The Role of Exosomes Derived From Mesenchymal Stromal Cells in Dermatology

The skin is the largest organ of the human body and its main functions include providing protection from external harmful agents, regulating body temperature, and homeostatic maintenance. Skin injuries can damage this important barrier and its functions so research focuses on approaches to accelerate wound healing and treat inflammatory skin diseases. Due to their regenerative and immunomodulatory properties, mesenchymal stromal cells (MSCs) have been reported to play a significant role in skin repair and regeneration. However, it seems that the secretome of these cells and exosomes in particular may be responsible for their functions in skin regeneration and the immunomodulation field. The present review aims to gather the available information about the role of MSC-derived exosomes for both in vitro and in vivo models of different skin conditions and to highlight the need for further research in order to overcome any limitations for clinical translation.

Reproductive Potential and Outcomes in Patients with Hidradenitis Suppurativa: Clinical Profile and Therapeutic Implications

There are scarce data available regarding the impact of hidradenitis suppurativa (HS) on fertility, course and outcome of pregnancy and risk associated with treatments. The aims of this study are (1) to describe the clinical profile of HS women of childbearing age with and without accomplished reproductive desires and (2) to describe the prescribed treatments based on the fulfillment of reproductive intentions. We conducted a prospective observational study that included 104 HS women of childbearing age, 50.96% (53/104) with unfulfilled reproductive desires. These women were younger (29.08 vs. 42.06 years, p < 0.001), less frequently married and higher educated than women with fulfilled reproductive desires. Their age of disease onset was lower, but disease duration was shorter, in concordance with a lower International Hidradenitis Suppurativa Severity Score System (IHS4) and lower number of draining tunnels. Combined oral contraceptives were more frequently prescribed in women with unfulfilled reproductive desires (30.19% vs. 9.80%, p = 0.013) while biologics were less used in this group (3.77% vs. 13.73%, p = 0.08). In conclusion, a higher educational level and an earlier disease onset, with potential implications in finding a partner, may make the fulfillment of reproductive desires difficult for patients with HS. This study could help clinicians to achieve a better understanding of the specific characteristics of HS during childbearing age and consider reproductive desires when making treatment decisions.

Treatment challenges in clinically amyopathic dermatomyositis: A case series and review of new therapeutic options for skin involvement

The term clinically amyopathic dermatomyositis (CADM) is used to represent a subgroup of patients with the typical cutaneous features of dermatomyositis (DM) in the absence of muscle involvement. Similar to classic DM, CADM can be associated with other connective tissue disorders and systemic manifestations such as interstitial lung disease and malignancy. Owing to the frequent discordance between muscle response and skin disease, the therapeutic approach to CADM represents a challenge. The current literature suggests that CADM treatment should follow a specific protocol, influenced by visceral involvement and the expression of certain myositis-specific antibodies, and different from the recommendation in the presence of myositis. Here, we present five new cases of CADM. We describe the available therapeutic options for skin manifestations in this type of DM, and we propose a step-by-step therapeutic scheme, using the cutaneous dermatomyositis disease area and severity index to assess response. Our literature review establishes mycophenolate mofetil and intravenous immunoglobulin as the most frequently successful therapies in refractory skin disease.

Itchy Capillary Malformations: Unusual Appearance of Meyerson Phenomenon, a Case Series

Meyerson phenomenon, also known as "halo-eczema," has been widely described over melanocytic and non-melanocytic lesions. However, its appearance over vascular anomalies is rarely observed and could lead to diagnostic errors. A case study of five patients aged between four months and two years is reported. These patients developed unique erythematous and pruritic scaly patches, being diagnosed and treated as fungal infections. Due to the lack of response to the treatment, they were referred to the pediatric dermatology practice, where the diagnosis of Meyerson phenomenon over capillary malformations was made. Topical treatment with corticosteroids led to improvement in all cases. Although Meyerson phenomenon developing over vascular anomalies is a rare condition, it is important for pediatricians and dermatologists to assess it as a part of the differential diagnosis when treating a patient with skin lesions. Recognizing this phenomenon will prevent diagnostic and therapeutic errors.

