedation, regional blocks in extremities or general anaesthesia in the intensive care unit room or in the operating theatre.

RESULTS

After these first 25 cases, we have observed that patients with partial thickness burns treated with Nexobrid^®, experienced great benefits in the reduction of the need for autografting compared with the standard of care. This is because after selective enzymatic debriding of the burn scar we can distinguish different wound beds, which can coexist in the same patient, and we also managed to associate each one to its ability to epithelize. In major burns, besides the improvement in wound healing, we observed an important improvement in their general state. This may be because SIRS significantly improved through a bloodless debridement of necrotic tissue, decreasing the requirements of vasoactive drugs and fluid resuscitation. Circumferential burns also benefited from enzymatic debridement, observing a decrease in the number of compartment syndromes and the need for escharotomies. At present, we have not observed a positive effect in the evolution and outcome of major burns with inhalation injury.

CONCLUSION

The introduction of Nexobrid^® shows significant improvement in burn treatment. Cumulative experiences are necessary to adapt its application in all Burns Centres.

Cutaneous implications of essential oils

Essential oils (EOs) as home remedies and for health benefits have been used for millennia, but with the recent surge in the popularity of natural products, these oils have garnered increased attention. EOs are complex natural mixtures obtained plant materials, and have demonstrated potent biological effects in vitro. They have commercial value in the food, cosmetics, and fragrance industries, and also have also experienced a steady rise in personal and home use as part of aromatherapy. Currently, widespread acceptance and use of EOs is limited by a lack of large-scale clinical trials in humans. In addition, they are associated with notable side effects such as contact and allergic dermatitis, among a myriad of rare but serious systemic side effects. This review is intended to provide the clinician with key background information and biology of essentials oils, identify key trials demonstrating benefits, and describe adverse effects, with a focus on cutaneous presentations.

Review of the initial treatment and avoidance of scald injuries

Scald injuries, which describe burns to living tissue from hot liquids, are a very common injury that occur across geographical, social, economic, and national boundaries. Despite their ubiquitous nature, a complete understanding of the conditions which are required to cause scald burns is not yet available. In addition, clear guidance to medical practitioners is available through various guidelines however in actual situations, the extent of the burn is not fully known and this lack of knowledge complicates care. Here, a comprehensive review is made of the available knowledge of temperatures and scald durations which lead to skin-burn injuries. The range of volumes and liquid temperatures are typical of those found in heated consumer beverages. This review can help medical practitioners design initial treatment protocols and can be used by manufacturers of hot-liquid products to avoid the most severe burns. Next, within the context of this ability to quantify burn depths, a review of current burn treatment guidelines is given. Included in this review is a visual recognition of the extent of burns into the dermal layer as well as decision guidelines for selection of patients which would benefit from referral to a dedicated burn center. It is hoped that by bringing together both the quantified burn-depth information and current treatment guidelines, this review can be used as a resource for persons in the medical, manufacturing, beverage service, and other industries to reduce the human impact of scald injuries.

Evidence based review of negative pressure wound therapy

Vacuum-assisted closure, sometimes referred to as microdeformational wound therapy or most commonly negative pressure wound therapy (NPWT), has significantly improved wound care over the past two decades. NPWT is known to affect wound healing through four primary mechanisms (macrodeformation, microdeformation, fluid removal, and alteration of the wound environment) and various secondary mechanisms (including neurogenesis, angiogenesis, modulation of inflammation, and alterations in bioburden) which are described in this review. In addition, the technique has many established uses, for example in wound healing of diabetic and pressure ulcers, as well as burn and blast wounds. This therapy also has many uses whose efficacy has yet to be confirmed, for example the use in digestive surgery. Modifications of the traditional NPWT have also been established and are described in detail. This therapy has various considerations and contraindications which are summarized in this review. Finally, future perspectives, such as the optimal cycling of the treatment and the most appropriate interface material, are touched upon in the final segment. Overall, despite the fact that questions remain to be answered about NPWT, this technology is a major breakthrough in wound healing with significant potential use both in the hospital but also in the community.

