Comparison of Intralesional Sodium Stibogluconate versus Intralesional Meglumine Antimoniate for the Treatment of Leishmania major Cutaneous Leishmaniasis

Israel is endemic for Old-World cutaneous leishmaniasis. The most common species is Leishmania major. However, the available treatment options are limited. This study's objective was to compare the authors' experience with different antimony intralesional treatments of Leishmania major cutaneous leishmaniasis. A retrospective evaluation was undertaken for cases of Leishmania major cutaneous leishmaniasis treated by pentavalent antimony in a university-affiliated medical centre in Israel. The previous treatment of intralesional sodium stibogluconate (Pentostam®) was compared with the current treatment of meglumine antimoniate (Glucantime®). One hundred cases of cutaneous leishmaniasis were treated during the study period, of whom 33 were treated with intralesional sodium stibogluconate and 67 were treated with intralesional meglumine antimoniate. The patients were 78 males and 22 females, mean age 24 (range 10-67) and there was a total of 354 skin lesions. Within 3 months from treatment, 91% (30/33) of the intralesional sodium stibogluconate group and 88% (59/67) of the intralesional meglumine antimoniate group had complete healing of the cutaneous lesions after an average of 3 treatment cycles (non-statistically significant). In conclusion, the 2 different medications have the same efficacy and safety for treating cutaneous leishmaniasis. Pentavalent antimoniate intralesional infiltration treatment is safe, effective, and well tolerated with minimal side effects for Old-World cutaneous leishmaniasis.

Frequency of skin cancer among psoriasis, vitiligo, and mycosis fungoides patients treated with narrowband ultraviolet B phototherapy

BACKGROUND

Narrowband ultraviolet B (NB-UVB) phototherapy is a popular and relatively contemporary treatment option. However, only a few studies to date have explored the potential risk of skin cancer following NB-UVB treatment.

OBJECTIVE

This study aimed to investigate the potential long-term risk of skin cancer in patients treated with NB-UVB.

METHODS

This cohort study included patients with psoriasis, vitiligo, and mycosis fungoides treated with NB-UVB at two university hospitals in Israel in 2000-2005. Patients were followed up for skin cancer for at least 10 years. Data were extracted from the hospital and community medical records.

RESULTS

A total of 767 patients were included in this study: 509 with psoriasis, 122 with vitiligo, and 136 with mycosis fungoides. The mean follow-up duration was 13 years. Among these patients, 4.43% developed skin cancer during the follow-up (3.93% had psoriasis, 2.46% had vitiligo, and 8.09% had mycosis fungoides). Old age and fair skin type were the only significant independent risk factors for skin cancer. There was no significant difference in the mean number of NB-UVB treatments among patients who developed skin cancer and those who did not (99.09 vs. 94.79, respectively).

CONCLUSION

No association was observed between the number of NB-UVB treatments and carcinogenesis in any study group. Age is a significant risk factor, and older patients treated with NB-UVB should be followed up carefully.

Pediatric Psoriasis with or without Arthritis: Does It Make a Difference?

BACKGROUND

Psoriasis and psoriatic arthritis can present simultaneously or separately in children and may pose a diagnostic challenge.

OBJECTIVE

To compare the dermatological manifestations in pediatric psoriatic patients with and without arthritis.

METHODS

A retrospective case-control study of psoriatic patients ≤ 18 years old at Sheba Medical Center was conducted between 2011 and 2021. Patients with psoriatic arthritis versus psoriasis-only were compared according to body surface area (BSA) involvement, cutaneous distribution, severity of skin disease, response to treatment and related side effects.

RESULTS

The study cohort included 29 psoriatic arthritis and 64 psoriasis-only patients matched by age and sex. The psoriasis-only group had a significantly higher mean BSA (19.7%, SD ± 18.7) than the psoriatic arthritis group (6.1%, SD ± 11.4), (p = 0.029). The skin distribution differed with the psoriasis group showing more involvement of the extremities, scalp, trunk, and genitals. Both groups primarily experienced partial responses to methotrexate, whereas the psoriasis group mainly saw complete responses to biologics. Adverse events were rare, with a higher incidence in the psoriasis group.