Current Advanced Therapies Based on Human Mesenchymal Stem Cells for Skin Diseases

Skin disease may be related with immunological disorders, external aggressions, or genetic conditions. Injuries or cutaneous diseases such as wounds, burns, psoriasis, and scleroderma among others are common pathologies in dermatology, and in some cases, conventional treatments are ineffective. In recent years, advanced therapies using human mesenchymal stem cells (hMSCs) from different sources has emerged as a promising strategy for the treatment of many pathologies. Due to their properties; regenerative, immunomodulatory and differentiation capacities, they could be applied for the treatment of cutaneous diseases. In this review, a total of thirteen types of hMSCs used as advanced therapy have been analyzed, considering the last 5 years (2015-2020). The most investigated types were those isolated from umbilical cord blood (hUCB-MSCs), adipose tissue (hAT-MSCs) and bone marrow (hBM-MSCs). The most studied diseases were wounds and ulcers, burns and psoriasis. At preclinical level, in vivo studies with mice and rats were the main animal models used, and a wide range of types of hMSCs were used. Clinical studies analyzed revealed that cell therapy by intravenous administration was the advanced therapy preferred except in the case of wounds and burns where tissue engineering was also reported. Although in most of the clinical trials reviewed results have not been posted yet, safety was high and only local slight adverse events (mild nausea or abdominal pain) were reported. In terms of effectiveness, it was difficult to compare the results due to the different doses administered and variables measured, but in general, percentage of wound's size reduction was higher than 80% in wounds, Psoriasis Area and Severity Index and Severity Scoring for Atopic Dermatitis were significantly reduced, for scleroderma, parameters such as Modified Rodnan skin score (MRSC) or European Scleroderma Study Group activity index reported an improvement of the disease and for hypertrophic scars, Vancouver Scar Scale (VSS) score was decreased after applying these therapies. On balance, hMSCs used for the treatment of cutaneous diseases is a promising strategy, however, the different experimental designs and endpoints stablished in each study, makes necessary more research to find the best way to treat each patient and disease.

Hair Shaft Examination: A Practical Tool to Diagnose Griscelli Syndrome

Griscelli syndrome (GS) is a rare disease that is characterized by silvery hair and fair skin. It is included in congenital grey hair syndromes, a rare group of autosomal recessive disorders characterized by silvery grey hair and severe multisystem disorders, such as immune system impairment, defects in immunological function, ocular and skeletal alterations, and nervous system defects. Herein, we report a rare case of GS type 1 and highlight the importance of a dermatological and hair examination to make an early diagnosis of these life-threatening diseases.

Epidermal Barrier Function and Skin Homeostasis in Skin with Permanent and Adhesive Tattoos: A Cross-Sectional Study

Tattoos are a current trend, but their impact on skin homeostasis and epidermal barrier function is not well known. So, the aims of this study are (1) to investigate epidermal barrier function and skin homeostasis in skin with permanent tattoos, adhesive temporary tattoos and non-tattooed skin, and (2) to analyze the effect of petrolatum on skin with permanent and adhesive tattoos. In total, 67 tattoos were enrolled (34 permanent tattoos and 33 adhesive tattoos). Temperature, transepidermal water loss (TEWL), stratum corneum hydration (SCH), erythema and total antioxidant capacity (TAC) were measured in skin with permanent tattoos, adhesive tattoos and non-tattooed skin before and after petrolatum application. The temperature was lower (30.47 °C vs. 31.01 °C; p = 0.001) on skin with permanent tattoos than non-tattooed skin, while SCH (48.24 Arbitrary Units (AU) vs. 44.15 AU; p = 0.008) was higher. Skin with adhesive tattoos showed lower temperature, SCH (21.19 AU vs. 41.31 AU; p < 0.001) and TAC (1.27 microcoulombs (uC) vs. 3.48 uC; p < 0.001), and higher TEWL (8.65 g/h/m² vs. 6.99 g/h/m²; p = 0.003), than non-tattooed skin. After petrolatum application, the temperature decreased on skin with permanent tattoos, and TEWL and SCH decreased on skin with adhesive tattoos. Adhesive tattoos may affect skin barrier function, while permanent tattoos may have a lower impact. Tattooed and non-tattooed skin responds in different ways to moisturizers.

