The Significance of Eosinophil-to-Lymphocyte Ratio in Predicting Response to Omalizumab Treatment in Patients with Bullous Pemphigoid: A Case Series

Omalizumab, a monoclonal anti-IgE antibody, has been used off-label in a few case series of bullous pemphigoids (BPs) with rapid efficacy and high safety profile. However, there is a lack of data to select patients who would get the most therapeutic benefit from omalizumab therapy. To assess if eosinophil-to-lymphocyte ratio (ELR), total serum IgE level, and serum eosinophil percentage would be useful in predicting response to omalizumab therapy in patients with BP. Medical records of 10 patients with BP treated with omalizumab were retrospectively analysed for clinical and laboratory data. ELRs, total serum IgE levels, and serum eosinophil percentages were compared between groups of complete responders and partial responders/flare-ups, but the results were not statistically significant. Studies with larger sample sizes should be done to predict the role of type 2 immunity markers in omalizumab therapy of BP patients.

The effect of patient characteristics on illness perception and sun protection behaviors in melasma

BACKGROUND/AIM

Melasma, a significant cosmetic problem, has been accepted by some authors as a photoaging illness in recent times. There is no published study evaluating the effects of the clinical and sociodemographic findings on illness perception and sun protection behaviors (SPBs) in patients with melasma.

PATIENTS/METHODS

Sociodemographic data, personal characteristics, and clinical features of 150 patients with melasma were recorded in this cross-sectional study. They were analyzed for their SPBs in three groups as "never," "rarely/sometimes," and "often/always." Patients completed the Melasma Quality of Life (QoL) Scale and Revised-Illness Perception Questionnaire.

RESULTS

Melasma patients with higher clinical severity and Qol scores, lower education level, concomitant chronic illness, and a history of previous melasma treatment thought more frequently that melasma had negative serious consequences. Majority of the patients blamed sun exposure as the cause of the melasma. However, SPBs were more frequent only in patients with higher socioeconomic and educational levels, a previous history of melasma treatment, and evaluating their disease as a chronic condition. Neither Qol nor clinical severity score had a significant effect on sun exposure causal attribution or SPBs. No significant effect of patients' perception of melasma was determined on the use of sunscreen or protective hat.

CONCLUSION

Being aware of the factors affecting the perception of melasma and QoL of patients might be helpful in making persistent individual recommendations for the regulation of SPBs.

The effect of diode laser application on restoration of non carious cervical lesion: Clinical follow up

Aims

The aim of this study is to evaluate the effect of the diode laser used for dentin sensitivity on the clinical success of non-carious cervical lesion (NCCL) restorations restored with different adhesive systems.

Methods

20 NCCLs were restorated with Universal Single Bond (Self Etch) (3M, USA) and Grandio (Voco, Germany), 20 NCCLs were restorated with Universal Single Bond (Total Etch) and Grandio. After diode laser application, 20 NCCLs were restorated with Universal Single Bond and Grandio, 20 NCCLs were restorated with Universal Single Bond (Total Etch) and Grandio. The restorations were clinical evaluated by two examiners at baseline, for 6 and 18 months using modified United States Public Health Service (USPHS) Criteria. Chi-square test was used for statistical analyse.

Results

The lowest rates of retention was found in the Group 1. There was no statistically significant difference among the groups in marginal discoloration, marginal integrity, sensitivity (P > 0.05).

Conclusion

Diode laser application prior to the restoration of teeth with NCCL don't reduce the retention rate of restorations, may reduce hypersensitivity and may affect the success of restoration. However, further laboratory and clinical studies are required.

