Efficacy and safety of tofacitinib for treatment of alopecia areata in children: A systematic review and meta-analysis

BACKGROUND

Tofacitinib, a potent JAK inhibitor, has gained increasing interest, in recent years, among dermatologists for the management of refractory alopecia areata. Despite a growing number of studies on its safety and efficacy, there is still a lack of clarity, especially in the pediatric population, in treatment considerations such as proper dosage, treatment duration, side-effect profile, and therapeutic strategies to guide clinicians.

METHODS

Multiple databases were systematically searched. Following the PRISMA diagram, of a pool of 601 papers, seven met a checklist of inclusion criteria. These were observational studies including a total of 59 patients from four to 19 years of age.

RESULTS

In the evaluated studies, tofacitinib was administered either orally at a 2.5 to 15 mg daily (mostly 5 mg twice a day) dosage for 2 to 38 months or in the form of a 2% topical solution for 3-17 months. Metanalysis showed that 49% (95% CI: 29%-69%, I²  = 59.94%) of patients experienced a reversal of alopecia after a minimum of 3 to 9 months of therapy. Fifty-five percent (95% CI: 23%-86%, I²  = 75.07%) and 41% (95% CI: 23%-59%, I²  = 0.00%) showed Good/complete and partial response rates, respectively. Oral administration was significantly more efficacious than topical application (73% vs 23%, p-Value = 0.04). Few side effects such as diarrhea and mild liver transaminases abnormalities were noted in several patients.

CONCLUSION

Results of this review suggest that tofacitinib at 2.5-15 mg daily (especially 5 mg twice daily) oral formulation or 2% topical solution can be regarded as a viable alternative or adjunct to the conventional treatment options for moderate to severe forms of alopecia areata in children owing to its acceptable efficacy and side-effect profile. However, uncertainties continue to exist around treatment strategies including initial and maintenance dosages, route of administration, dose adjustments, the timing of tapering or discontinuation, and associated treatment modalities.

Platelet-rich plasma in the treatment of scars, to suggest or not to suggest? A systematic review and meta-analysis

Despite the rising trend for applying platelet-rich plasma (PRP) in the management of various types of scars, there is no convincing evidence supporting its use. This motivated us to review the randomized clinical trials that examine the effectiveness and safety of PRP, alone or in combination with other methods, for the management of atrophic or hypertrophic/keloidal scars. The Web of Science, Scopus, Google Scholar, and Cochrane Library databases were systematically searched until September 1^st , 2020. Thirteen clinical trials were enrolled in the meta-analysis, and 10 more were reviewed for their results. The random effect meta-analysis method was used to assess the effect size of each outcome for each treatment type, and I² was used to calculate the statistical heterogeneity between the studies. Patients treated with PRP experienced an overall response rate of 23%, comparable to the results seen with laser or micro-needling (22% and 23%, respectively) When used alone, moderate improvement was the most frequently observed degree of response with PRP (36%) whereas, when added to laser or micro-needling, most patients experienced marked (33%, 43%, respectively) or excellent (32% and 23%, respectively) results. Concerning the hypertrophic/keloid scars, the only study meeting the required criteria reported a better improvement and fewer adverse effects when PRP was added to the intralesional corticosteroids. Platelet-rich plasma appears to be a safe and effective treatment for various types of atrophic scars. In addition, when added to ablative lasers or micro-needling, it seems to considerably add to the efficacy of treatment and reduce the side effects.

Efficacy, safety, tolerability, and satisfaction of N-acetylcysteine and pentoxifylline in lichen planopilaris patients under treatment with topical clobetasol: A triple arm blinded randomized controlled trial

