Triggers, clinical manifestations and assessment of paediatric fixed drug eruptions: A systematic review of the literature

Fixed drug eruption (FDE) is a cutaneous drug reaction characterised by recurrent skin lesions occurring at the same site after each exposure to a causative agent. There is currently limited evidence in the paediatric population. The objective of this systematic review is to investigate the clinical features, causative agents and management of paediatric FDE. A systematic search of the English and French literature on paediatric FDE was conducted using the Medline and Embase databases. After full-text article review, 92 articles were included, representing a total of 233 patients. Antibiotics were the most frequent triggering agents, mainly sulfonamides (65.0% of antibiotics). Systemic symptoms were rare, and most patients only received supportive therapy. One hundred and six patients (106) performed a test to confirm the causative agent. Of these, 72.6% had oral provocation tests (OPTs) and 28.3% had patch tests. The patient's age, presence of bullous lesions and mucosal lesions were similar between tested and untested patients. It did not seem to influence the decision to perform OPTs. Paediatric FDE is a non-severe skin drug reaction. Antibiotics were the most reported triggering agents. Drug testing, including oral provocation test, was safely performed in the paediatric population.

Dermatological manifestations associated with COVID-19 and COVID-19 vaccination: results from the Lebanese COVID registry

BACKGROUND

A number of cutaneous manifestations and adverse cutaneous reactions have been associated with COVID-19 infection and vaccine.

OBJECTIVES

A Lebanese national registry was established to characterize the dermatologic manifestations and adverse cutaneous reactions associated with COVID-19 infection and vaccination in a sample of the Lebanese population.

METHODS

An observational cross-sectional study was conducted via a web-based clinical form distributed to physicians wishing to report their cases from May 2021 till May 2022.

RESULTS

In total, 142 patients were entered in the registry, of which 133 were adults and nine were pediatric patients. The main dermatological manifestations reported with COVID-19 infection in the adult group were urticaria (32.9%), telogen effluvium (21.4%), morbilliform (10%), and papulosquamous (8.6%) eruptions. Urticaria was the most common adverse cutaneous reaction to the vaccine (33%). Interestingly, herpes zoster was triggered in 12 patients post vaccination in our series with this finding more frequently seen in patients above the age of 41 (P = 0.013). In the pediatric group, the most reported dermatological findings associated with COVID-19 infection were malar erythema (25%) and telogen effluvium (25%). One 16-year-old patient developed lichen planus after one dose of a COVID-19 vaccine. No deaths were reported in both age groups.

CONCLUSION

This Lebanese registry adds more robust evidence that clinical manifestations of the COVID-19 virus and vaccine are diverse. More studies are necessary to establish the pathophysiology of these dermatological findings in the context of COVID-19 infection and vaccination.

Prevalence of adverse events varies with the different oral isotretinoin brands in acne treatment: a retrospective observational study

Oral isotretinoin remains the most effective treatment for acne. The aim of this retrospective single-center cohort study was to estimate the prevalence of adverse events with the different oral isotretinoin brands used in acne treatment. The population consisted of all patients who consulted for acne between January 2015 and January 2020. The inclusion criterion was the initiation of treatment with oral isotretinoin. The exclusion criteria were the use of two or more brands during the same course of treatment and previous treatment with oral isotretinoin. Statistical analysis was carried out using Chi-square and Mann-Whitney tests. We analyzed 468 patients of whom 68.6% were female. The median age was 21 years. The median weight was 65 kg. The treatment was Roaccutane®, Curacné®, Acnotren®, Isosupra®, Contracné®, or Acnogen® in 44.2%, 28%, 14.5%, 10.5%, 1.7% and 0.4% of cases, respectively. Xerosis was the most frequently reported side effect regardless of the brand. The highest frequencies of hypercholesterolemia (25.6%) and eczema (13%) were noted with Roaccutane®; hypertriglyceridemia (16.8%), epistaxis (9.9%) and fatigue (3.1%) with Curacné®; excessive sweating (4.1%) and headache (4.1%) with Isosupra®; and abnormal liver function tests (11%) with Acnotren®. We found a significant correlation mainly between abnormal ASAT and Acnotren® (p = 0.009), hypercholesterolemia and Roaccutane® [OR = 1.652 (95% CI 1.056-2.585)], hypertriglyceridemia and higher body weight (p = 0.004). Factors related to the drug brand and to characteristics of acne patients could explain the variability in the prevalence of some adverse events.