Dermoscopic Differentiation of Facial Lentigo Maligna from Pigmented Actinic Keratosis and Solar Lentigines

The differential diagnosis of lentigo maligna (LM) from pigmented actinic keratosis (PAK) and solar lentigines (SL) remains a challenge for clinicians, especially in the early stages of LM when there are no distinctive dermoscopic features. Objective of this study was to evaluate the frequencies of selective dermoscopic criteria in LM, PAK, and SL and to find the specific combination of distinguishing dermoscopic criteria for LM. Dermoscopists blinded to histopathological diagnosis evaluated 42 LM, 107 PAK, and 16 SL for the presence of predefined dermoscopic criteria. The differences in the presence of dermoscopic criteria between LM and others were evaluated with the chi-squared test or Fisher's exact test as appropriate. Multivariate logistic regression analysis with the forward conditional stepwise method were performed and odds ratios and corresponding 95% confidence intervals for LM, PAK, and SL were calculated. LM, PAK, and SL showed many common dermoscopic findings. In multivariate logistic regression analysis, darkening at dermoscopic examination (sevenfold), gray circles (sevenfold), target-like pattern (sixfold), gray rhomboids (sixfold), and slate-gray dots/globules (threefold) represented the strongest predictors of LM, while hyperkeratosis (thirteenfold), white circles (twelvefold), and red rhomboids (sixfold) represented the strongest predictors of PAK. The dermoscopic diagnosis of a given lesion should be based on the presence of the combination of specific dermoscopic criteria rather than a single benign or malignant criterion. Our results suggest that the presence of darkening at dermoscopic examination, gray circles, target-like pattern, gray rhomboids, and slate-gray dots/globules should be considered supportive findings for the diagnosis of early LM.

Piebaldism Associated with Café-au-lait Macules and Intertriginous Freckling: A Case Report and Review of the Literature

We present 9-year-old fraternal twins from a family with piebaldism, having congenital depigmented macules and meeting the diagnostic criteria for neurofibromatosis type 1 (NF1) due to the multiple café-au-lait macules (CALMs) and intertriginous freckling at the same time. It's still a debatable issue that CALMs and intertriginous freckling may be seen in the clinical spectrum of piebaldism or these patients should be regarded as coexistence of piebaldism and NF1. However, based on recent literature and our patients' findings, we suggest that this rare phenotypic variant of piebaldism may not need the careful clinical follow-up and molecular testing for NF1. Besides, it may be suitable that these individuals with piebaldism showing NF1-like clinical phenotypes should be further tested for KIT and SPRED1 gene mutations.

Comparison of serum lipid parameters between patients with classic cutaneous lichen planus and oral lichen planus

OBJECTIVES

Previous studies have shown that patients with lichen planus (LP) have an increased occurrence of inflammation-related dyslipidemia. Although classic cutaneous LP (CCLP) and oral LP (OLP) are basically known as the different subtypes of the same disease sharing the common histopathological features, they actually have significant differences both in the clinical behavior and in the molecular inflammatory pathogenesis. We aimed to compare the lipid profile of patients with CCLP and OLP.

MATERIALS AND METHODS

This study included 120 patients, 30 with isolated CCLP, 30 with isolated OLP, 30 with CCLP + OLP, and 30 controls consecutively admitted to the outpatient clinics of Dermatology Department of Dokuz Eylul University Hospital, Izmir, Turkey.

RESULTS

Triglycerides (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) values, TC/high-density lipoprotein cholesterol (HDL-C), and LDL-C/HDL-C atherogenic indexes were significantly higher, and HDL-C values were significantly lower in all LP subtypes compared with the controls. Among LP subtypes, although the differences were not statistically significant, TG, TC, and LDL-C values were markedly higher in OLP and OLP + CCLP patients compared with CCLP patients. OLP and CCLP + OLP patients also showed significantly higher TC/HDL-C and LDL-C/HDL-C atherogenic indexes compared with CCLP patients.

CONCLUSIONS

Patients with OLP have a more impaired lipid metabolism and significantly higher atherogenic indexes compared with patients with CCLP. The differences in the molecular inflammatory pathways between OLP and CCLP and the longer disease duration of OLP leading to long-lasting inflammation may elucidate this distinction.

CLINICAL RELEVANCE

We recommend to pay close attention to the early recognition of coexisting atherogenic dyslipidemia and to apply the early protective measures against the development of cardiovascular disease in OLP patients.

Xerosis cutis and associated co-factors in women with prurigo nodularis

BACKGROUND

Current data regarding the associated factors of prurigo nodularis are still uncertain, except for atopic predisposition.