CONCLUSION

This retrospective study highlights the differences in cutaneous disease characteristics, severity, and treatment response in pediatric patients with psoriasis and psoriatic arthritis, providing valuable insights for diagnosis and disease course in the pediatric population.

Improved effectiveness of an increased dose of griseofulvin for treating Tinea capitis among refugee children in Israel: A retrospective cohort study

BACKGROUND

Tinea capitis (TC), a fungal infection that occurs in children, is primarily caused by dermatophytes such as Trichophyton and Microsporum species. For Trichophyton species, treatment with terbinafine is considered more effective than griseofulvin treatment. Specific populations, such as refugee children, are more susceptible to TC.

OBJECTIVE

This study aimed to describe and compare the response to treatment among Israeli and refugee children with TC.

PATIENTS/METHODS

We retrospectively reviewed data collected on refugee and Israeli children with TC between January 2004 and January 2020.

RESULTS

Overall, 3358 children with TC (refugees: 1497; Israelis: 1861) were identified. Among these, 86% of the refugee children had TC caused by Trichophyton violaceum, 65% of the Israeli children had TC caused by Microsporum canis and 83% of all children were treated with griseofulvin. Overall, 14% of the refugees showed a partial response to a griseofulvin dose of ≤25 mg/kg/day; however, they showed a complete response upon increasing the dose to ≥30 mg/kg/day. No significant adverse effects were observed.

CONCLUSION

The over-crowded day care centres and dense living make refugee children more susceptible to TC than the general population, and griseofulvin dosage adjustment is necessary. TC, due to Trichophyton species, could benefit from receiving an increased dose of griseofulvin in a suspension form, which is cheaper than terbinafine.

Bath psoralen plus ultraviolet-A photochemotherapy for chronic graft-versus-host disease: a retrospective cohort study

BACKGROUND

Chronic graft-versus-host disease is a severe complication of allogeneic stem cell and bone marrow transplantation. First-line immunosuppressive agents, such as steroids, are used to prevent this disease; however, they have multiple side effects. Therefore, bath psoralen plus ultraviolet-A (PUVA) is an alternative second-line treatment. This study aimed to evaluate the clinical efficacy of bath PUVA for managing chronic graft-versus-host disease.

METHODS

This retrospective, case-control study included 14 patients with extensive cutaneous chronic graft-versus-host disease, resistant to systemic corticosteroid, treated with bath PUVA. Major and partial responses were defined as clinical improvements of >70% and 50-70%, respectively. We analyzed the graft-versus-host disease clinical presentation and timing after allogeneic stem cell and bone marrow transplantation, bath PUVA doses, background diseases, additional treatments, and adverse effects.

RESULTS

We observed eight major (three lichenoid and five sclerodermatoid) and six partial (three lichenoid and three sclerodermatoid) responses after a mean of 28 treatment sessions. After 6 to 25 months, four of the eight patients with sclerodermatoid lesions and all those with lichenoid lesions experienced relapse but responded to additional treatment cycles.

CONCLUSIONS

Bath PUVA is well-tolerated and effective for extensive cutaneous chronic graft-versus-host disease. It allows rapid tapering of adjuvant immunosuppressants; however, most patients require prolonged maintenance phototherapy.

Psori Silk in Mild to Moderate Psoriasis: A Randomized Phase I-II Trial Study

In patients with mild to moderate psoriasis, topical corticosteroids are usually the first-line of treatment; however, they are not suitable for long-term use. The purpose of this study was to assess the efficacy and safety of a multi-fruit-and-vegetable compound, Psori Silk, in the treatment of patients with psoriasis. This was a randomized double-blind trial comprising 12 weeks of treatment with Psori Silk versus a vehicle, and a 4-week follow-up. The primary endpoint was 50% reduction in the modified Psoriasis Area and Severity Index (MPASI 50) score at week 12, while the secondary endpoint was quality of life assessment using the Dermatology Life Quality Index (DLQI). The Psori Silk group consisted of 23 patients with 34 lesions to be treated versus 22 patients in the vehicle group with 36 lesions. The MPASI 50 score was observed in 59% patients in the active group versus 22.7% patients in the vehicle group (P < 0.001). A mean 33% DLQI improvement was observed in 65.2% patients in the active group versus 27.2% patients in the vehicle group (P < 0.001). Mild and temporary discomfort at the site of application was reported in 39% patients in the active group versus 23% patients in the vehicle group. Psori silk appears to be an effective and safe treatment option for mild to moderate plaque psoriasis.