Combination Topical Tranexamic Acid and Vitamin C for the Treatment of Refractory Melasma

BACKGROUND

Melasma is a widespread condition that affects people of many ethnicities and is prevalent in the Middle East. To date, the therapeutic arsenal is still not effective, especially in countries with high ultraviolet light index. New treatment options are needed.

OBJECTIVE

The aim of this pilot study was to assess the efficacy of topical tranexamic acid (TA) 2% combined with vitamin C 2% in the treatment of resistant melasma in the Mediterranean region.

METHODS

This prospective interventional pilot study included 10 women, aged 18 to 55 years, with resistant melasma. Intervention consisted in application of a topical formulation containing 2% TA and 2% vitamin C, every night for eight weeks. The primary outcome was the Melasma Area and Severity Index (MASI) score measured at baseline and at Weeks 4 and 8. Melasma Quality of Life Scale (MelasQoL) and Physician Global Assessment (PGA) were used at baseline and at Weeks 4 and 8 of treatment, and they were set as the secondary outcomes.

RESULTS

The mean MASI score varied from 12.76±3.91 at baseline to 7.00±4.85 at Week 4 (p<0.01) then to 3.39 ± 1 at Week 8 (p=0.03). The mean MelasQoL decreased from 35.2 ± 16.03 at baseline to 28.8 ± 12.96 at Week 4 (p<0.01) then to 24.9±13.96 at Week 8 (p=0.14). The PGA increased between Weeks 4 and 8 passing from 2.2±0.79 to 2.4±1.07. No major side effects were reported.

CONCLUSION

Our pilot study demonstrated the possibility of a topical combination of TA 2% and vitamin C 2 %, which may be a useful therapeutic strategy in the treatment of resistant melasma in the Middle east, a region of the world with high UV index. This combination treatment is a safer alternative to dangerous bleaching treatments that are still being used.

Botulinum Toxins and Zinc: From Theory to Practice-A Systematic Review

OBJECTIVE

The aims of this study were to determine whether zinc supplementation affects botulinum toxin's effect and longevity and to establish a transition from the molecular to the clinical aspect.

METHODS

We conducted a systematic review in which we included all published studies on PubMed and Embase using the combination of the following terms: "zinc" AND (botox OR botulinum OR onabotulinumtoxinA OR abobotulinumtoxinA OR incobotulinumtoxinA).

RESULTS

From the 260 yielded articles, 3 randomized control trials and 1 case report were retained. Three of them found a significant improvement with zinc supplementation in the toxin's effect and longevity. This was observed in neurological conditions and cosmetic uses.

CONCLUSIONS

Zinc supplementation could be an interesting asset in the potentialization of botulinum neurotoxin effect and longevity. Larger clinical trials and objective measurement tools should be used to further defining the role of zinc in maximizing botulinum neurotoxin effect.

Has the core outcome (domain) set for vitiligo been implemented? An updated systematic review on outcomes and outcome measures in vitiligo randomized clinical trials

BACKGROUND

In 2015, a major achievement in vitiligo research was the development of an internationally agreed upon core outcome domain set for randomized clinical trials (RCTs). Three outcomes were identified as being essential: repigmentation, side-effects/harms and maintenance of gained repigmentation. Four items were further recommended for inclusion. The following recommendations then followed: repigmentation should be assessed by measuring the percentage of repigmentation in quartiles (0-25%, 26-50%, 51-79%, 80-100%) and cosmetic acceptability of the results should be assessed using the Vitiligo Noticeability Scale.

OBJECTIVES

The primary objective of this study was to assess uptake of the core outcome domain set for RCTs in vitiligo. Secondary objectives were to update the systematic review on outcomes reported in vitiligo RCTs, and to assess whether repigmentation and cosmetic acceptability of the results were measured using the above-mentioned recommended scales.

METHODS

We searched PubMed, Cochrane Library (CENTRAL and Systematic Reviews) and ClinicalTrials.gov for vitiligo RCTs between November 2009 and March 2021. Screening and data extraction were independently performed on title and summary by two researchers. All outcomes and outcome measures reported in eligible RCTs were retrieved and collated.