OBJECTIVES

The purposes of this study were to (1) determine the frequencies of xerosis and other accompanying diseases of female patients with prurigo nodularis; (2) compare the demographic, clinical and accompanying disease characteristics by grouping these patients according to whether they have associated xerosis (who were subsequently subgrouped as atopic or non-atopic) or not.

METHODS

In this retrospective descriptive study, 80 females with PN were categorized according to the accompanying diseases (dermatological, systemic, neurological, psychogenic, mixed, or undetermined origin).

RESULTS

A total of 45 associated co-factors including dermatological in 63 (78.8%), systemic in 57 (71.3%), psychological in 33 (41.3%) and neurological co-factors in 14 (17.5%) of all patients with prurigo nodularis were detected. Xerosis was observed in 48 (60%) patients (non-atopic co-factors in 66.7% of them). The ratio of patients with mixed co-factors, dermatological+systemic co-factors and dermatological+systemic+psychological co-factors were found to be significantly higher in patients with xerosis compared to those without xerosis.

STUDY LIMITATIONS

Our study has certain limitations such as the absence of an age-matched control group, absence of follow-up data and the fact that the diagnosis of xerosis has not been based on objective methods.

CONCLUSIONS

Xerosis has been identified in more than half of the patients with PN and it has been determined that in most patients xerosis is associated especially with diabetes mellitus and other conditions related to prurigo nodularis.

Blocking or enhancing effects of some basic emollients in UVA penetration

BACKGROUND

Topical agents used in combination with phototherapy or photochemotherapy may have both blocking or enhancing effects in ultraviolet rays.

OBJECTIVE

In this in vivo study, the effects of topical petrolatum, basis cream, glycerine, and olive oil on the transmission of ultraviolet A radiation were investigated.

METHODS

A test was performed to determine the minimal phototoxic dose on 29 volunteers with only psoralen plus ultraviolet A (PUVA) and then the same test was repeated with white petrolatum, basis cream, glycerine, olive oil, and sunscreen (0.3cc/25cm2). The effects of each agent on the minimal phototoxic dose were determined after 72 h.

RESULTS

When compared to pure PUVA, there was a statistically significant increase in the mean minimal phototoxic dose values by the application of white petrolatum (P = 0.011), but there was no significant increase or decrease in the mean minimal phototoxic dose values after the application of basis cream (P = 0.326), glycerine (P = 0.611) or olive oil (P = 0.799).

STUDY LIMITATIONS

Low number of patients Conclusion: The application of white petrolatum, which has a blocking effect, and also of basis cream immediately before PUVA therapy should not be recommended. Although we specify that glycerine and maybe olive oil can be used before photochemotherapy, there is a need for further research in larger series.

Examination of the Microbial Spectrum in the Etiology of Erythema Nodosum: A Retrospective Descriptive Study

Even though infections are the most common cause of erythema nodosum (EN), only certain microorganisms take the great interest such as streptococci in knowledge. Our aim was to examine the frequency and type of infections in EN, to determine the characteristics of patients with an infectious etiology, and to discuss the role of these microbes in EN pathology in the context of their interactions with humans. Charts of 81 patients with EN who were seen between 2003 and 2017 were retrospectively reviewed. Identified etiological factors were classified into three groups: infectious, noninfectious, and idiopathic. While there were no significant demographic and clinical differences between the infectious and idiopathic groups, systemic symptoms (p = 0.034) and the number of EN lesions (p = 0.016) were significantly lower; the mean erythrocyte sedimentation rate was significantly higher (p = 0.049), but the mean aspartate aminotransferase value was significantly lower in the infectious group compared to the noninfectious group (p = 0.019). Besides streptococci, many other microbes, including the ones living on and inside us, were identified in the etiology of EN. There is a need for large-scale prospective studies involving control groups for a better understanding of the microbial immunopathology of EN.

Influence of demographic and clinical characteristics of actinic keratosis patients on illness perceptions and readiness to increase sun protection behaviours: an exploratory study

BACKGROUND/PURPOSE

There are no data comprehensively investigating the key beliefs and sun protection behaviours in patients with actinic keratosis (AK). Our aim was to determine and correlate the AK perceptions and readiness to increase sun protection (RISP) behaviours.