What Proportion of the Caseload at Dermatology Outpatient Clinics in Spain Do Skin Tumors Account for? Results from the DIADERM National Random Sampling Project

INTRODUCTION AND OBJECTIVE

A significant part of a dermatologist's activity involves the diagnosis and management of tumors. The aim of this study was to analyze the caseload at public and private dermatology outpatient clinics in Spain to determine the proportion of tumor diagnoses.

MATERIAL AND METHOD

Observational cross-sectional study of diagnoses made in dermatology outpatient clinics during 2 data-collection periods in the DIADERM study, an anonymous survey of a random, representative sample of dermatologists across Spain. Diagnoses made during the 2 periods were coded according to the CIE-10. There were 165 tumor-related codes, classified into 24 groups. For the purpose of this study, these groups were then reduced to benign melanocytic lesions, malignant melanocytic lesions, benign nonmelanocytic lesions, and malignant nonmelanocytic lesions.

RESULTS

Tumors accounted for 46.2% of all diagnoses; 18.5% of the tumors were malignant (a category that included in situ forms of keratinocyte cancers). Four of the 10 most common diagnoses were of malignant tumors: in situ keratinocyte cancers, basal cell carcinoma, melanoma, and squamous cell carcinoma. Significant differences were observed between malignant and benign tumors according to type of practice (public vs. private) and geographic region.

CONCLUSION

Skin cancer accounts for a significant part of the dermatologist's caseload in Spain. Differences can be observed depending on the public/private healthcare setting and other factors.

The role of biologic treatment in special scenarios in hidradenitis suppurativa: Facial and nape phenotype, dissecting cellulitis of the scalp, and lymphedema

Hidradenitis suppurativa (HS) is a chronic inflammatory disorder affecting the hair follicle which typically affects the axilla, inguinal, submammary, and perianal areas. Atypical HS, such as facial HS, dissecting cellulitis of the scalp (DCS), nape HS, and HS lymphedema has also been described. There is scarce evidence about the treatment of atypical HS. To describe the efficacy of biologic drugs and adjuvant therapeutic interventions used in patients with atypical HS who had an inadequate response to systemic antibiotics. Prospective case series study of patients with atypical HS (facial HS, DCS, nape HS, and HS lymphedema) treated with biologic drugs in a HS Clinic setting. Disease activity indexes, sociodemographic, clinical, and safety variables were collected. Two patients met criteria for Facial HS, three met criteria for DCS/nape HS and three patients met criteria for HS lymphedema. Patients with facial HS achieved rapid improvement without requiring other therapies. Patients with DCS, nape HS, and HS lymphedema showed variable response, with decrease of activity indexes, and requiring adjuvant treatments. Biologic drugs are useful in the management of special HS locations. In the case of facial HS, biologic therapy seems to be quite effective as monotherapy. In the cases of DCS, HS lymphedema and nape HS, treatment combination or intensification may be needed.

Cytotoxicity and Epidermal Barrier Function Evaluation of Common Antiseptics for Clinical Use in an Artificial Autologous Skin Model

Bioengineered artificial skin substitutes (BASS) are the main treatment used in addition to autografts when skin injuries involve a large body surface area. Antiseptic/antibiotic treatment is necessary to prevent infections in the BASS implant area. This study aims to evaluate the effect of antiseptics and antibiotics on cell viability, structural integrity, and epidermal barrier function in BASS based on hyaluronic acid during a 28 day follow-up period. Keratinocytes (KTs) and dermal fibroblasts (DFs) were isolated from skin samples and used to establish BASS. The following antibiotic/antiseptic treatment was applied every 48 h: colistin (1%), chlorhexidine digluconate (1%), sodium chloride (0.02%), and polyhexanide (0.1%). Cell viability (LIVE/DEAD® assay), structural integrity (histological evaluation), and epidermal barrier function (trans-epidermal water loss, (TEWL), Tewameter®) were also evaluated. Cell viability percentage of BASS treated with chlorhexidine digluconate was significantly lower (p ≤ 0.001) than the other antiseptics at day 28. Compared to other treatments, chlorhexidine digluconate and polyhexanide significantly affected the epithelium. No significant differences were found regarding epidermal barrier. These results may be useful for treatment protocols after implantation of BASS in patients and evaluating them in clinical practice. BASS represent a suitable model to test in vitro the impact of different treatments of other skin wounds.

