Behçet Disease: An Update for Dermatologists

Biosensors for autoimmune diseases

Diagnosis of autoimmune diseases (ADs) is usually based on symptoms and laboratory tests that measure the occurrence of serological and genetic biomarkers such as peptides, autoantibodies, and complement proteins. Early detection of AD is essential to reduce the severity of symptoms and organ damage as a result of progressive disease. Biosensors are tools that convert biochemical signals produced by molecular elements into optical, electrical, and other physical signals for analysis. In recent years, peptides, antigens, aptamers, autoantibodies, and other biomolecules have provided suitable diagnostic features for development of biosensors in detecting and follow up the diagnoses and treatment of diseases. This study reviews the introducing of different biomarkers in ADs with the novel vision to use of biosensor technology for research and development in this regard. Therefore, this study has the required innovation for using biosensor technology with more attention to electrochemical based biosensors to developing, targeting and designing the easy applicable and available diagnostic and response to treatment products using key biomolecules for ADs. It will help readers to understand the research trends of biosensors in ADs and further advance the development of this paramount field.

Approaches based on miRNAs in Behçet's Disease: Unveiling pathogenic mechanisms, diagnostic strategies, and therapeutic applications

Behçet's Disease (BD) is an intricate medical puzzle, captivating researchers with its enigmatic pathogenesis. This complex ailment, distinguished by recurrent mouth and genital lesions, eye irritation, and skin injuries, presents a substantial obstacle to therapeutic research. This review explores the complex interaction of microRNAs (miRNAs) with BD, highlighting their crucial involvement in the disease's pathophysiology. miRNAs, recognized for regulatory influence in diverse biological processes, hold a pivotal position in the molecular mechanisms of autoimmune diseases, such as BD. The exploration begins with examining miRNA biogenic pathways and functions, establishing a foundational understanding of their regulatory mechanisms. Shifting to the molecular landscape governing BD, the review highlights miRNA-mediated impacts on critical signaling pathways like Notch, nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), and protein kinase B (AKT)/mammalian target of rapamycin (mTOR), offering insights into intricate pathophysiological mechanisms. Dissecting the immunological landscape reveals the profound influence of miRNAs on BD, shedding light on the intricate modulation of immune responses and offering novel perspectives on disease etiology and progression. Beyond molecular intricacies, the review explores the clinical relevance of miRNAs in BD, emphasizing their potential as diagnostic and prognostic indicators. The discussion extends to the promising realm of miRNA-based therapeutic interventions, highlighting their potential in alleviating symptoms and altering disease progression. This comprehensive review, serving as a valuable resource for researchers, clinicians, and stakeholders, aims to decipher the intricate molecular tapestry of BD and explore the therapeutic potential of miRNAs.

Fecal microbiota transplantation for the treatment of chronic inflammatory skin diseases

The regulation of immune functions and the maintenance of homeostasis in the internal environment are both integral to human gut microbiota (GM). If GM is disturbed, it can result in a range of autoimmune diseases, including chronic inflammatory skin conditions. Chronic inflammatory skin diseases driven by T or B-cell-mediated immune reactions are complex, including the most prevalent diseases and some rare diseases. Expanding knowledge of GM dysbiosis in chronic inflammatory skin diseases has emerged. The GM has some causal roles in the pathogenesis of these skin conditions. Targeting microbiota treatment, particularly fecal microbiota transplantation (FMT), is considered to be a promising strategy. FMT was commonly used in intestinal diseases by reshaping and balancing GM, serving as a reasonable administration in these skin inflammatory diseases. This paper summarizes the existing knowledge of GM dysbiosis in chronic inflammatory skin diseases and the research data on FMT treatment for such conditions.