RESULTS

In total, 174 RCTs were identified: 62 were published between 2009 and 2015, and 112 were published between 2016 and 2021.Thirty-eight different outcomes were reported. Repigmentation was the primary outcome in 89% of trials (150 of 169). Forty-nine different tools were used to measure repigmentation. Side-effects and harms were reported in 78% of trials (136 of 174). Maintenance of gained repigmentation was reported in only 11% of trials (20 of 174) and duration of follow-up varied greatly from 1 to 14 months. Cosmetic acceptability of the results and cessation of disease activity were assessed in only 2% of trials (four of 174). Quality of life of patients with vitiligo was assessed in 13% of trials (22 of 174). Finally, only 11 of 112 RCTs (10%) published between 2016 and 2021 reported all three essential core outcome domains (repigmentation, side-effects and maintenance of gained repigmentation) and none of the trials reported both essential and recommended core outcome domains.

CONCLUSIONS

Efforts are still needed to close the gap between set recommendations and RCT outcome reporting.

The impact of acne treatment on quality of life and self-esteem: A prospective cohort study from Lebanon

Background

Acne is highly prevalent among teenagers and young adults, with proven negative psychological and emotional impact. To our knowledge, no study has been conducted to quantify the repercussions of acne on quality of life (QoL) and self-esteem in Lebanon.

Objective

This study aimed to highlight the effect of acne treatment on QoL and self-esteem of Lebanese adolescents and young adults.

Methods

In this observational prospective study, patients between 15 and 40 years old with moderate-to-severe acne were allocated to one of two treatment groups (isotretinoin vs. systemic antibiotics combined with topical treatments) and followed for a period of 6 months. The effect of acne on QoL was measured using the Dermatology Life Quality Index, Cardiff Acne Disability Index, and Rosenberg Self-esteem Scale before treatment initiation (T1), after 3 months (T2), and after 6 months (T3). A multivariate analysis of covariance model was used.

Results

Sixty-two patients were included, of whom 79% were female and 61.3% had moderate acne. Fifty-five percent of patients were treated with systemic antibiotics combined with topical treatments, and 45% received isotretinoin. Mean scores of Cardiff Acne Disability Index, Dermatology Life Quality Index, and Rosenberg Self-esteem Scale at T1 were comparable between the two groups. A significant improvement was noticed in both groups at T2 and T3. The multivariate analysis of covariance model showed an interaction of time and age that concerned 25- to 40-year-old patients in both groups, who were the most negatively affected by acne at T1 and improved the most at T3.

Conclusion

This study demonstrated the equivalence between acne treatments in improving QoL and revealed the social obstacle that acne creates and its recrudescence in the subgroup of women of childbearing age.

Pediatric lichen planus: a systematic review of 985 published cases

BACKGROUND

Lichen planus (LP) is a chronic inflammatory disorder usually occurring in middle-aged adults. Data are scarce in the pediatric population.

OBJECTIVE

To describe the patients' characteristics, clinical presentation, and management of pediatric LP.

METHODS

A systematic literature review of pediatric LP was performed in the Medline and Cochrane databases up to February 1, 2020. Demographic and clinical data were extracted for analysis, in addition to laboratory and histology findings, treatments used, and response to treatment. LP pemphigoides (LPP) was further pooled for a subcategory analysis.

RESULTS

One hundred and sixty-four articles were included representing 985 patients. The most common country of origin was India. The most common clinical signs were flat-topped papules (51%); the linear variant was present in 9%. Oral involvement was present in 22%. The most commonly used treatment was topical corticosteroids followed by systemic corticosteroids. The mean duration of treatment was 124.4 days. LPP patients had a short disease duration before diagnosis (4.1 months, P < 0.001) and failed previous treatment more frequently (P < 0.001). Systemic corticosteroids were more often prescribed in this subgroup (75%, P < 0.001) with more recurrence after treatment (31%, P = 0.048).

LIMITATIONS

Lack of randomized controlled studies, in addition to publication bias.

CONCLUSION

In children, LP had a wide polymorphous clinical presentation, and the reported cases were mostly from India. The linear variant was more common and the oral mucosa was less affected in children. LPP, a rare subtype in children, was treated with systemic corticosteroids and recurred more frequently.