Impact of Gloves and Mask Use on Epidermal Barrier Function in Health Care Workers

BACKGROUND

Coronavirus disease 2019 has rapidly spread all over the world. Personal protective equipment (PPE) including masks and gloves is needed to avoid transmission. Adverse skin reactions associated with PPE have been described, but there is no information regarding objective measures to assess skin impairment related to PPE.

OBJECTIVE

The aim of the study was to evaluate the impact of using facial mask and nitrile gloves on epidermal barrier function and skin homeostasis.

METHODS

A cross-sectional study was designed. Thirty-four health care workers wearing nitrile gloves and a mask for 2 hours were included. Transepidermal water loss, stratum corneum hydration, erythema, and temperature were measured.

RESULTS

Transepidermal water loss (31.11 vs 14.24 g·m-2·h-1), temperature (33.29°C vs 32.57°C), and erythema were significantly greater at the area covered by gloves compared with the noncovered area. Transepidermal water loss (22.82 vs 13.69 g·m-2·h-1), temperature, and erythema (411.43 vs 335.52 arbitrary units) were significantly increased at the area covered by mask, whereas stratum corneum hydration was lower. Transepidermal water loss was greater at the area covered by a surgical mask than at a filtering respirator mask coded filtering facepiece 2 (27.09 vs 18.02 g·m-2·h-1, P = 0.034).

CONCLUSIONS

Skin homeostasis and epidermal barrier function may be impaired by gloves and mask use. High-quality PPE should be provided, and adequate skin prevention measures should be implemented to reduce epidermal barrier damage.

Implications of Hidradenitis Suppurativa Phenotypes in Cardiovascular Risk and Treatment Decisions: A Retrospective Cohort Study

BACKGROUND

New integrative hidradenitis suppurativa (HS) lesion pattern phenotypes have been proposed, an inflammatory phenotype (IP) and a follicular phenotype (FP). They are characterized by different lesion patterns, symptoms, and risks of disease progression.

OBJECTIVES

To evaluate whether lesion pattern phenotypes (1) have a different cardiovascular risk factor profile, and (2) are associated with a different therapeutic approach in the setting of an HS clinic.

METHODS

A retrospective cohort study was conducted on 233 patients with HS. They were classified according to lesion pattern phenotype criteria. Data regarding cardiovascular risk factors and treatment decisions were gathered.

RESULTS

One hundred and seventeen HS patients (50.21%) were classified as FP and 112 (48.07%) as IP. IP was associated with more severe disease and greater impairment of quality of life. Regardless of disease severity, patients with IP may have a higher cardiovascular risk, assessed according to higher C-reactive protein (CRP) levels (12.75 vs. 5.89, p = 0.059). The lesion pattern phenotype also influenced treatment decisions regardless of disease severity. Patients with IP were more likely to be treated with systemic corticosteroids and adalimumab, showing that lesion pattern phenotypes are associated with different therapeutic approaches.

CONCLUSIONS

IP is associated with higher CRP values, suggesting a greater cardiovascular risk in these patients and also a different therapeutic approach. This information could help guide dermatologists in the management of HS patients and help to determine future treatment recommendations.

Exploring Patients' Insight, Concerns, and Expectations at Dermatology Clinic: An Observational Study in 2 Centers in Scotland and Spain

Background:

Effective doctor–patient communication is of great importance in order to optimize medical consultation outcomes. However, it can be difficult to address all patients’ concerns and expectations in clinic.

Objective:

To identify how much patients know about their medical condition, their fears and concerns, and their expectations, as well as evaluate the benefits of using a preconsultation questionnaire routinely.

Methods:

This study included consecutive patients attending dermatology outpatients from Dundee (Scotland) and Granada (Spain) who completed a simple preconsultation 3-part questionnaire. Answers to this questionnaire were discussed during clinic visits.