METHODS

AK patients' (n = 200) demographics and clinical findings were recorded. Participants completed questionnaires (Illness Perception Questionnaire-Revised and RISP behaviours scales).

RESULTS

The mean scores of giving up sunbathing of the patients aged <65 years, and giving up sunbathing and staying in the shade behaviours of females were higher. As the level of education increased, while the mean scores of giving up sunbathing decreased, using sunscreen scores increased. The mean scores of giving up sunbathing, using sunscreen and wearing protective clothing of those with the history of non-skin cancer (had cancer other than of the skin) were lower. The readiness to increase using sunscreen was found to be higher in patients with more chronic timeline beliefs, more positive perceived personal control and blaming sunlight more, and the wearing protective clothing was found to be higher in those with more cyclical timeline beliefs.

CONCLUSION

AK patients, especially the subjects aged ≥65 years, have non-skin cancer history, and male gender should be informed to apply sun-protective behaviours.

Lupus Band Test in Patients with Borderline Systemic Lupus Erythematosus with Discoid Lesions

Patients with lupus erythematosus (LE) that have discoid lesions who fulfill the four diagnostic criteria of systemic lupus erythematosus (SLE) with only mucocutaneous findings and antinuclear antibody (ANA) positivity were classified as borderline SLE in the literature. Objective of this study was to determine the place of borderline SLE with discoid lesions on the LE spectrum according to the lupus band test (LBT). Lesional and sun-protected non-lesional (SPNL) skin LBTs of 94 patients with LE that had discoid lesions were retrospectively evaluated. Firstly, patients were divided into two main groups: discoid LE (DLE; group A) and SLE (Group B); three subgroups were then classified as DLE (Group A), borderline SLE (Group B1) and SLE (Group B2) using another method. Each group had its own comparisons. Immunoreactant (IR) deposition was observed on the lesional skin in all patients and on the SPNL skin in 42 (44.7%). In patients with borderline SLE, the deposition of IgM was lower on the lesional LBTs, whereas isolated IgG was higher than SLE; thus, it shows similarity with DLE. Additionally, it was also closer to DLE because of the low deposition of C3, multiple IRs, and a double conjugate of IRs on the SPNL skin. However, it showed similarity with SLE in the high percentage of LBT positivity and more immunoglobulin M (IgM) and immunoglobulin G (IgG) deposition on the SPNL skin. The deposition of multiple conjugates on SPNL skin in patients with LE with discoid lesions may reflect systemic involvement. Despite the fact that LBT positivity on SPNL skin in borderline SLE was higher than DLE, less deposition of multiple conjugates compared to SLE indicates that the classification of borderline SLE with discoid lesions in the LE spectrum is questionable.

Possible Triggering Effect of Influenza Vaccination on Psoriasis

Psoriasis is a chronic, recurrent, immune-mediated inflammatory disease and it can be provoked or exacerbated by a variety of different environmental factors, particularly infections and drugs. In addition, a possible association between vaccination and the new onset and/or exacerbation of psoriasis has been reported by a number of different authors. The aim of this study is to investigate the effects of influenza vaccination on patients with psoriasis. Here, we report the findings from 43 patients suffering from psoriasis (clinical phenotypes as mixed guttate/plaque lesions, palmoplantar or scalp psoriasis) whose diseases had been triggered after influenza vaccination applied in the 2009-2010 season. The short time intervals between vaccination and psoriasis flares in our patients and the lack of other possible triggers suggest that influenza vaccinations may have provocative effects on psoriasis. However, further large and controlled studies need to be carried out to confirm this relationship.

Dermato-neuro syndrome in a case of scleromyxedema

Scleromyxedema is an uncommon connective tissue disease characterized by mucin deposits, fibrosis, and proliferation of fibroblasts in the dermis. Although it shares similar sclerodermoid features, it is a different clinical entity than scleroderma. A monoclonal gammopathy is almost always present; however, progression to multiple myeloma is rare. It may have many systemic manifestations, of which the most notable being the dermato-neuro syndrome because of its rarity and potential fatal outcome. We present a case of a 50-year-old woman with scleromyxedema in whom the dermato-neuro syndrome developed.