Bullous pemphigoid and dipeptidyl peptidase-4 inhibitors: evaluation of clinical course and treatment response

BACKGROUND

Dipeptidyl peptidase-4 inhibitors (DPP4is), drugs used to treat type 2 diabetes mellitus (DM2), show a significant association with bullous pemphigoid (BP) development.

OBJECTIVES

To evaluate the clinical course and development of BP among patients with DM2 treated with DPP4is.

METHODS

This retrospective cohort study included all the patients with BP and comorbid DM2 who visited Sheba Medical Center during 2015-2020.

RESULTS

Among 338 patients with BP, 153 were included in our study. In 92 patients, BP diagnosis was attributed to the use of DPP4is. The patients with DPP4i-associated BP had fewer neurological and cardiovascular comorbidities and higher blistered body surface area (BSA) at first presentation, with noticeable upper and lower limb involvement. These patients were younger and more responsive to treatment, with a greater reduction in their BSA score after 2 months of treatment.

CONCLUSIONS

The clinical features of patients with BP treated with DPP4is were initially more severe; however, during follow-up, a marked clinical improvement was noticed, especially among patients who had ceased the drug. Therefore, although withdrawal of the drug may not impose disease remission, it can alleviate the disease course and avert the need for treatment escalation.

Predictors of adherence to Narrowband ultraviolet B first-month treatment dosage plan

BACKGROUND

The adherence to a narrowband ultraviolet B (NB-UVB) treatment plan is derived, in large part, from the patient's skin tolerance to the phototherapy dose. At present, the initial and first-month incremental phototherapy doses are determined prior to treatment initiation based on the patient's Fitzpatrick skin phototyping.

OBJECTIVES

To identify variables that predict adherence to NB-UVB first-month treatment dosage plan.

METHODS

Charts of 1000 consecutive patients receiving NB-UVB at a hospital-based phototherapy unit were retrospectively analyzed. We included patients receiving NB-UVB for atopic dermatitis, psoriasis, vitiligo, and mycosis fungoides. The first-month NB-UVB treatment plan was determined based on the patient's Fitzpatrick phototype. Adherence to treatment was defined as receiving at least 80% of the planned first-month cumulative dose. We compared adherent vs. non-adherent patient groups for age, sex, Fitzpatrick phototype, presence of freckles, nevus count category, and type of dermatological disease.

RESULTS

The study included 817 eligible patients, mean age 40 (2-95) years; 54% men; 32% had Fitzpatrick phototype I-II. Distribution by diagnosis was atopic dermatitis (29%), psoriasis (27%), vitiligo (23%), and mycosis fungoides (21%). Adherence to NB-UVB treatment plan was observed in 71% of patients. Adherence decreased with age, with 7% decrease per year (P = 0.03) and was higher among mycosis fungoides patients (77.3%) compared to all other diagnoses (69.8%; P = 0.02).

CONCLUSIONS

Adherence to NB-UVB treatment may be related to age and diagnosis. Fitzpatrick phototype-based first-month treatment plans should be modified accordingly.

Narrowband Ultraviolet B Radiation for Lichen Planus: Long-term Follow-up of 192 Patients

BACKGROUND

Narrowband UVB (NB UVB) has been suggested as an option for lichen planus control. However, the literature is lacking in reports of long-term results. OBJECTIVE: We sought to evaluate the long-term results of NB UVB therapy in lichen planus.