The place of 5-aminolaevulinic acid-photodynamic therapy in the treatment landscape of urethral warts: A systematic review

BACKGROUND

Human papilloma virus (HPV) infection is the most common sexually transmitted disease worldwide and the main cause of genital warts. Clear recommendations for the management of urethral warts, which are often hard to detect and difficult to treat, are still lacking.

OBJECTIVE

To summarize all available data describing treatment modalities of urethral warts, compare their efficacy and side effects, and provide physicians a treatment strategy outline.

MATERIAL AND METHODS

Till June 2020, we conducted a systematic review of articles studying the different treatment modalities of urethral condylomas. A chi-square test was used to compare the recurrence rates between treatment modalities, the complete clearance rates at first follow-up and the rates of adverse events.

RESULTS

A total of 26 articles with 1730 patients were included in our review. 61 % of patients were deemed completely cured on the first follow-up while 21 % recurred. 5-aminolevulinic acid (ALA) mediated photodynamic therapy (PDT) was the most common treatment and yielded the lowest recurrence rate (7.5 %) followed by laser therapy (24 %) and topical therapy (31 %) (p < 0.01). ALA-PDT resulted in a higher rate of clearance on follow up (96 %) compared to laser therapy (69 %) and topical therapy (14 %) (p < 0.01). Adverse events were more frequent in the ALA-PDT group (69 %) compared to laser therapy (28 %) and topical treatment (30 %) (p < 0.01).

CONCLUSION

ALA-PDT appears to be the most effective treatment of urethral condylomas in term of clearance and recurrence rate, but with a higher risk of adverse events. Management should be tailored to the type of lesion found at presentation.

Pediatric drug reaction with eosinophilia and systemic symptoms: A systematic review of the literature, with a focus on relapsing cases

BACKGROUND

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous adverse drug reaction with systemic symptoms. This study aims to investigate clinical features, causative drugs, and available treatments for pediatric DRESS, particularly for relapsing cases.

METHODS

A systematic search of the English and French literature on pediatric DRESS was conducted using the Medline, Embase, and Cochrane collaboration databases. Confirmed cases of pediatric DRESS fulfilling the RegiSCAR diagnostic criteria with a probable or a definite diagnosis were included.

RESULTS

After full-text article review, 144 articles were included, representing a total of 354 pediatric patients with a mean age of 8.8 years. The mean time from the drug intake until the onset of the first symptom was 18.9 days. Antiepileptic drugs were the main trigger, followed by anti-infectious agents. Relapsing DRESS was reported in 17 children. In comparison to non-relapsing cases, relapsing patients had more comorbidities. The initial clinical presentation was more commonly erythroderma. Facial edema, fever, and enlarged lymph nodes in more than two sites were more commonly found in relapsing cases. Systemic steroids were more frequently administered.

CONCLUSION

Pediatric DRESS is a potentially severe adverse drug reaction. Antiepileptic agents are the most common causative agents. Fever, facial edema, lymph node enlargement, and pharyngeal and visceral involvement predicted DRESS reactivation in children. Corticosteroids were the mainstay of treatment.

Acquired ungual fibrokeratoma: a systematic review of the literature

BACKGROUND

Acquired ungual fibrokeratomas (AUFKs) are benign recurrent fibrokeratotic tumors of the nail unit of uncertain etiology. Little is known about the optimal modality to successfully treat these lesions. No systematic review addressing ungual fibrokeratomas has been published to date.

OBJECTIVES

The aim of this study is to summarize all the published data regarding diagnostic and therapeutic challenges of AUFKs.

METHODS

On August 9, 2019, a systematic search of Medline and Cochrane databases was conducted. All the studies describing the treatment of ungual fibrokeratomas, procedure description, pathological findings, outcome, and follow-up period were included in this review.

RESULTS

After full-text article review, 103 articles were included, representing a total of 78 lesions. The commonly used treatments for fibrokeratomas were complete tumor resection (90.5%), shave excision (8.3%), and cryotherapy (1.2%). Complete surgical excision yielded the highest cure rate among all treatment modalities (90.8%) compared to partial surgical excision (28.6%) and cryotherapy (0%). The mean follow-up period was 12.1 months (1-144).

CONCLUSION

Complete surgical removal preserving the matrix showed the highest cure rates and should be considered as first-line treatment for AUFKs. Future adequately designed randomized control trials are warranted to compare different treatment modalities.