Cardiovascular Manifestations in Behçet's Disease

Cardiovascular involvement in Behçet's disease (BD) is considerably related to morbidity and mortality. However, the cardiovascular manifestation is sometimes difficult to distinguish from those of other causes. The suspicion of BD and proper treatment is pivotal in the management of BD. Histology demonstrates perivasculitis. Neutrophil seems to play an important role in the inflammation of BD. It is thought that inflammation causes venous thrombosis and arterial aneurysm. Characteristically, BD involves both arteries and veins of variable size in any region. Venous thrombosis needs immunosuppression, and inferior vena cava thrombosis and Budd-Chiari syndrome require intensive immunosuppressive therapy. Arterial involvement causes aneurysm which usually is treated by surgical or endovascular intervention with immunosuppression. Pulmonary artery aneurysm and cardiac involvement require multimodal managements.

Possible Association between Behçet's Disease and Periodontal diseases

AIM

This study explores the connection between Behçet's disease (BD), characterized by persistent oral and genital ulcers alongside iritis, and periodontal disease. It examines the levels of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and nitric oxide (NO) in gingival crevicular fluid (GCF) and saliva.

METHODS

Forty Behçet's patients with gingivitis or periodontitis and 47 patients with either gingivitis or periodontitis but without BD were studied. Periodontal status was recorded with standard clinical indexes. GCF and saliva samples were obtained. NO, IL-1β and TNF-α levels were analysed. Current Behçet's symptoms and medications usage were recorded.

RESULTS

Mean salivary IL-1β was elevated (p = .045), and mean NO level was decreased in BD patients with gingivitis compared to patients without BD (p = .000). In contrast, mean NO level in crevicular fluid was higher in Behçet's patients with periodontitis than in patients without BD (p = .009). Furthermore, among Behçet's patients, those with vascular involvement had lower salivary NO level compared to patients without vascular involvement (p = .000).

CONCLUSIONS

Based on our findings, the elevated levels of IL-1β in the saliva of Behçet's patients with gingivitis, along with the decreased NO level, indicate an altered inflammatory response in the oral cavity.

Behçet disease: epidemiology, classification criteria and treatment modalities

INTRODUCTION

Behçet disease (BD) is an inflammatory multisystem disorder of unknown etiology, believed to be triggered by infection and environmental factors in genetically predisposed individuals. The significance of understanding BD lies in its impact on global health due to its diverse clinical manifestations and geographical distribution.

AREAS COVERED

This review discusses the epidemiology of BD, emphasizing its prevalence estimated at 10.3 (95% CI, 6.1, 17.7) per 100,000 population, with higher rates observed in regions historically linked to the Silk Route. The criteria for diagnosis are explored, focusing on clinical manifestations that guide healthcare professionals in identifying and managing BD. Additionally, the review encompasses treatment strategies, highlighting TNF-alpha inhibitors as pivotal biologics and newer agents like IL-1 inhibitors and Ustekinumab that broaden the therapeutic options for BD.

EXPERT OPINION

Our work provides insights into the evolving landscape of treatments for BD, emphasizing the expanding role of newer agents alongside established therapies like TNF-alpha inhibitors.

The clinical manifestations and treatment outcomes of Behçet's disease: A single-center experience

Background and Aims

Behçet's disease is a chronic, multisystemic, and relapsing inflammatory disorder. It lacks a permanent cure, the focus of treatment is on mitigating symptoms, decreasing the frequency and severity of relapses, and preventing life-threatening complications. This study aims to report the experience of a single center in managing patients with Behçet's disease and discuss the treatment outcomes.

Methods

This study was a retrospective case series conducted over 2 years. All cases were clinically diagnosed according to the International Criteria for Behçet's Disease. The extracted data were demographics, family history, clinical findings, criteria scores, treatment, and outcomes.

Results

A total of 31 patients were included, consisting of 13 males (42%) and 18 females (58%). Most cases were over the age of 30, and both genders were nearly equally distributed among age groups. The most commonly affected site was the oral cavity, observed in 96.77% of cases. Genital, cutaneous, and vascular involvements were more common in males, while females were more likely to have oral, ocular, and musculoskeletal involvements. For various treatment regimens, oral, cutaneous, vascular, and musculoskeletal involvements showed complete response in all cases. Among cases with genital involvement, complete response was achieved in seven cases (41.2%), while four cases (23.5%) showed only partial response, and six cases (35.3%) experienced recurrence. In cases with ocular involvement, only partial responses were observed.