Single versus repetitive injection of lignocaine in the management of carpal tunnel syndrome--a randomized controlled trial

The aim of this study was to determine the efficacy of single versus repetitive injection of lignocaine into the carpal tunnel for the management of carpal tunnel syndrome. The 42 patients included were randomly assigned to two Groups: group 1 was injected with 4 mL of 1% lignocaine once and Group 2 was injected with 4 mL of 1% lignocaine twice a week for 2 weeks. Clinical and electrophysiological evaluations were performed at the study onset, and at 6 and 12 weeks following the final injection. Initially, the groups were similar with respect to clinical and electrophysiological findings. All parameters in Group 2 improved 6 weeks post treatment (p < 0.05), and these improvements persisted at 12 weeks post treatment (p < 0.05). Repetitive local lignocaine injection was effective in reducing the symptoms of carpal tunnel syndrome and improving electrophysiological findings.

Severe neurologic involvement of Degos disease in a pediatric patient

A 14-year-old male presented with paresthesias on the right upper and lower extremities, headache, and vomiting. In addition to worsening paresthesia and weakness on the right side of his body, blurred vision, fever, and skin lesions developed. He also had skin lesions characterized with 3-10 mm papules with a white atrophic center surrounded by pink rim mostly on the trunk and lower extremities. Brain magnetic resonance imaging showed chronic subdural effusion and encephalomalacia of the left cerebral hemisphere. Cerebrospinal fluid (CSF) examination revealed increased protein levels. Electromyography was consistent with diffuse polyradiculoneuropathy. Skin biopsy confirmed the diagnosis of a rare vasculopathy: Degos disease. A case presenting with chronic subdural effusion, encephalomalacia, elevated CSF protein, and polyradiculopathy should be carefully examined for skin lesions, which may suggest the diagnosis of Degos disease.

Can long-term bisphosphonate use causes low-energy fractures? A case report

Bisphosphonates are inorganic pyrophosphate analog which accumulate on the bone surface, cause osteoclast apoptosis, and inhibit bone resorption. The nitrogen-containing bisphosphonates continue to be the drug of choice for the treatment of osteoporosis in both men and women. Although histomorphometric studies including bone biopsies have not shown any evidence of microcracks, recent studies have revealed that potent bisphosphonates are responsible for the oversuppression of bone turnover leading to microdamages, reduced bone strength, and increased fracture risk. There are individual cases reporting atypical femoral fractures and severely suppressed bone turnover along with long-term (≥ 5 years) use of biphosphonates. In this study, we report on a 74-year-old woman with a history of continuous alendronate use for nearly 16 years who presented to the emergency department with right proximal humerus and left femur fracture.

Erythema multiforme-like eruption localized to a sun-exposed area

We report on a 35-year-old woman with cutaneous lesions characterized by an erythema multiforme-like appearance localized in the photo-distributed pattern. She had no history of systemic drug ingestion, herpes simplex virus or any other infection, possible causes of erythema multiforme, before the sun exposure. She had normal tolerance to a phototest, but photoprovocation tests could not be performed because she did not agree to them. This case was diagnosed to be an erythema multiforme-like variant of a polymorphous light eruption; the differential diagnosis of target-like lesions in a photo-distributed pattern is discussed.

Quantification of female pattern hair loss: a study in a Turkish population

Studies dealing with the relationship between the clinical staging of female pattern hair loss (FPHL) and quantitative measurements of hair parameters are limited. This study was performed to quantify Turkish women's hair characteristics in FPHL, to assess the relationship between clinical presentations of FPHL with hair density and anagen hair ratio and to compare the differences in hair parameters between FPHL and normal women, using epiluminescence microscopy combined with digital image analysis (Trichoscan). Hair density and anagen hair ratio measurements of 39 patients with FPHL were evaluated according to clinical stages and compared with those of 31 healthy volunteers. The results of digital image analysis were compared with the results of visual counting using the photomacrographs of the same images. Mid-scalp hair density and anagen ratio of the patients were detected to be significantly lower than those of the controls. The visual counting detected significant differences among the hair densities of all groups including controls, Ludwig I, and Ludwig II/III groups, while digital image analysis revealed a significant difference only between controls and Ludwig II/III groups. Thus digital image analysis was found to underestimate hair density, and the amount of underestimation demonstrated a positive correlation with hair density. In conclusion, diminished hair density seems to be the main sign in the clinical diagnosis of hair loss, although digital image analysis was found to be less competent than visual counting in detecting hair density. Thus, the increase in hair density in the assessment of various treatment modality effects may be underestimated by digital image analysis.