"The Evolution of Eyebrow Morphology: The Westmore Model Revisited"

BACKGROUND

The most widely recognized eyebrow model was described by Westmore in 1974. With the rapidly changing concept of beauty, an accurate up-to-date model is needed.

METHODS

The Westmore model was tested on fashion models that were randomly selected from the covers of the 1965-1975 (group 1) and 2006-2016 (group 2) Vogue magazine. The eyebrows of fashion models, which represent the beauty ideals of these decades, were objectively measured and compared. We proposed a modified eyebrow model more adapted to the modern standards of beauty, applied it to group 2, and objectively compared it to the Westmore model. This new model was validated on a group of randomly selected Caucasian women.

RESULTS

Thirty women were included in each group. The medial edge of the eyebrow was better defined by the Westmore model in group 1 compared to group 2. The lateral edge of the eyebrow was better defined by the Westmore model in group 2. The peak of the eyebrow was not well defined by the Westmore model in both groups. The new model was more adapted than the Westmore model for both the medial edge and the peak of the eyebrow in group 2. It was also accurate in non-model Caucasian women.

CONCLUSION

Eyebrow morphology has evolved since the description of the Westmore model. Our model represents a simple way to accurately predict the eyebrow landmarks according to the modern ideals of beauty.

Religious stigmata: a dermato-psychiatric approach and differential diagnosis

BACKGROUND

Stigma refers to the wounds reproduced on the human body, similar to the ones inflicted on the Christ during his crucifixion, on the palms, soles, and head, as well as the right or the left side of the chest, the lips and, the back. Whether they are genuine or fabricated, stigmata are still considered a medical enigma.

OBJECTIVE

To summarize and analyze all available medical data about stigmata, integrating both its dermatological and psychiatric features.

METHODS AND MATERIALS

A systematic search of Pubmed and Embase databases was conducted on August 19, 2016, using the terms stigma, stigmata, and religious.

RESULTS

Around 300 cases of stigma have been described since the 13th century. Hematidrosis, hemolacria, bloody otorrhea, vicarious menstruation, and Gardner-Diamond syndrome were all dermatological disorders that resulted in signs and symptoms similar to that of stigma. Stigma was often associated with the occurrence of intense emotion or great psychological stress. It also occurred in the context of simulation, factitious disorder, conversion disorder, and functional neurological symptom disorder.

CONCLUSION

Stigma remains an example of the intricate relationships existing between medicine, psychiatry, psychology, spirituality, and the human body.

Vitamin D and the Skin: An Update for Dermatologists

Vitamin D plays a key role in skeletal and cardiovascular disorders, cancers, central nervous system diseases, reproductive diseases, infections, and autoimmune and dermatological disorders. The two main sources of vitamin D are sun exposure and oral intake, including vitamin D supplementation and dietary intake. Multiple factors are linked to vitamin D status, such as Fitzpatrick skin type, sex, body mass index, physical activity, alcohol intake, and vitamin D receptor polymorphisms. Patients with photosensitive disorders tend to avoid sun exposure, and this practice, along with photoprotection, can put this category of patients at risk for vitamin D deficiency. Maintaining a vitamin D serum concentration within normal levels is warranted in atopic dermatitis, psoriasis, vitiligo, polymorphous light eruption, mycosis fungoides, alopecia areata, systemic lupus erythematosus, and melanoma patients. The potential determinants of vitamin D status, as well as the benefits and risks of vitamin D (with a special focus on the skin), will be discussed in this article.

Botulinum Toxin for Eyebrow Shaping: A Systematic Review

BACKGROUND

Currently, there is no standardized approach for eyebrow shaping with botulinum toxin, and controversies still exist regarding this subject.

OBJECTIVE

The objective of this systematic review is to summarize and compare all the published data regarding eyebrow shaping with botulinum toxin.

METHODS

On March 10, 2017, an online search of published articles in the Medline, Embase, and Cochrane databases were conducted. All articles that used objective measurements to quantify the eyebrow changes after botulinum toxin injection were included in this review.

RESULTS

Eleven studies were selected for inclusion with a total of 585 patients. All the included studies used onabotulinumtoxin A. Seven studies injected both the lateral and the medial eyebrow depressors, 2 studies injected the lateral depressors alone, and 2 studies injected the medial depressors alone. The highest elevation was observed in the lateral brow (0.4-4.8 mm). Bruising and headache were the most frequently reported complications, and only 5 cases of eyelid ptosis were noted.