Conclusion

Oral, cutaneous, vascular, and musculoskeletal involvements may have a higher likelihood of a complete response to treatment regimens. However, genital involvement may be the most recurrent manifestation, followed by ocular involvement.

Characterization and Management of Amicrobial Pustulosis of the Folds, Aseptic Abscess Syndrome, Behçet Disease, Neutrophilic Eccrine Hidradenitis, and Pyostomatitis Vegetans-Pyodermatitis Vegetans

Neutrophilic dermatoses are a broadly heterogeneous group of inflammatory skin disorders. This article reviews 5 conditions: amicrobial pustulosis of the folds, aseptic abscess syndrome, Behçet disease, neutrophilic eccrine hidradenitis, and pyostomatitis vegetans-pyodermatitis vegetans.The authors include up-to-date information about their epidemiology, pathogenesis, clinicopathologic features, diagnosis, and management.

Overview of Vasculitides in Adults

Vasculitis is characterized by the inflammation of blood vessels. Vasculitides refers to the different forms of vasculitis, often classified according to the size of the blood vessel that is involved. Vasculitis may occur as a primary process or secondary to many systemic diseases. This topic provides an overview of the clinical features, diagnosis, and classification of the different forms of vasculitides.

HLA-B*51 Frequency in Transplant Patients and Donors

OBJECTIVES

HLA molecules play a crucial role in transplantation. The best treatment modality in patients with end-stage renal disease is renal transplant. HLA mismatches between patients and donors can prolong time for renal transplant therapy, reduce graft survival, and increase mortality. HLA region is the most polymorphic genetic region and is essential for antigen presentation. The main target of the recipient's immune system is HLA molecules on the surface of donor cells. HLA-B*51 is associated with Behcet disease, a rare multisystemic disease characterized by autoimmunity and inflammatory processes. In transplant recipients, inflammation and vasculitis are immunologic mechanisms that are responsible for damage of graft tissue. In this retrospective study, we aimed to investigate the frequency of HLA-B*51 in patients diagnosed with end-stage renal disease and in controls and to investigate correlations with rejection episodes.

MATERIALS AND METHODS

Patients who applied to Baskent University Adana Dr. Turgut Noyan Research and Medical Center (between 2010 and 2022) with end-stage renal disease (n = 1732) and a control group (n = 5277) received HLA typing for class I (HLA-A, HLA-B). Sequence-specific primers or sequencespecific oligonucleotides were used. Among patients diagnosed with end-stage renal disease, 321 had kidney transplant.

RESULTS

Frequency of HLA-B*51 was 25.92% in patients and 25.22% in controls. No significant differences were found between patients and controls in the frequency of HLA-B*51. Among kidney transplant recipients with HLA-B*51 (n = 72), 38.89% had rejection episodes and 61.11% had no rejection. No significant association was found between HLA-B*51 allele positivity and rejection.

CONCLUSIONS

No significant relationship was shown between patients diagnosed with end-stage renal disease and HLA-B*51 positivity. Previous studies support frequency of the HLA-B*51 allele in the control group. Although Behçet disease is known to cause renal vasculitis, HLA-B*51 positivity alone was not associated with vasculitis or inflammation.

Clinical features of Behçet's disease and prediction of the use of biologics in 488 cases: a single tertiary center study