METHODS

This was a prospective, retrospective analysis of patients with lichen planus treated with NB UVB at our institution since 2004. The clinical response and relapse rate were recorded according to age, sex, mouth involvement, skin phototype, number of treatments, and total radiation dose.

RESULTS

One hundred thirty-seven of 192 (71%) eligible patients had a major response (MR) and 102 (74%) patients had no recurrence after an average follow-up period of 58.7 months. MR was achieved in 66 percent and 75 percent of men and women, respectively (p=0.021) and 76 percent and 68 percent of patients with Fitzpatrick Skin Types I and II and Skin Types IV and V, respectively (p=0.017). Age at the onset of the disease, number of treatments, and total UVB dose had no effect on the MR rate. The disease-free periods were 131 and 101 months for male and female patients, respectively (p=0.06), and 128 and 103 months for patients 40 years or younger and older than 40 years of age, respectively (p=0.07).

CONCLUSION

Based on our results, female patients and patients with lighter skin phototypes appeared to have higher MR rates. However, female and older patients appear to be at increased risk of recurrence.

The effect of narrow-band ultraviolet B radiation on sleep, happiness, and appetite: A prospective cohort study

BACKGROUND

The health benefits of sunlight are well documented, including the effects on happiness and sleep. However, only a few studies have investigated the benefits of artificial narrow-band ultraviolet B (NB-UVB) radiation.

OBJECTIVES

To investigate the effect of NB-UVB on sleep quality, happiness, and appetite.

METHODS

Patients from a single phototherapy unit were selected, and their epidemiological characteristics were documented. Subjects were asked to complete questionnaires including the Pittsburg Sleep Quality Index (PSQI), Subjective Happiness Scale (SHS), and the Simplified Nutritional Appetite Questionnaire (SNAQ) 4 weeks before and after the initiation of the NB-UVB therapy. The sample consisted of 52 patients.

RESULTS

Four weeks after the initiation of NB-UVB sessions, sleep quality was significantly improved (the PSQI decreased from 6.5 to 5.23 (t = -3.52, P < .01). In contrast, subjective happiness did not improve (the SHS decreased from baseline 5.5 to 5.2, P > .05). Similarly, appetite did not change (the SNAQ score increased from baseline 14.75 to 15.05, P > .05) and body mass index was not affected by phototherapy. In general, men were found to have better sleep quality before and after UV light therapy.

CONCLUSION

Our data suggest that NB-UVB exposure over 4 weeks improves sleep quality; however, it does not influence happiness or appetite.

The risk for severe COVID 19 in patients with autoimmune and/or inflammatory diseases: First wave lessons

Data regarding the risk for severe COVID19 in patients with autoimmune or inflammatory diseases are scarce. To estimate the risk of those patients to develop a more severe COVID19 infection All active patients and those with dermatologic and/or rheumatologic autoimmune/inflammatory diseases were identified in a single tertiary center. The charts of those tested positive for COVID19 between 1 March 2020 and 31 May 2020 reviewed including demographics, co‐morbidities, and medications. COVID19 outcome of those with dermatologic and/or rheumatologic autoimmune/inflammatory diseases were compared to COVID19 infected matched controls without an autoimmune/inflammatory background. Overall, 974 of 381 268 active patients were tested positive for COVID19, including 35 out of 13 225 with dermatologic and/or rheumatologic autoimmune/inflammatory diseases. No statistically significant difference in severity of COVID19 infection or mortality rate was found. The rate of asymptomatic, mild, moderate, severe/critical and fatal COVID19 infection was 11.4%, 37.1%, 22.8%, 11.4%, and 17.1%, respectively, for the patients with autoimmune diseases and 17.8%, 45.8%, 10.9%, 6.8%, and 18.4%, respectively for the controls . Patients with autoimmune/inflammatory diseases seem not to develop a more severe COVID19 infection than controls.

Illness perception, coping, and quality of life in early-stage Mycosis fungoides

Background

Mycosis fungoides is the most common type of cutaneous T-cell lymphoma. Most early-stage mycosis fungoides cases follow an indolent course, hence considered by doctors a relatively easy condition. However, since mycosis fungoides bears the title of cancer, patients might perceive it differently.