Lichen planoplaris (LPP) is one of the most common causes of inflammatory cicatricial alopecias. There is no definitive cure for the disease and most of the available therapeutic options can potentially lead to serious complications following their use for extended durations. In this study, we aimed to evaluate the efficacy, safety and tolerability of N-acetylcysteine (NAC) and pentoxyfillin (PTX), as adjunctive therapies, in the management of LPP. In a randomized, assessor- and analyst-blinded controlled trial, patients with proven LPP were randomly assigned to three groups of 10. Group I (the control group) received clobetasol 0.05%lotion; Group II, a combination of clobetasol 0.05% lotion and oral PTX; Group III, a combination of clobetasol lotion 0.05% and oral NAC. Lichen planopilaris activity index (LPPAI), the possible side effects, tolerability and patients satisfaction were assessed before and two and four months after the initiation of the treatments. Thirty patients, 96.7% women, with a mean age of 46.8 ± 13.3 years old, were included in the study. Four months into the treatments, the overall LPPAI and the severity and/or frequency of most of its determinants significantly decreased in all groups. In a comparison among the groups, patients who received either of the combination therapies showed more decline in their LPPAI than those receiving only clobetasol. The decline was more noticeable and statistically significant only in the NAC group. Three patients in the PTX group developed complications that were not statistically significant when compared with the other groups. There were no substantial differences in the tolerability of the treatments among the study arms. The use of oral NAC and PTX added to the therapeutic efficacy of topical clobetasol in the treatment of LPP, suggesting that they might be beneficial and safe adjuvant therapies and add to the efficacy of topical treatment without any noticeable impact on the adverse effects experienced by patients.

The Influence of Brass Compensator Thickness and Field Size on Neutron Contamination Spectrum in 18MV Elekta SL 75/25 Medical Linear Accelerator with and without Flattening Filter: A Monte Carlo Study

BACKGROUND

One of the most significant Intensity Modulated Radiation Therapy treatment benefits is a high target to normal tissue dose ratio. To improve this advantage, an additional accessory such as a compensator is used to deliver doses. Compensator-based IMRT treatment is usually operated with an energy higher than 10 MV. Photoneutrons, which have high linear energy transfer and radiobiological effectiveness, are produced by colliding high-energy photon beams with linear accelerator structures, then they deliver the unwanted doses to patients and staff. Therefore, the neutron energy spectra should be determined in order to calculate and reduce the photoneutron risk.

OBJECTIVE

We have conducted a comprehensive and precise study on the influence of brass compensator thickness and field size on neutron contamination spectrum in an Elekta SL 75/25 medical linear accelerator with and without the flattening filter by Monte Carlo method.

MATERIAL AND METHODS

MCNPX MC Code version 2.6.0 was utilized to simulate the detailed geometry of Elekta SL 75/25 head components based on Linac's manual. This code includes an important feature to simulate the photo-neutron interactions. Photoneutrons spectrum was calculated after the Linac output benchmarking based on tuning the primary electron beam.

RESULTS AND CONCLUSION

Based on the Friedman and Wilcoxon nonparametric tests results (P<0.05), photoneutron fluence directly depends on the field size and compensator thickness. Moreover, the unflattened beam provides lower photoneutron fluence than the flattened beam. Photoneutrons fluence is not negligible in compensator-based IMRT treatment. However, in order to optimize treatment plans, this additional and unwanted dose must be accounted for patientss.

Temporal course of avascular femoral head necrosis in patients with pemphigus vulgaris

BACKGROUND AND OBJECTIVES

Pemphigus vulgaris (PV) is typically treated with systemic corticosteroids and immunosuppressive agents. Avascular necrosis (AVN) of the femoral head is a well-recognized major complication of corticosteroid therapy. The characteristics of this serious complication in PV remain unknown.

PATIENTS AND METHODS

Uncontrolled, retrospective study of all PV-related AVN cases diagnosed at an Iranian autoimmune bullous disease clinic between 1985 and 2013.

RESULTS

Of the 2,321 medical records of PV patients reviewed, 45 (1.93 %) cases showed femoral AVN, with 30 (66.7 %) individuals being male. The mean age at diagnosis of AVN was 47.4 ± 14.2 years. The mean interval between the diagnosis of PV and the onset of AVN was 25.3 ± 18.3 months. With the exception of eight cases (17.8 %), the majority of patients developed AVN within three years after the diagnosis of PV. The mean cumulative dose of prednisolone in patients with AVN was 13,115.8 ± 7041.1 mg. There was a strong correlation between the total prednisolone dose and the time of onset of AVN (p = 0.001). In patients with a history of alendronate intake, that interval was significantly shorter (p = 0.01).

CONCLUSIONS

Occurring in about 2 % of patients, AVN is a serious complication of corticosteroid treatment in patients with PV, predominantly in the first three years of treatment. In individuals receiving higher doses of prednisolone, AVN tends to occur earlier.

Evaluating effective factors on the activity and loading of immobilized α-amylase onto magnetic nanoparticles using a response surface-desirability approach

The effects of different operational conditions of α-amylase covalent immobilization on magnetic nanoparticles were investigated using a central composite design.