The objectives are to describe the demographic and clinical properties of Behçet's disease (BD) and investigate their relationship with the use of biological agents. Four hundred-eighty-eight patients, (299 (61.3%) males, 189 (38.7%) females), who fulfilled the ISG classification criteria for BD were included, retrospectively. The patient's demographics, disease onset age (DOA), clinical findings of the disease, and the drugs were determined and analyzed statistically. The means of patient age and DOA were 40.7 ± 9.9 and 30.8 ± 8.8 years, respectively. The most common initial findings were oral ulcer (OU)s (30.1%), genital ulcer (GU) (27.5%), ocular involvement (OI) (12.5%), and papulopustular lesion (PPL)s (10.1%). The most common clinical manifestations were OUs (96.9%), PPLs (70.2%), HLA-B51 (64.4%), positive pathergy reaction (26.4%), GU (58.8%), OI (44.7%), erythema nodosum (29.8%), and vascular involvement (VSI) (27.3%). Although, the frequency of GU was higher in females (p = 0.01), PPLs (p = 0.001) and VSI (p = 0.001) were higher in males. Sixty-three (8.9%) patients used a biological agent. Its frequency was higher in younger patients (< 40 years) (p = 0.006), males (p = 0.012) and patients with OI (p = 0.001). Besides, the DOA (p = 0.012) and the current age (p = 0.001) were lower in biological agent users. The possibility of using biological agent was increased in males (OR = 2.2), patients with OI (OR = 2.7) and young patients (OR = 0.9). Mucocutaneous lesions are distinctive features of BD, especially OUs precede other findings. GU was more common in females and PPLs and VSI were in males. The probability of using biologics is higher in males, patients with OI, and young patients.

The role of miRNAs in Behçet's disease

The symptoms of Behçet's disease (BD), a multisystemic condition with autoimmune and inflammation as hallmarks, include arthritis, recurring oral and vaginal ulcers, skin rashes and lesions, and involvement of the nervous, gastrointestinal, and vascular systems. Non-coding RNAs (ncRNAs), including microRNAs (miRNAs), long non-coding RNAs (lncRNAs), and circular RNAs (circRNAs), may be important regulators of inflammation and autoimmune disease. These ncRNAs are essential to the physiological and pathophysiological disease course, and miRNA in particular has received significant attention for its role and function in BD and its potential use as a diagnostic biomarker in recent years. Although promising as therapeutic targets, miRNAs must be studied further to fully comprehend how miRNAs in BD act biologically.

Measuring the Whole Wall Thickness of the Common Femoral Vein as a Distinctive Diagnostic Tool to Distinguish Behçet's Disease Presenting with Oral Ulcers from Recurrent Aphthous Stomatitis

Recurrent oral ulcers, which are the first and most common manifestation of Behçet's disease (BD), have several etiological causes but are often idiopathic and known as recurrent aphthous stomatitis (RAS). In recent years, publications have drawn attention to the fact that whole-wall thickness (WWT) and intima-media thickness (IMT) measurements of the common femoral vein (CFV) may be useful in the diagnosis of BD, which are independent of organ involvement. In this study, the usefulness of the WWT and IMT of the CFV measured by venous Doppler ultrasound (US) was investigated in differentiating BD presenting with oral ulcers from RAS. Patients with BD (n = 84), patients with RAS (n = 85), and healthy controls (HCs) (n = 70) were the three groups included. Both the right and left WWT of the CFV were significantly higher in the BD compared with the HCs and RAS groups (p < 0.001). The diagnostic cutoff values of ≥0.58 mm for the WWT of the CFV performed well against both the patients with RAS and HCs for the discrimination of BD (sensitivity = 79.8%, specificity = 64.7%). In patients with recurrent oral ulcers, the WWT of the CFV measurement may be a distinctive new diagnostic tool for the differential diagnosis of BD and RAS.

Associations of IL-17 and IL-17 receptor polymorphisms with Behçet's disease in Denizli Province of Turkey