Papular mycosis fungoides: Six new cases and association with chronic lymphocytic leukemia

Papular mycosis fungoides (MF) is a rare presentation of MF. Six illustrative cases of papular MF were retrospectively reviewed. Five of the cases studied by immunohistochemistry had variable numbers (range: 1%-20%) of CD30+ cells in the dermal infiltrate, a finding that is characteristic of lymphomatoid papulosis but may occasionally occur in typical early MF. Although none of our papular MF patients had progressive disease, lesions with relatively high numbers of CD30+ cells in 3 patients did not respond well to skin-directed treatments used for MF. Interestingly, these patients had evidence of co-existing clonal B cell populations in the blood (one with clonal B cell lymphocytosis and two with B-cell chronic lymphocytic leukemia). We conclude that: (1) papular MF may contain CD30+ cells, thereby causing confusion with lymphomatoid papulosis; and (2) papular MF, like more typical MF, may be associated with clonal B-cell proliferations including chronic lymphocytic leukemia.

Multi-channeling optimized radiofrequency energy: A new age in well-established radiofrequency technology

AIM

To evaluate the safety and efficacy of Viora’s new multi-polar radiofrequency (RF) handpiece.

METHODS

A group of twelve volunteers (11 females and 1 male) participated in the current study, ranging in age from 23-70 years with Fitzpatrick skin type II-V. The inclusion criteria for the enrollment were no contraindications for the treatment, body mass index (BMI) < 35 and local fat accumulation or cellulite formation. A total of 19 treatment areas were treated in the study: 9 abdomen, 2 abdomen plus flanks, 2 arms and 6 thighs. The treatment performed with new multi-polar RF handpiece (V-FORM) with 4 levels of RF power (up to 50 W), 4 levels of vacuum pressure intensity (up to 500 mbar) and 4 operational modes (0.8, 1.7 and 2.45 MHz). Circumferential reduction and cellulite reduction treatments were performed once a week (7 ± 1 d) for a treatment series of 3-8 sessions. The clinical assessment of the treatment outcomes included skin moisture level, skin impedance, body temperature, circumferential measurements, clinical photographic assessment and BMI.

RESULTS

Ten of twelve patients completed the treatment course. No side effects were recorded during the study. The skin responded with slight erythema and sometimes edema, which is considered a positive end-point. All patients maintained a stable weight during the entire period of the study. No patient underwent any treatments or took medications for fat volume reduction during the study. A moderate positive correlation was found between the patient’s age and BMI (correlation coefficient 0.54). The initial body temperature increased in average to 34.0 °C from 31.9 °C, the initial skin moisture level increased to an average 40.98% from 38.9% and the initial skin impedance decreased by 3.8%-35.9% by the end of the treatment course. The pre-heating time for all body areas ranged between 1-6 min with negative correlation to the body’s end-point temperature (correlation coefficient -0.31). All patients responded to the treatment and showed some degree of circumferential reduction (up to 15 cm), on at least one of two-three measured points.

CONCLUSION

According to clinical data collected in this study, the new V-FORM handpiece represents an effective treatment with 100% response rate, with the safest treatment profile.

Local hyperthermia cleared multiple cutaneous warts on a nephrotic syndrome patient

Cutaneous warts are caused by human papillomavirus infection. Immunosuppressive state is one of the risk factors of human papillomavirus infection. A girl diagnosed of nephrotic syndrome and on immunosuppressive therapy developed multiple common warts. We treated her on a single lesion by local hyperthermia therapy at 44 °C for 3 consecutive days, each therapy lasted for 30 min. Ten days later, the patient received another 2 consecutive therapy. All lesions are completely resolved at the 9^th week after the treatment. No recurrent sign was observed in a 3-mo follow-up. Side effects included burning sensation, stabbing pain at the target site during treatment.