CONCLUSION

Botulinum toxin injection for eyebrow shaping is a noninvasive, safe, and reproducible procedure. Eyebrow reshaping can be achieved by targeting different muscle groups. However, further randomized controlled trials are warranted.

Labia Majora Augmentation: A Systematic Review of the Literature

BACKGROUND

Currently, there is no standardized approach for labia majora augmentation and controversies still exist regarding this subject.

OBJECTIVES

This systematic review aimed to assess the evidence in the literature regarding labia majora augmentation.

METHODS

On November 20, 2016, we conducted an online search of published articles in the Medline, Embase, and Cochrane databases. All articles describing labia majora augmentation were included in this review.

RESULTS

Nine studies were selected for inclusion in the systematic review. Only 2 studies were prospective trials. The most commonly used technique was fat grafting with a total of 4 articles and 183 patients. The mean total injected fat volume ranged from 18 mL to 120 mL per session. Two articles described hyaluronic acid injection techniques. The total injected volume of hyaluronic acid ranged from 2 to 6 mL per session. Three articles used surgical techniques for labia majora augmentation. All included articles did not report any major or life-threatening complications. All techniques demonstrated high satisfaction rates.

CONCLUSIONS

Labia majora augmentation appears to be a safe, efficient technique with a high satisfaction rate and no reported major complications. However, further randomized controlled trials are warranted.

LEVEL OF EVIDENCE

4.

Pediatric pyoderma gangrenosum: a systematic review and update

Pyoderma gangrenosum (PG) is a sterile neutrophilic disorder that rarely affects children. Clinical, epidemiological, and therapeutic data on pediatric PG is poor as there are many newly reported associated diseases and drugs. This paper aims to review all recent available data on pediatric PG. A systematic review of the literature was conducted using Embase, Medline, and Cochrane databases. A total of 132 articles were included in the review. The most commonly reported underlying diseases in pediatric PG are inflammatory bowel diseases followed by hematologic disorders, vasculitis, immune deficiencies and Pyogenic Arthritis, Pyoderma gangrenosum and Acne (PAPA) syndrome. More than half of the cases occur with no underlying disease. The most frequently reported clinical presentation is multiple disseminated ulcers. Treatment should be tailored according to the underlying etiology. It includes systemic steroids, corticosteroid sparing agents such as dapsone and cyclosporine, and TNF-alpha inhibitors such as adalimumab and infliximab. Response to treatment is high with cure rates reaching 90%. A high index of suspicion and a thorough workup are mandatory in the management of pediatric PG.

Lamotrigine-induced Hypersensitivity Syndrome with Histologic Features of CD30+ Lymphoma

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome or drug-induced hypersensitivity syndrome (DIHS) is a severe adverse drug reaction. It can present with clinical, paraclinical, and histological findings mimicking skin and/or systemic lymphomas. We report the first case of a lamotrigine-induced DRESS with histologic features of a cutaneous CD30+ lymphoma. The patient responded well to a tapering course of oral steroids. This case highlights the atypical presentation of a lamotrigine-induced DRESS/DIHS in the presence of a cutaneous and a lymph node CD30 + lymphocytic infiltrate mimicking systemic lymphoma. Pathologists and clinicians must be aware of this “lymphomatous” presentation of drug reactions.

A case of generalized bromhidrosis following whole-body depilatory laser

BACKGROUND

Laser treatment is a widespread method for hair removal. Despite its very common use, side effects remain relatively rare and transient.

OBJECTIVE

Axillary hyperhidrosis and bromhidrosis have already been reported in the literature after depilatory lasers. We report here a novel side effect of total body bromhidrosis following hair removal laser.

RESULTS

A 27-year-old man, phototype 3 underwent four sessions of total body depilatory laser, combining pulsed alexandrite and pulsed diode lasers. A few days afterwards, a generalized foul odor was noted and was resistant to regular deodorants and Aluminum chloride based antiperspirants. Possible mechanisms include the activation of dormant bacteria in the skin flora, sweat gland dysfunction, altered skin flora, sweat gland hormone receptor disturbances, and genetic factors.

CONCLUSION

Total body bromhidrosis and hyperhidrosis are potential complications of total body laser hair removal.