Results:

Two hundred patients participated in the study. Of all, 111 (55.5%) patients already knew their diagnosis or were able to describe their symptoms and/or feelings quite accurately at their visit to Dermatology. Most patients (85%) had fears regarding their dermatological problem. A majority of patients (97%) came to clinic with specific expectations, and many (41.5%) had multiple expectations. A high proportion of patients (74%) found the questionnaire useful.

Conclusion:

Patients attend clinic with different levels of knowledge, fears, and expectations. We recommend using a brief and easy to use preconsultation questionnaire as a cost-effective way of enhancing doctor–patient communication.

Skin Barrier Function in Psoriasis and Atopic Dermatitis: Transepidermal Water Loss and Temperature as Useful Tools to Assess Disease Severity

Multiple diagnostic tools are used to evaluate psoriasis and atopic dermatitis (AD) severity, but most of them are based on subjective components. Transepidermal water loss (TEWL) and temperature are skin barrier function parameters that can be objectively measured and could help clinicians to evaluate disease severity accurately. Thus, the aims of this study are: (1) to compare skin barrier function between healthy skin, psoriatic skin and AD skin; and (2) to assess if skin barrier function parameters could predict disease severity. A cross-sectional study was designed, and epidermal barrier function parameters were measured. The study included 314 participants: 157 healthy individuals, 92 psoriatic patients, and 65 atopic dermatitis patients. TEWL was significantly higher, while stratum corneum hydration (SCH) (8.71 vs. 38.43 vs. 44.39 Arbitrary Units (AU)) was lower at psoriatic plaques than at uninvolved psoriatic skin and healthy controls. Patients with both TEWL > 13.85 g·m⁻²h⁻¹ and temperature > 30.85 °C presented a moderate/severe psoriasis (psoriasis area severity index (PASI) ≥ 7), with a specificity of 76.3%. TEWL (28.68 vs. 13.15 vs. 11.60 g·m⁻² h⁻¹) and temperature were significantly higher, while SCH (25.20 vs. 40.95 vs. 50.73 AU) was lower at AD eczematous lesions than uninvolved AD skin and healthy controls. Patients with a temperature > 31.75 °C presented a moderate/severe AD (SCORing Atopic Dermatitis (SCORAD) ≥ 37) with a sensitivity of 81.8%. In conclusion, temperature and TEWL values may help clinicians to determine disease severity and select patients who need intensive treatment.

Colour Doppler ultrasound study in patients with frontal fibrosing alopecia

BACKGROUND

The sonographic characteristics of frontal fibrosing alopecia have been scarcely studied. The aim of this study was to perform a colour Doppler ultrasound evaluation in frontal fibrosing alopecia.

MATERIALS AND METHODS

A cross-sectional study including 99 women with frontal fibrosing alopecia and 40 control subjects was performed using ultrasound equipment with a lineal 18 MHz probe. Three areas were evaluated per patient: the alopecic area (a), the hairline implantation area (b) and healthy scalp (c). The diameter (cm) and flow (m/s) of the two most significant vessels were recorded.

RESULTS

With regard to the hairline implantation area, patients presented higher vessel diameter (0.127 cm vs 0.103 cm, P = .03) and vessel flow (8.183 m/s vs 7.670 m/s, P = .05) than the control group. Vessel diameter was higher in the healthy scalp area in patients than in the control group (0.088 cm vs 0.078 cm, P = .03).

CONCLUSION

Patients presented higher vessel diameter and flow in the hairline implantation area compared to the control group.

Epidermal barrier changes in patients with psoriasis: The role of phototherapy

BACKGROUND

Some skin diseases may modify epidermal barrier function. Psoriasis is a chronic multi-systemic inflammatory disease that affects the epidermal barrier. Phototherapy is an option for treating psoriasis, but little is known about how epidermal barrier function is modified by phototherapy in psoriatic patients.

OBJECTIVES

(a) To compare skin homeostasis between involved and uninvolved skin in psoriatic patients with healthy controls (b) To evaluate changes in the epidermal barrier function in psoriatic patients treated with phototherapy.