Although the etiopathogenesis of Behçet's disease is not known, studies conducted in different populations show that it is a multifactorial disease that is thought to develop as a result of the interaction of environmental and genetic factors. IL-17 is thought to induce the neutrophilic inflammation and the tissue damage mediated by immune response in patients. Polymorphisms in the gene region encoding IL-17 and IL-17R molecules may play a critical role in the pathogenesis of the disease and contribute to the elucidation of disease mechanism. We aimed to show the association of IL-17A, IL-17F, and IL-17RC polymorphisms and haplotypes in Behçet's disease patients and its clinical features. We genotyped IL-17A (rs4711998 (A/G), rs8193036 (C/T), rs2275913 (A/G), rs3819025 (A/G), rs8193038 (A/G), rs3804513 (A/T), rs1974226 (C/T), rs3748067 (C/T)); IL-17F (rs763780 (T/C), rs2397084 (T/C)); and IL-17R (IL-17RC) (rs708567 (C/T)) polymorphisms in 88 patients with Behçet's disease and 133 healthy controls using PCR-RFLP-based approach. The results of our study showed that polymorphisms of IL-17A, rs8193036 (C/T), rs3819025 (G/A), rs3804513 (A/T), IL-17F rs2397084 (T/C), and IL-17RC rs708567 (C/T) are associated with the susceptibility to the BD. When the haplotype distributions of all loci of IL-17Aand IL-17A/IL-17F together were examined and in contrast to the data obtained from the controls, the GTGGAACC (27.84%) and GTGGAACCTT (25.57%) have the highest frequencies. In conclusion, the allele and genotype frequency differences of the IL-17A, IL-17F, and IL-17R and haplotype frequencies between Behçet's disease and controls indicate that the genetic structure of Behçet's disease may be different.

Gut microbial signatures and their functions in Behcet's uveitis and Vogt-Koyanagi-Harada disease

BACKGROUND

A number of public metagenomic studies reveal an association between the gut microbiome and various immune-mediated diseases including Behcet's uveitis (BU) and Vogt-Koyanagi-Harada disease (VKH). Integrated-analysis and subsequent validation of these results could be a potentially powerful way to understand the microbial signatures and their functions in these two uveitis entities.

METHODS

We integrated the sequencing data of our previous metagenomic studies on two major uveitis entities, BU and VKH as well as four other publicly available immune-mediated diseases datasets, including Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA), Crohn's disease (CD) and Ulcerative Colitis (UC). Alpha-diversity and beta-diversity analysis were used to compare the gut microbiome signatures between both uveitis entities and other immune-mediated diseases and healthy controls. Amino acid homology between microbial proteins and a uveitogenic peptide of the interphotoreceptor retinoid-binding protein (IRBP)161-180 was investigated using a similarity search in the NCBI protein BLAST program (BLASTP). Enzyme-linked Immunosorbent Assay (ELISA) was performed to evaluate the cross-reactive responses of experimental autoimmune uveitis (EAU)-derived lymphocytes and BU patients-derived peripheral blood mononuclear cells (PBMCs) against homologous peptides. The area under the curve (AUC) analysis was used to test the sensitivity and specificity of gut microbial biomarkers.

RESULTS

Depleted Dorea, Blautia, Coprococcus, Erysipelotrichaceae and Lachnospiraceae as well as enriched Bilophila and Stenotrophomonas were identified in BU patients. An enriched Alistipes along with a lower level of Dorea were observed in VKH patients. A peptide antigen (SteTDR) encoded by BU specifically enriched Stenotrophomonas was identified to share homology with IRBP161-180. In vitro experiments showed that lymphocytes from EAU or PBMCs from BU patients reacted to this peptide antigen as shown by the production of IFN-γ and IL-17. Addition of the SteTDR peptide to the classical IRBP immunization protocol exacerbated EAU severity. Gut microbial marker profiles consisted of 24 species and 32 species respectively differentiated BU and VKH from each other as well as from the other four immune-mediated diseases and healthy controls. Protein annotation identified 148 and 119 specific microbial proteins associated with BU and VKH, respectively. For metabolic function analysis, 108 and 178 metabolic pathways were shown to be associated with BU and VKH, respectively.

CONCLUSIONS

Our study revealed specific gut microbial signatures and their potentially functional roles in BU and VKH pathogenesis that differ significantly from other immune-mediated diseases as well as healthy controls.