Objective

To investigate patients’ illness perception, and its relationships to quality of life, depression, anxiety, and coping among early-stage mycosis fungoides patients.

Methods

A cross-sectional questionnaire-based study was conducted. Patients from a single tertiary medical center completed the Revised Illness Perception Questionnaire, the MF/SS-CTCL Quality of Life scale, the Hospital Anxiety and Depression Scale, and The Mental Adjustment to Cancer Scale.

Results

Thirty patients (25 males, five females, mean age 51.60) with stage I mycosis fungoides were enrolled. Mycosis fungoides had a little impact on patients’ daily life, quality of life, and levels of depression and anxiety, and they generally coped well. Disease understanding was low and was negatively correlated with impairment to quality of life and depression. Patients felt that stress and worry were features of the disease’s etiology.

Study limitations

A small sample of patients was included.

Conclusion

Patients with early-stage mycosis fungoides adapt well to their disease. Psychological interventions should be aimed at improving patients coping style and enhancing illness understanding, in order to maintain high quality of life.

Efficacy of Repeated Courses of Rituximab as Treatment for Pemphigus Vulgaris

Rituximab targets the B-lymphocyte antigen CD20, providing pemphigus vulgaris patients with long-term remissions. However, the effects of repeated courses have not yet been established. This study aimed to evaluate the effect of repeated rituximab courses on remission length in pemphigus vulgaris. A total of 73 patients with pemphigus vulgaris treated with rituximab at a single centre were retrospectively analysed. Of 73 study participants (28 men, 45 women), 42 (58%) received a 2^nd course of rituximab, 24 (33%) received a 3rd course, 4 (6%) received a 4th course, and one (1%) received a 5th course. Rituximab remained efficacious in each course, irrespective of previous treatments (complete remission 75–81%). Following the 2^nd and 3rd courses, the results indicated longer remissions with reduced flare-ups, and the remission length increased with each subsequent course. We conclude that rituximab serves as a disease-modifying agent, notably for patients with moderate-to-severe pemphigus vulgaris.

[XANTHOTRICHIA (YELLOWING OF THE HAIR) DUE TO MINOXIDIL TREATMENT]

Different drugs can affect the hair. Among the various types of drug-induced hair changes, hair colour change is a rare phenomenon which is less reported in the literature. Hair colour changes include lightening of the hair, whitening or returning to the original colour and even change to a new colour. In this article we report a patient presenting with hair yellowing due to topical treatment with minoxidil and discuss the phenomenon of drug-induced hair colour changes.

Unusual forms of cutaneous leishmaniasis due to Leishmania major

BACKGROUND

Cutaneous leishmaniasis (CL) due to Leishmania major (L. major) is common in the Middle East; however, this skin infection may be under-diagnosed when it presents atypically.

OBJECTIVE

To highlight the occurrence of uncommon presentations of CL that may elude diagnosis.

MATERIALS AND METHODS

A retrospective study was performed among patients who presented at The Sheba Medical Center between 2005 and 2014 with atypical clinical presentations of CL due to L. major.

RESULTS

Twelve patients with unusual clinical presentations of L. major CL were identified. All infections were acquired in L. major - endemic areas of Israel. The average age was 37 years. The average number of lesions was 2. Nine patients presented with a form that mimicked other forms of CL, such as lupoid, giant ulcer, sporotrichoid and recidivans, and three had a variant resembling other infectious skin diseases, such as erysipeloid and verruciform. All patients required systemic therapy.

CONCLUSION

Cutaneous leishmaniasis due to L. major can masquerade as many other infectious and inflammatory diseases. In addition, it can mimic clinical forms of New World CL. We suggest that in endemic countries or in travellers returning from countries where L. major is endemic, polymerase chain reaction (PCR) for Leishmania-specific DNA should be performed routinely in cases of unusual presentations of dermatitis with a single or a few lesions, even if a diagnosis of CL was not considered by the referring clinician.