METHODS

Sixty patients with plaque-type psoriasis and sixty gender and age-matched healthy controls were enrolled. Temperature, transepidermal water loss (TEWL), stratum corneum hydration (SCH), pH, elasticity, erythema and melanin index were measured using non-invasive tools in the healthy control and involved and uninvolved psoriatic skin before and after phototherapy.

RESULTS

Healthy controls had lower TEWL and erythema index and higher SCH than psoriatic patients, both at uninvolved psoriatic skin and psoriasis plaques. TEWL was higher at psoriasis plaques than at uninvolved skin (19.20 vs 11.57 g/h/m² ; P < .001). Following phototherapy, a decreasing trend was observed for TEWL, of 1.03 (SD 0.75) and 0.97 (SD 0.81) g/h/m² for uninvolved and involved skin respectively. SCH was significantly lower at psoriatic plaques than at uninvolved skin (7.32 vs 36.62Arbitrary Units [AU]; P < .001). SCH increased by 1.15AU (SD 0.26) on psoriatic plaques after the phototherapy session (P < .001).

CONCLUSION

Psoriatic plaques showed epidermal barrier dysfunction compared to uninvolved skin and healthy controls. Phototherapy may improve epidermal barrier function in psoriatic patients. SCH increased after a phototherapy session on the psoriatic plaques.

Mesenchymal stromal cells in human immunodeficiency virus-infected patients with discordant immune response: Early results of a phase I/II clinical trial

Between 15% and 30% of HIV‐infected subjects fail to increase their CD4⁺ T‐cell counts despite continuous viral suppression (immunological nonresponders [INRs]). These subjects have a higher morbidity and mortality rate, but there are no effective treatments to reverse this situation so far. This study used data from an interrupted phase I/II clinical trial to evaluate safety and immune recovery after INRs were given four infusions, at baseline and at weeks 4, 8, and 20, with human allogeneic mesenchymal stromal cells from adipose tissue (Ad‐MSCs). Based on the study design, the first 5 out of 15 INRs recruited received unblinded Ad‐MSC infusions. They had a median CD4⁺ nadir count of 16/μL (range, 2‐180) and CD4⁺ count of 253 cells per microliter (171‐412) at baseline after 109 (54‐237) months on antiretroviral treatment and 69 (52‐91) months of continuous undetectable plasma HIV‐RNA. After a year of follow‐up, an independent committee recommended the suspension of the study because no increase of CD4⁺ T‐cell counts or CD4⁺/CD8⁺ ratios was observed. There were also no significant changes in the phenotype of different immunological lymphocyte subsets, percentages of natural killer cells, regulatory T cells, and dendritic cells, the inflammatory parameters analyzed, and cellular associated HIV‐DNA in peripheral blood mononuclear cells. Furthermore, three subjects suffered venous thrombosis events directly related to the Ad‐MSC infusions in the arms where the infusions were performed. Although the current study is based on a small sample of participants, the findings suggest that allogeneic Ad‐MSC infusions are not effective to improve immune recovery in INR patients or to reduce immune activation or inflammation. ClinicalTrials.gov identifier: NCT0229004. EudraCT number: 2014‐000307‐26.

Review of adverse cutaneous reactions of pharmacologic interventions for COVID-19: A guide for the dermatologist

The new coronavirus, severe acute respiratory syndrome coronavirus 2, is associated with a wide variety of cutaneous manifestations. Although new skin manifestations caused by COVID-19 are continuously being described, other cutaneous entities should also be considered in the differential diagnosis, including adverse cutaneous reactions to drugs used in the treatment of COVID-19 infections. The aim of this review is to provide dermatologists with an overview of the cutaneous adverse effects associated with the most frequently prescribed drugs in patients with COVID-19. The skin reactions of antimalarials (chloroquine and hydroxychloroquine), antivirals (lopinavir/ritonavir, ribavirin with or without interferon, oseltamivir, remdesivir, favipiravir, and darunavir), and treatments for complications (imatinib, tocilizumab, anakinra, immunoglobulins, corticosteroids, colchicine and low molecular weight heparins) are analyzed. Information regarding possible skin reactions, their frequency, management, and key points for differential diagnosis are presented.