Mucocutaneous Response to New Therapeutic Strategies in Behçet’s Disease: A Retrospective Cohort Study

Mucocutaneous lesions are the most frequent symptoms of Behçet’s disease (BD). Recently, new therapies are being used to treat refractory cases, but the effect of these treatments on mucocutaneous manifestations has been scarcely reported. Our objective was to describe the mucocutaneous response to the different therapies used to treat BD in routine clinical practice. We retrospectively reviewed the clinical records of all patients diagnosed with BD seen at our institution between January 2010 and January 2022. Patients with BD without mucocutaneous manifestations were excluded. We included 109 patients diagnosed with BD: 51 males (46.8%) and 58 females (53.2%). The mean age at diagnosis was 31.58 years (standard deviation (SD) 12.110) and the mean time of disease evolution was 14.94 years (SD 11.094). Oral ulcers were the most frequent symptom present in 100% of patients, followed by genital ulcers (GU) in 76.1% of patients. Twenty-four patients (22%) had severe mucocutaneous symptoms (>12 lesions/year) before treatment. We found that among patients with GU there was a higher prevalence of episodes of posterior uveitis and venous thrombosis ( $p=0.011$ and $p=0.045$ , respectively). In our series, we observed a lower complete cutaneous response to colchicine in patients with GU, pathergy or severe mucocutaneous symptoms ( $p<0.05$ ). Regarding the choice of a TNF-α inhibitor, we observed a lower prevalence of complete cutaneous response to adalimumab among patients with GU (53.3% complete response in patients with GU vs. 100% in patients without GU, $p=0.022$ ), whereas no differences were found between clinical characteristics in the response to infliximab.

Current Infections of the Orofacial Region: Treatment, Diagnosis, and Epidemiology

Undoubtedly, diagnosing and managing infections is one of the most challenging issues for orofacial clinicians. As a result of the diversity of symptoms, complicated behavior, and sometimes confusing nature of these conditions, it has become increasingly difficult to diagnose and treat them. It also highlights the need to gain a deeper insight into the orofacial microbiome as we try to improve our understanding of it. In addition to changes in patients' lifestyles, such as changes in diet, smoking habits, sexual practices, immunosuppressive conditions, and occupational exposures, there have been changes in patients' lifestyles that complicate the issue. Recent years have seen the development of new infection treatments due to the increased knowledge about the biology and physiology of infections. This review aimed to provide a comprehensive overview of the types of infections in the mouth, including the types that viruses, fungi, or bacteria may cause. It is important to note that we searched the published literature in the Scopus, Medline, Google Scholar, and Cochran databases from 2010 to 2021 using the following keywords: "Orofacial/Oral Infections," "Viral/Fungal/Bacterial Infections", "Oral Microbiota" And "Oral Microflora" without limiting our search to languages and study designs. According to the evidence, the most common infections in the clinic include herpes simplex virus, human papillomavirus, Candida albicans, Aspergillus, Actinomycosis, and Streptococcus mutans. The purpose of this study is to review the new findings on characteristics, epidemiology, risk factors, clinical manifestations, diagnosis, and new treatment for these types of infectious diseases.

Risk factors of cardiovascular involvement in patients with Behcet's disease

Objectives

Behcet's disease (BD) is a multi-systemic inflammatory vasculitis which may be life-threatening if combined with cardiovascular problems. The aim of the study was to identify potential risk factors associated with cardiovascular involvement in BD.

Methods

We reviewed the medical databases of a single center. All BD patients identified as fulfilling the 1990 International Study Group criteria or the International Criteria for Behcet's Disease criteria. Cardiovascular involvement, clinical manifestations, laboratory features, and treatments were recorded. The relationship between parameters and cardiovascular involvement was analyzed.

