Steroid-Induced Osteonecrosis in Dermatology: A Review

Dried root of Rehmannia glutinosa extracts prevents steroid-induced avascular necrosis of femoral head by activating the wingless-type (Wnt)/β-catenin signal pathway

Steroid-induced avascular necrosis of femoral head (SANFH) is one of the most common complications caused by long-term or excessive clinical use of glucocorticoids. This study aimed to investigate the effects of dried root of Rehmannia glutinosa extracts (DRGE) in SANFH. First, SANFH rat model was established by dexamethasone (Dex). Tissue change and proportion of empty lacunae were detected by hematoxylin and eosin staining. Protein levels were detected by western bloting analysis. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) was performed to assess apoptosis of femoral head tissue. Cell viability and apoptosis of MC3T3-E1 cells were assessed by Cell Counting Kit-8 assay and flow cytometry. ALP activity and cell mineralization were detected by ALP staining assay and Alizarin red staining. The findings showed that DRGE improved tissue damage, inhibited apoptosis, and promoted osteogenesis in SANFH rats. In vitro, DRGE increased cell viability, inhibited cell apoptosis, promoted osteoblast differentiation, reduced the levels of p-GSK-3β/GSK-3β, but increased the levels of β-catenin in cells treated with Dex. Furthermore, DKK-1, an inhibitor of the wingless-type (Wnt)/β-catenin signaling pathway, reversed the effect of DRGE on cell apoptosis and ALP activity in cells treated with Dex. In conclusion, DRGE prevents SANFH by activating the Wnt/β-catenin signaling pathway, indicating that DRGE may be a hopeful choice drug to prevent and treat patients with SANFH.

Angiogenesis and bone regeneration by mesenchymal stem cell transplantation with danshen in a rabbit model of avascular necrotic femoral head

The present study aimed to explore the potential of combined treatment with mesenchymal stem cells (MSCs) and danshen for angiogenesis and bone regeneration in a rabbit model of avascular necrosis of femoral head (ANFH). A rabbit model of ANFH was established using the Shwartzman reaction with methylprednisolone and Escherichia coli endotoxin injection. Magnetic resonance imaging (MRI) and histopathological examination were used to evaluate the rabbit model of ANFH. The rabbits were randomly divided into the danshen group, the MSCs group, the danshen combined with MSCs group and the model group (treated with physiological saline). The expression level of monocyte chemoattractant protein-1 (MCP-1) and stromal cell-derived factor-1 (SDF-1) were determined by reverse transcription polymerase chain reaction (RT-PCR). The expression level of bone morphogenetic protein-2 (BMP-2) and vascular endothelial growth factor (VEGF) were detected by immunofluorescence and the mRNA expression of BMP-2 and VEGF were detected by RT-PCR. Typical osteonecrosis occurred in the rabbit model of ANFH, which indicated that the model was successfully established. MCP-1 and SDF-1 were significantly increased in the model group compared with the normal group (P<0.05). Following the administration of MSCs and Salvia miltiorrhiza (danshen), MSCs labeled with 5-bromo-2-deoxyuridine were observed to be gathered in the necrotic area. The increased migration of MSCs to the necrotic area may be due to the upregulated expression of the chemokines MCP-1 and SDF-1. ANFH treated with danshen combined with MSCs may promote revascularization by increasing the expression of VEGF and BMP-2 in the femoral head, promoting re-ossification and revascularization. Danshen combined with the transplantation of MSCs may be regarded as a novel therapy for the treatment of ANFH in a clinical setting.

Epimedium protects steroid-induced avascular necrosis of femoral head in rats by inhibiting autophagy

The effect of epimedium extracting solution on bone mineral density (BMD) of steroid-induced avascular necrosis of femoral head (SANFH) in rats was evaluated to further explore its function mechanism. Twenty-four Sprague-Dawley (SD) rats (male/female: 1/1) were randomly divided into three groups: the control (n=8), the glucocorticoid (n=8) and the epimedium (n=8) group. Rats in the glucocorticoid and the epimedium group were injected with prednisolone acetate injection in gluteal muscles with 15 mg/kg/day twice a week. The epimedium group was given 10 ml/kg ephedra extracting solution containing crude drug with the concentration of 1.5 g/ml daily by gavage. After 6 weeks, all the experimental rats were sacrificed and materials were extracted. The expression of autophagy-related proteins were detected by observing the bone of the femoral head. After comparison of the control group with the model group in BMD, it was found that there were significant differences (P<0.05). There were no significant differences between the control and the epimedium group (P>0.05). Neither between the glucocorticoid and the epimedium group (P<0.05). Epimedium extracting solution can significantly enhance the BMD of femoral heads, prevent osteoporosis and lead to collapse, increase the expression of apoptotic and protective proteins and reduce the expression of autophagy-related proteins, thus providing a preliminary theoretical study for the prevention and treatment of SANFH.