P2X7 receptor in skin biology and diseases

The P2X7 receptor is a trimeric ligand-gated cation channel present on immune and other cells. Activation of this receptor by its natural ligand extracellular adenosine triphosphate results in a variety of downstream responses, including the release of pro-inflammatory mediators and cell death. In normal skin, P2X7 is present on keratinocytes, Langerhans cells and fibroblasts, while the presence of this receptor on other cutaneous cells is mainly inferred from studies of equivalent cell types present in other tissues. Mast cells in normal skin however express negligible amounts of P2X7, which can be upregulated in cutaneous disease. This review discusses the potential significance of P2X7 in skin biology, and the role of this receptor in inflammatory skin disorders such as irritant and chronic dermatitis, psoriasis, graft-versus-host disease, as well is in wound healing, transplantation and skin cancer.

Pediatric ocular rosacea, a misdiagnosed disease with high morbidity: Proposed diagnostic criteria

Ocular rosacea is an important and underdiagnosed chronic inflammatory disorder observed in children. A clinical spectrum ranging from chronic eyelid inflammation, recurrent ocular redness, photophobia and/or hordeola/chalazions and conjunctival/corneal phlyctenules evolving to neovascularization and scarring may occur. Visual impairment and consequent amblyopia are frequent and corneal perforation although rare is the most feared complication. Ocular manifestations usually precede cutaneous lesions. Although few cases of pediatric ocular rosacea (POR) have been reported in the literature, many cases must have been underdiagnosed or misdiagnosed. The delay in diagnosis is greater than one year in the large majority of cases and may lead to serious ocular sequelae. This review aims to highlight the clinical features of POR, its epidemiology, easy diagnosis and effective treatment. We also propose new diagnostic criteria, in which at least three of the five clinical criteria must be present: (1) Chronic or recurrent keratoconjunctivitis and/or red eye and/or photophobia; (2) Chronic or recurrent blepharitis and/or chalazia/hordeola; (3) Eyelid telangiectasia documented by an ophthalmologist; (4) Primary periorificial dermatitis and/or primary features of rosacea; and (5) Positive familial history of cutaneous and/or ocular rosacea.

Unraveling oral psoriasis and its relationship with geographic tongue: A literature review

Differentiating between oral psoriasis and geographic tongue is difficult and controversial because some patients with geographic tongue do not necessarily have psoriasis. Furthermore, the number of clinical studies, reporting histopathological and genetic evidence for the definitive diagnosis of oral psoriasis, is limited. The aim of this literature review was to obtain data for supporting the diagnosis of oral psoriasis with particular emphasis on the relationship between psoriasis and geographic tongue. Based on the current data, it can be concluded that geographic tongue is the most common oral lesion in psoriasis, and histopathological, immunohistochemical, and genetic similarities have been observed between the two diseases. This review also emphasizes the importance of conducting oral examinations in patients with psoriasis and skin examinations in patients with geographic tongue.

Review of narrowband ultraviolet B radiation in vitiligo

Vitiligo is a common, acquired pigmentary disorder of unknown etiology with great impact on patient’s appearance and quality of life. It presents a therapeutic challenge to many dermatologists. Photochemotherapy using psoralen and ultraviolet A (UVA) therapy, topical and oral immunosuppresants, as well as cosmetic camouflage are also commonly employed with varying clinical efficacy. Phototherapy is a popular treatment option, which includes both of the generalized ultraviolet B (UVB) therapies, broadband UVB and narrowband UVB (NB-UVB). It has been used favorably, both alone as well as in combination with other agents like topical calcineurin inhibitors, vitamin-D analogs. Combination therapies are useful and may provide quicker regimentation and treat vitiligo with an additive mechanism of action than UVB phototherapy. Advances in technology may lead to the continuing use of UVB phototherapy as a treatment for vitiligo through the development of sophisticated devices and delivery systems as well as innovative application methods. These will provide increased therapeutic options for all vitiligo patients, particularly those with refractory disease. In this article, I have reviewed the available data pertaining to efficacy and safety issues for NB-UVB as monotherapy, its comparison with psoralen plus UVA and other modes of phototherapy, combination regimens that have been tried and future prospects of NB-UVB in vitiligo.