Results

111 BD patients were included: 21 (18.9%) had documented cardiovascular involvement (CV BD group) and 99 (81.1%) had no cardiovascular involvement (non-CV BD group). Compared with non-CV BD, the proportion of males and smokers were significantly increased in CV BD (p = 0.024 and p < 0.001, respectively). Levels of activated partial thromboplastin time (APTT), cardiac troponin I and C-reactive protein were significantly higher (p = 0.001, p = 0.031, and p = 0.034, respectively) in the CV BD group. Cardiovascular involvement was associated with smoking state, the presence of papulopustular lesions, and higher APTT in multivariate analyzed (p = 0.029, p = 0.021, and p = 0.006, respectively). The ROC curve showed that APTT predicts the risk of cardiovascular involvement (p < 0.01) at a cut-off value of 33.15 s with a sensitivity of 57.1% and specificity of 82.2%.

Conclusion

Cardiovascular involvement in BD patients was associated with gender, smoking state, the presence of papulopustular lesions, and higher APTT. All patients newly diagnosed with BD should be systematically screened for cardiovascular involvement.

Mucocutaneous manifestations of Behçet's disease: Pathogenesis and management from perspectives of vasculitis

Behçet's disease (BD) is a systemic inflammatory disorder characterized by vasculitis affecting blood vessels of any caliber or type. It can present with a wide spectrum of vasculitic lesions, including erythema nodosum-like lesions and retinal vasculitis, and may also lead to larger vessel diseases, such as aortic aneurysm and deep vein thrombosis. The full etiology of BD remains unclear, but it is considered a polygenetic disease with multiple genetic risk factors that promote immune dysregulation and thrombophilia. Inflammation can be triggered by environmental factors, such as bacteria or viruses, and the dysregulation of innate and adaptive immune cell subsets. Neutrophils and lymphocytes are the primary players involved in BD pathogenesis, with specific innate (i.e., neutrophil-derived reactive oxygen species and neutrophil extracellular traps) and adaptive (i.e., anti-endothelial cell antibodies) processes inducing endothelial cell activation and chemotaxis of inflammatory cells, leading to coagulation and vasculitis. These inflammation-induced vasculitic or vasculopathic features are observed in most mucocutaneous BD lesions, although vasculitis per se is often pathologically evident only during a brief period of the disease process. Due to the multifactorial nature of BD-associated inflammation, broad-spectrum anti-inflammatory medications, including glucocorticoids and immunosuppressive drugs, have been the mainstay for managing BD. In addition, inhibitors of interleukin (IL)-1, tumor necrosis factor (TNF)-α, and IL-17, which target innate and adaptive immune functions dysregulated in BD, have emerged as promising new therapeutics. In this review, we discuss the muco-cutaneous manifestations of BD by focusing on the underlying vasculitic components in their pathologies, as well as the current array of treatment options.

Cutaneous vasculitis; An algorithmic approach to diagnosis

Vasculitides, characterized by inflammation and damage of blood vessels, encompass a broad spectrum of diseases. They can occur with different pathophysiological mechanisms and have a rich clinical heterogeneity depending on the vessel diameters they affect. Vasculitides may also present with a broad spectrum of severity, ranging from a mild self-limiting to a potentially life-threatening disease. The high prevalence of skin involvement in vasculitis, visible character and, finally, the easy accessibility of the skin for both physical examination and biopsy offers important advantages for prompt disease recognition and diagnosis. Thus, dermatologists are privileged to diagnose the disease earlier and more effectively than any other discipline. As a consequence, a detailed clinical and histopathological evaluation of the skin is one of the most critical steps in diagnosing vasculitis. Besides obtaining a good medical history, laboratory and radiological evaluation methods are used in the diagnosis. In this review, a practical and algorithmic approach is aimed to assist in the diagnosis of vasculitis. However, this approach should not be seen as strict rules. This stepwise algorithmic diagnostic approach for vasculitis was developed by combining the current literature knowledge and the author's experience in this field to provide a rational framework for selecting the most appropriate among various diagnostic approaches.

Serum Endocan Levels and Subclinical Atherosclerosis in Behçet's Syndrome

Background and Aim

Behçet disease (BD) is a rare chronic relapsing-remitting inflammatory systemic vasculitis. BD patients were reported to have marked acceleration of subclinical atherosclerosis (SCA). Endocan is a soluble proteoglycan mainly secreted by the activated endothelium. The present study aimed to assess the relation between serum endocan levels and SCA in BD patients.