Frequency of seropositivity against infectious agents amongst pemphigus vulgaris patients: a case-control study on Strongyloides stercoralis, Helicobacter pylori, Toxoplasma gondii, Leishmania major, and Epstein-Barr virus

BACKGROUND

Environmental and genetic factors may contribute to the pathogenesis of pemphigus vulgaris (PV) as an autoimmune disease. We aimed to determine rates of seropositivity for immunoglobulin G (IgG) antibodies against a number of infectious agents in untreated and treated PV patients and in healthy individuals.

METHODS

Eighty-two newly diagnosed untreated PV patients (34 men and 48 women; mean ± standard deviation [SD] age: 44.18 ± 14.43 years) and 36 previously diagnosed patients under immunosuppressive therapy (16 men and 20 women; mean ± SD age: 38.53 ± 9.96 years) were enrolled in the study. The clinical diagnosis of PV was confirmed by histopathology and direct immunofluorescence findings. As a control group, 131 healthy individuals (68 men and 63 women; mean ± SD age: 42.56 ± 19.69 years) were recruited. In all patients and controls, serum IgG antibodies against Strongyloides stercoralis, Helicobacter pylori, Epstein-Barr virus (EBV) capsid antigen, and Leishmania major were measured using enzyme-linked immunosorbent assays. The indirect immunofluorescence test was used to detect IgG antibodies against Toxoplasma gondii.

RESULTS

Newly-diagnosed untreated PV patients had significantly higher rates of seropositivity of IgG antibodies against S. stercoralis and H. pylori compared with the control group (69.5% vs. 16.0% [P < 0.001] and 79.3% vs. 59.5% [P = 0.004], respectively). For the other agents, namely T. gondii, L. major, and EBV capsid antigen, the differences between groups in seropositivity for IgG antibodies were not statistically significant.

CONCLUSIONS

Significant associations between S. stercoralis and H. pylori seropositivity rates and untreated disease led to the hypothesis that these pathogenic agents may contribute to the pathogenesis of PV.

Effect of Gold Nanoparticles on Prostate Dose Distribution under Ir-192 Internal and 18 MV External Radiotherapy Procedures Using Gel Dosimetry and Monte Carlo Method

BACKGROUND

Gel polymers are considered as new dosimeters for determining radiotherapy dose distribution in three dimensions.

OBJECTIVE

The ability of a new formulation of MAGIC-f polymer gel was assessed by experimental measurement and Monte Carlo (MC) method for studying the effect of gold nanoparticles (GNPs) in prostate dose distributions under the internal Ir-192 and external 18MV radiotherapy practices.

METHOD

A Plexiglas phantom was made representing human pelvis. The GNP shaving 15 nm in diameter and 0.1 mM concentration were synthesized using chemical reduction method. Then, a new formulation of MAGIC-f gel was synthesized. The fabricated gel was poured in the tubes located at the prostate (with and without the GNPs) and bladder locations of the phantom. The phantom was irradiated to an Ir-192 source and 18 MV beam of a Varian linac separately based on common radiotherapy procedures used for prostate cancer. After 24 hours, the irradiated gels were read using a Siemens 1.5 Tesla MRI scanner. The absolute doses at the reference points and isodose curves resulted from the experimental measurement of the gels and MC simulations following the internal and external radiotherapy practices were compared.

RESULTS

The mean absorbed doses measured with the gel in the presence of the GNPs in prostate were 15% and 8 % higher than the corresponding values without the GNPs under the internal and external radiation therapies, respectively. MC simulations also indicated a dose increase of 14 % and 7 % due to presence of the GNPs, for the same experimental internal and external radiotherapy practices, respectively.

CONCLUSION

There was a good agreement between the dose enhancement factors (DEFs) estimated with MC simulations and experiment gel measurements due to the GNPs. The results indicated that the polymer gel dosimetry method as developed and used in this study, can be recommended as a reliable method for investigating the DEF of GNPs in internal and external radiotherapy practices.

Hydroa vacciniforme with eye involvement: report of two cases

We herein report two patients with hydroa vacciniforme and concomitant ophthalmic involvement, primarily in the form of keratoconjunctivitis leading to corneal opacity. Awareness of this occasional manifestation may help to prevent severe complications.