Bilateral osteonecrosis of the femoral head associated with corticosteroid therapy for alopecia areata: a case report and review of the literature

Corticosteroids have been widely used for the treatment of various inflammatory diseases because they provide an acute response of immunosuppression. Numerous side effects of corticosteroids have also been known, with varying degrees of severity. Osteonecrosis of the femoral head (ONFH) is a rare and serious complication that directly inhibits walking because of femoral head collapse. However, sometimes, clinicians who consider that corticosteroids are required for primary disease do not recognize steroid-induced ONFH. The final stage of ONFH is severe osteoarthritis, requiring total hip arthroplasty. We describe a 23-year-old woman with bilateral ONFH after corticosteroid treatment for alopecia areata (AA). She was administered several intralesional corticosteroid injections to the scalp and repeated systemic corticosteroid therapy for extensive AA. While undergoing therapy, she lost her balance and complained of right groin pain when standing. The patient was subsequently diagnosed with bilateral ONFH. She recovered from AA, but she complained of persistent right hip pain, which subsequently required total hip arthroplasty. We would like to emphasize that patients on corticosteroid therapy for any common disease should be considered as having a potential risk for ONFH. An early stage detection of ONFH is crucial for its treatment. MRI evaluation warrants a higher level of accuracy in early diagnosis of ONFH for the opportunity to undergo joint-preservation surgery in patients with ONFH.

EXPERIENCE OF COMBINED APPLICATION OF METHYLPREDNISOLONE ACEPONATE AND MOLETOLO COSMETICS STEROIDSANDVIAGRAJY IN THE TREATMENT OF DERMATOSES

Skin diseases of non-infectious etiology, such as allergic contact dermatitis, atopic dermatitis, eczema  and chronic actinic dermatitis have a significant impact on the quality of patient’s life, greatly reducing it. The most important place in the therapy of these diseases is found in topical glucocorticosteroids in combination with competent basic therapy.The aim of the study was to evaluate the clinical efficacy, safety profile, and tolerability of an external corticosteroid drug with a combination composition: methylprednisolone aceponate 0.1 % + urea 2 % (Komfoderm M2) in combination with dextpanthenol, allantoin and Shea butter (Dexpan plus cream) in dermatological practice in the treatment of eczematous process.Materials and methods. 48 patients, from 18 to 58 years old with mild to middle-severe eczematous process, were under observation, including 16 with allergic contact dermatitis, 14 patients with atopic dermatitis and 10 patients with eczema brushes, and 8 people with actinic dermatitis. Cream Komfoderm M2 was applied to the affected skin areas once a day in combination with cream Dexpan plus as standard therapy and emollient cosmetic. We investigated the parameters of the DLQI questionnaire “Dermatological Quality of Life Index” .Results As a result of the conducted observational study, data were obtained on the high effectiveness of therapy with the combined use of the drug Komfoderm M2 and Dexpan plus. An excellent evaluation of the efficacy of the scheme used was found in 37 (77 %) patients, a good one in 9 (18,8 %) and 2 (4.2 %) patients had a satisfactory result.Conclusions. This clinical study proves the high efficacy, safety and tolerability of the drugs — Cream with 0.1 % MPA and urea 2 % (Komfoderm M2) in combination with a cream containing dexpanthenol, allantonoin and Shea butter (Dexpan plus) in the treatment of eczematous process.

Chemical and Radiation-Associated Jaw Lesions

Osteonecrosis of the jaw is a major public health concern throughout the world. Use of radiotherapy for head and neck cancer and bone antiresorptives and antiangiogenic agents have increased its incidence. Medication-related osteonecrosis of the jaw is more common relative to other types of osteonecrosis. Osteoradionecrosis occurs despite better treatment planning and shielding to minimize collateral damage to bone. Other related necrotic lesions are secondary to usage of recreational drugs and steroids. This article provides comprehensive information about these different types of bone necrosis; provides the readers with radiographic diagnostic criteria and updates on current theories on pathophysiology of osteonecrosis.

Management of imported cutaneous larva migrans: A case series and mini-review

BACKGROUND

Cutaneous larva migrans (CLM), a zoonotic helminthiasis imported to Canada by travelers to the tropics, causes morbidity due to severe, intractable pruritus. Treatment in Canada is only available through the Special Access Program (SAP) of Health Canada, thus, many patients are prescribed ineffective courses of non-targeted therapy.

OBJECTIVE

We analyzed patients with CLM referred to our specialized Tropical Disease Unit (TDU) having failed non-targeted therapy prior to referral, and characterized demographic and travel related correlates of CLM.

METHODS

Patients with CLM evaluated between June 2012 and December 2014 were identified through our SAP application log, and charts were reviewed for demographic, clinical, and travel-related data following IRB approval.

RESULTS

25 patients with CLM were identified: 12 women, and 13 men. Median age was 35 years (range 4-58 years). Patients had primarily acquired their CLM in the Caribbean (80%), with Jamaica being the most well represented source destination (N = 10, 40%). Reported symptoms included intense, function-limiting pruritus (N = 25, 100%) and loss of sleep (N = 3, 12%). Twelve patients (48%) with CLM had received at least 1 course of non-targeted therapy prior to referral. Non-targeted therapies included topical steroids (N = 7), cryotherapy (N = 3), oral antibiotics (N = 2), and oral mebendazole (N = 11). Median duration of symptoms was 34 days (range 5-226 days). Of 25 patients with CLM, 23 (92%) were prescribed a single 3-day course of albendazole and responded appropriately, and 2 (8%) required a second 3-day course of albendazole.

CONCLUSIONS

Although CLM is non-communicable and of little public health relevance in Canada, it causes significant morbidity. A substantial proportion of patients with CLM referred to our specialized TDU had a prolonged course of illness and were prescribed ineffective and non-targeted therapies. Oral albendazole or ivermectin, or topical thiabendazole, are the drugs of choice for CLM, and should be prescribed as first-line therapy.