Subjects and Methods

The study included 40 adult BD patients in addition to twenty age- and sex-matched healthy controls. BD was diagnosed according to International Study Group criteria. Upon recruitment, all participants were subjected to careful history taking and thorough clinical examination. BD activity was assessed using Behçet Syndrome Activity Score. Measurement of serum endocan was performed using quantitative double-antibody sandwich ELISA kit. CIMT measurement was done using B-mode ultrasound.

Results

Comparison between patients and controls regarding serum endocan levels revealed significantly higher endocan levels in BD patients [median (IQR): 155.0 (69.3–610.0) versus 73.8 (51.9–94.6)]. Using ultrasound assessment, SCA was found in 14 BD patients (35.0%). Comparison between patients with SCA and patients without regarding the clinical and laboratory data revealed that the former group had significantly higher CRP [median (IQR): 36.5 (26.8–43.5) versus 21.0 (11.8–26.8) mg/dL, p < 0.001] and endocan [median (IQR): 622.0 (107.4–974.8) versus 104.5 (64.0–342.0) mg/dL, p = 0.004] levels. Logistic regression analysis recognized endocan [OR (95% CI): 1.0 (1.0–1.012), p0.035] levels as significant predictor of SCA in multivariate analysis.

Conclusion

The present study identified the clinical value of serum endocan levels as a possible early marker of vascular involvement in BD patients.

Skin manifestation as an explaining factor of heterogeneity in Behçet's disease: A focused analysis in full-blown conditions

Behçet's disease (BD), a chronic multi-systemic disorder, presents diverse clinical manifestations depending on patient ethnicity and geographic region. Use of varying diagnostic criteria augments clinical heterogeneity. We aimed to characterize heterogenous manifestations in patients with full-blown BD fulfilling the major diagnostic criteria in use. We retrospectively analyzed 338 patients diagnosed with complete BD based on Japanese diagnostic criteria, which fulfill both International Study Group (ISG) criteria and the International Criteria for BD (ICBD). Unbiased clustering analysis was performed to elucidate the heterogeneous spectrum, followed by subgroup analysis of identified clusters. Results of unbiased clustering analysis identify dominant skin lesion type as an important factor that determines clustering among the heterogenous BD patients. Regression analysis reveals that presence of predominantly papulopustular lesions has protective effect for vascular involvement compared to other skin phenotypes. In conclusion, unbiased clustering analysis highlights that dermatologic manifestation can be a factor to understand the heterogeneity of BD and determining the dominant type of skin lesions may help clinicians predict major vascular involvement.

Contribution of Arab countries to Behçet disease research: a PubMed-based bibliometric and altmetric analysis

Behçet's disease (BD), a rare multisystemic disorder, has an unknown etiology. Interactions between genetic and environmental factors play a major role in this disorder. Human leukocyte antigen B51 allele is the strongest risk factor for the development of Behçet disease. The high prevalence of BD in the Arab world makes it necessary to undergo local research and publications, to target particular genetic, geographical, or even cultural risk factors. This study aims to assess the numerical contribution of the Arab world to research on Behçet disease. Using the PubMed platform, the number of BD-related publications from 2005 to 2019 was assessed for all 22 Arab countries, and countries having the highest prevalence of the disease. Number of publications on BD was normalized to the average population size and GDP for each Arab country. From 2005 to 2019, Arab countries published 198 articles related to BD. This accounts for 0.1% of the total number of BD-related articles published in this period (4170). A significant, positive correlation of moderate strength exists between the number of publications and the average population, while a non-significant, positive correlation of week strength exists between the number of publications and GDP. Concerning the top 15 countries according to Behçet disease prevalence, Turkey had the greatest number of articles, while the USA had the highest ratio of publications per prevalence. The high prevalence of BD in Arabic countries was faced by paradoxically low research activity in this field. Arab countries are lagging behind in the field of Behçet disease-related research, which highlights the need for improving research productivity.