Actinic keratosis and field cancerization

While actinic keratoses (AKs) have been considered precancerous until recently for being able to turn into squamous cell carcinomas (SCCs), it is now agreed that it would be more appropriate to call them cancerous. Although not all AKs turn into SCC and some of them may even have a spontaneous regression, there is an obvious association between SCC and AK. Approximately 90% of SCs have been reported to develop from AKs and AKs are the preinvasive form of SCCs. The presence of two or more AKs on a photodamaged skin is an indicator of field cancerization and represents an increased risk of invasive SCC. All lesions should be treated since it cannot be foreseen which of the lesions will regress and which will progress to SCC. AK can be a single lesion or it can involve multiple lesions in a field of cancerization; thus, AK treatment is grouped under two headings: (1) Lesion-specific treatment; and (2) Field-targeted treatment. Lesion-specific treatments are practicable in patients with a small number of clinically visible and isolated lesions. These treatments including cryotherapy, surgical excision, shave excision, curettage and laser are based on physical destruction of the visible lesions. Field-targeted treatments are effective in the treatment of visible lesions, subclinical lesions and keratinocyte changes in the areas surrounding the visible lesions. Field targeted treatment options are topical imiquimod cream, 5% 5-fluorouracil cream, ingenol mebutate, diclofenac gel, resimiquimod and photodynamic therapy.

CD34+ dermal dendritic cells and mucin deposition in dermatomyositis

Dermal mucinosis is often associated with collagen diseases such as rheumatoid arthritis, lupus erythematosus, and dermatomyositis, in addition to autoimmune thyroiditis. We report eight cases of dermal mucin deposition secondary to typical dermatomyositis with cutaneous lesions known as heliotrope rash and Gottron’s papules. Striking mucin deposition was observed in both the papillary dermis and reticular dermis of all biopsy specimens. Immunohistochemical analysis showed that CD34+ dermal dendritic cells (DDCs) in the perilesional area in combination with vimentin+ cells within the mucinous lesion might be important in giving rise to abnormal deposition of dermal mucin. On the other hand, numbers of factor XIIIa+ DDCs and tryptase+ mast cells were reduced within and surrounding the mucin deposition, as compared with those in the dermis of normal controls. A pathogenic mechanism of dermal mucin deposition is proposed.

Clinical pharmacokinetics profile of ivermectin 1% cream after dermal applications on the face

AIM: To investigate the pharmacokinetics profile of Ivermectin 1% cream after topical treatment in patients with papulopustular rosacea (PPR).

METHODS: Ivermectin 1% cream is a new, effective, and safe treatment for PPR. The human pharmacokinetic (PK) profile of ivermectin and its circulating metabolites were assessed following topical application of ivermectin 1% cream to the face. Clinical PK assessments were conducted after 4 wk of treatment using healthy volunteers and PPR subjects. Additionally, PK sampling was conducted up to 1 year of treatment in clinical phase 3 studies. Plasma concentrations of ivermectin and ivermectin metabolites were determined using high-performance liquid chromatography with fluorescence detection after a specific derivation to increase sensitivity.

RESULTS: Systemic exposure to ivermectin was quantifiable at low levels in healthy and moderate to severe PPR subjects following the first topical application of ivermectin 1% cream (mean C_max of 0.5 ± 0.2 ng/mL and 0.7 ± 0.5 ng/mL in healthy volunteers and PPR subjects, respectively). Ivermectin plasma levels reached a plateau after 2 wk of repeated topical application, indicating that steady-state concentrations had been reached. No further ivermectin plasma accumulation was observed during the long-term clinical studies that investigated ivermectin treatment up to 1 year. Investigation of ivermectin metabolites indicated that 2 circulating metabolites represented more than 10% of parent drug systemic exposure at steady state. Repeated topical application of ivermectin 1% cream resulted in lower systemic exposure levels when compared with orally administered ivermectin, suggesting limited transdermal absorption of ivermectin. Topically applied ivermectin is cleared from the plasma slowly (with a prolonged plasma half-life when compared to the oral route).

CONCLUSION: Applications of ivermectin 1% cream result in low systemic exposure levels. Steady–state conditions are achieved by 2 wk without further accumulation under chronic treatment.