Pemphigus disease activity measurements: pemphigus disease area index, autoimmune bullous skin disorder intensity score, and pemphigus vulgaris activity score

IMPORTANCE

Recently, the clinical pemphigus disease activity indexes of Pemphigus Disease Area Index (PDAI), Autoimmune Bullous Skin Disorder Intensity Score (ABSIS), and Pemphigus Vulgaris Activity Score (PVAS) were validated to correlate with physician global assessment. The antidesmoglein (anti-Dsg) autoantibodies are known to correlate mostly with pemphigus disease activity. The correlation between these indexes and anti-Dsg1 and anti-Dsg3 enzyme-linked immunosorbent assay values has not been previously evaluated.

OBJECTIVES

To evaluate the PDAI, ABSIS, and PVAS in a large number of patients with pemphigus vulgaris and to compare the interrater reliability of these indexes and the convergent validity according to anti-Dsg values.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study was performed in 2012 in a referral university center for autoimmune bullous diseases. One hundred patients with confirmed diagnoses of pemphigus vulgaris and clinical pemphigus lesions (mean [SD] age, 43.3 [1.7] years; age range, 14-77 years; female-male ratio, 1:3) were studied. Three dermatologists familiar with immunobullous diseases and the indexes rated the patients.

INTERVENTIONS

All 100 patients were evaluated with the PDAI, ABSIS, and PVAS. Three dermatologists independently rated all 3 indexes for each of the patients on the same day. Serum anti-Dsg1 and anti-Dsg3 enzyme-linked immunosorbent assay values were measured simultaneously.

MAIN OUTCOMES AND MEASURES

Analyses of interrater reliabilities, convergent validities according to anti-Dsg titers, correlation between the distribution and types of lesions with disease activity, predictors of higher titers of antibody (multiple regression analysis), and cutoff values of measures for 2 titers of anti-Dsg with optimal area under the curve, sensitivity, and specificity were performed.

RESULTS

The interrater reliabilities were highest for the PDAI, followed by the ABSIS and the PVAS (intraclass correlation coefficients of 0.98 [95% CI, 0.97-0.98], 0.97 [95% CI, 0.96-0.98], and 0.93 [95% CI, 0.90-0.95], respectively). The convergent validity was highest for the PDAI, followed by the PVAS and the ABSIS (Spearman ρ = 0.67, 0.52, and 0.33, respectively). Head, neck, and trunk involvement were predictors of higher titers of anti-Dsg1.

CONCLUSIONS AND RELEVANCE

Among the 3 studied indexes, the PDAI had the highest validity and is recommended for use in multicenter studies for rare diseases, such as pemphigus vulgaris.

Demographic and histopathologic study of Kaposi's sarcoma in a dermatology clinic in the years of 2006 to 2011

Kaposi's sarcoma is a low-grade vascular tumor that its prevalence is increasing all around the world due to the increasing prevalence of HIV and organ transplantations. In this study, we assessed risk factors of Kaposi's sarcoma among Iranian patients were referred to Dermatopathology Department of Razi Hospital of Tehran University of Medical Sciences between the years of 2006 to 2011. Also, disease stages have been assessed on pathologic specimens. Thirty four patients diagnosed with Kaposi's sarcoma entered the study. Of the 34 patients, 29% were female, and 71% were male, mean age was 66 years and average disease duration was 6 months. The most common patient's pathologic stages were reported: patch 32%, patch to plaque 24%, plaque 12%. The most prevalent location of involvement was lower extremity (88%), and upper extremity was involved in 24%. At presentation time, the mean number of lesions was 3 to 4. 15% of patients had a history of smoking and 15% had a history of immunosuppressive drugs. HIV infection did not observe in the patients. Based on the present study, Kaposi's sarcoma is a disease of elderly and is higher in older men. The most common site of Kaposi's sarcoma involvement is lower extremity, and the most common pathologic stage was the patch to plaque.

Pemphigus vulgaris-associated Kaposi's sarcoma: response to paclitaxel and review of the literature

Systemic corticosteroids have long been the mainstay of treatment for pemphigus patients. However, the necessity of their high-dose and long-term administration has brought about a number of complications, sometimes causing significant morbidities. Maintaining a balance between therapeutic and undesirable effects of medications is not always easily achievable. Therefore, additional treatment modalities are frequently needed to control side-effects. Kaposi's sarcoma (KS) is a rare, potentially life-threatening complication in this setting. Due to the rarity of data on pemphigus-associated KS treatment, the best therapeutic approach is still undecided. Here, we report two cases of pemphigus patients who had developed extensive KS as a result of severe immunosuppressive therapy and were successfully treated with paclitaxel. In addition, we performed a review of literature to assess the results of the previously employed treatment modalities in this setting.