Evaluation of dermoscopic and histopathologic features and their correlations in pigmented basal cell carcinomas

BACKGROUND

Because of their clinical similarities, pigmented basal cell carcinomas (BCCs) can be confused with melanocytic pigmented lesions especially with melanoma. Since special dermoscopic features have been described for pigmented BCCs, dermoscopy is accepted as a useful tool for the diagnosis of pigmented BCCs.

OBJECTIVE

To investigate dermoscopic and corresponding histopathologic features of BCCs and to evaluate their correlations in pigmented BCCs.

METHODS

In this study, 32 pigmented BCCs in 30 patients whose diagnoses were confirmed with clinical and histopathologic features were included. Before the histopathologic evaluation, the lesions were analysed for dermoscopic features. Histopathologic correlations of dermoscopic features of BCCs and the localization of pigment accumulation in tumour mass were investigated.

RESULTS

In addition to ulceration, large grey-blue ovoid nests, multiple grey-blue globules, maple leaf areas and arborizing telangiectasia; dermoscopically yellow-brown, whitish-yellow, and black-dark brown colour showed statistically significant correlation with their histopathologic counterparts (P < 0.05). Whitish veil, which is among dermoscopic features of BCCs, did not show significant correlation with its histopathologic counterpart (P > 0.05). It was histopathologically determined that pigmentation is found within the tumour mass as well as in the tumour stroma and in the hyperplastic epidermal melanocytes.

CONCLUSIONS

Ulceration, large grey-blue ovoid nests, multiple grey-blue globules, maple leaf-like areas and arborizing telangiectasia, which are specific dermoscopic features for the diagnosis of pigmented BCC, were found to correlate with their histopathologic counterparts. In conclusion, dermoscopy can be described as a valuable tool for the diagnosis of pigmented basal cell carcinomas.

Verruca vulgaris: pulsed dye laser therapy compared with salicylic acid + pulsed dye laser therapy

BACKGROUND

In recent years, lasers have been used in verruca therapy and some successful results have been obtained in some types of verruca. In some of these laser studies, peeling processes have been used to increase penetration.

OBJECTIVE

This study aimed to compare the effects of pulsed dye laser (PDL) therapy with the effects of PDL therapy following salicylic acid (SA) application. The purpose of the SA application is to increase the laser penetration by decreasing the hyperkeratosis of verruca vulgaris.

METHODS

This controlled study included 66 lesions from 19 patients enrolled in the study. PDL was applied to 33 lesions following 30% SA application twice a day for 5 days, and the remaining 33 lesions underwent PDL therapy. PDL was administered in both groups at 4-week intervals varying from one to five sessions. In the comparison of these two groups, the changes in verruca dimensions were recorded in width x length x height (mm3), and the results of the therapy were evaluated statistically.

RESULTS

In both PDL and SA + PDL groups, the regressions observed in the size of the lesions were statistically significant at the end of the fifth session compared with those observed at the onset of the therapy (P < 0.05). At the end of the fifth session, the difference between the two groups was not statistically significant (P = 0.451); however, the clearance rate in the SA + PDL group was more statistically significant than that in the PDL group after the second session (P = 0.049). The complete clearance rate in the SA + PDL group was 54.6% after the second session, but 66.4% in the PDL group only after the fifth session. Complete clearance in the SA + PDL group was observed after 2.2 sessions, and in the PDL group after 3.1 sessions (P < 0.05).

CONCLUSIONS

Although there was no difference between the clearance rate of the SA + PDL group and that of the PDL group after the fifth session, adding SA to PDL decreased the number of sessions to a large extent.