Late-onset onchocercal skin disease among Ethiopian immigrants

BACKGROUND

Onchocerciasis is an infectious disease caused by the filaria Onchocerca volvulus. Very little is known regarding onchocerciasis imported from endemic to nonendemic areas.

OBJECTIVES

To evaluate pruritic dermatitis simulating atopic dermatitis in Ethiopian immigrants in Israel.

PATIENTS AND METHODS

A retrospective study of 27 Ethiopian immigrants to Israel was conducted. Demographics and clinical and laboratory data were collected.

RESULTS

Of the group of 27 patients, 10 (37%) were men and 17 (63%) were women. The average age at referral was 29 years. All of the patients emigrated from Kuwara, Ethiopia. Diagnosis was done by either positive skin snip test or immunoglobulin (Ig) G4 serology of onchocerciasis in 14 patients. The most common presentation was a combination of lichenified onchodermatitis with atrophy and depigmentation (36%). Eosinophilia and elevated IgE levels were common. Seventeen patients were treated with a single administration of oral ivermectin 200 μg mg(-1). Thirteen patients responded to the treatment.

CONCLUSIONS

Immigrants from endemic regions to developed countries presenting with pruritic diseases, especially those with a clinical picture suggestive of atopic dermatitis, should be evaluated for possible onchocerciasis infection. Ivermectin, a relatively safe and low-cost treatment, should be considered even in the absence of a proven disease. Physicians should have a high index of suspicion in patients with the corresponding residential history.

Narrow band UVB: is it effective and safe for paediatric psoriasis and atopic dermatitis?

BACKGROUND

Phototherapy has a time-honoured place in the treatment of variety of skin diseases in adults. The use of this modality in children is limited mainly due to concerns about long-term carcinogenic potential. Only a few clinical trials have been performed on the efficacy and safety of phototherapy in children.

OBJECTIVES

To determine the efficacy and safety of NB-UVB phototherapy in children with atopic dermatitis (AD) and psoriasis.

METHODS

This is a retrospective review of the treatment outcomes of 129 children with psoriasis and AD, who were treated with NB-UVB between 1998 and 2006 at our institute.

RESULTS

Fifty per cent of the psoriatic patients and 25% of patients with AD achieved clearance by the end of the treatment. NB-UVB phototherapy was well-tolerated, with no serious adverse effects except one doubtful case of melanoma in situ.

CONCLUSIONS

NB-UVB may be considered as a viable therapeutic option in children with psoriasis and AD. Children who are treated by phototherapy should remain under annual dermatologic observation. To determine true carcinogenic risk of UV therapy, longer follow-up is essential.

Pulsed versus continuous terbinafine dosing in the treatment of dermatophyte onychomycosis

BACKGROUND

The accepted regimen for terbinafine, one of the most effective treatments for dermatophyte onychomycosis, is continuous administration of 250 mg/day over 16 weeks. A few small studies, however, have raised the possibility of an alternative regimen: pulsed administration of 500 mg/day for 1 week, every 4 weeks (over 16 weeks), without decreasing treatment efficacy.

OBJECTIVE

Our aim was to compare the efficacy and safety of both regimens in a large group of patients.

METHODS

Retrospective analysis of 260 patients with culture proven dermatophyte onychomycosis treated in seven outpatient clinics run by two dermatologists using one of the terbinafine protocols on a chronological basis: 105 patients were treated using the continuous regimen during 1998/1999 and 155 patients were treated using the pulsed regimen during 1999/2002. Mycological and clinical cure were assessed 2 and 3 months, respectively, after completion of the last therapeutic course. Side effects were documented for the pulse regimen group only and compared with historical data previously published for the continuous protocol.

RESULTS

The mycological, clinical and complete (mycological and clinical) cure rates of the toenails were 72.1%, 53.5% and 47.1% in the pulse regimen versus 82%, 35% and 34% in the continuous regimen, respectively (p=0.091, 0.0002 and 0.047, respectively). The mycological, clinical and complete cure rates of the fingernails were 91.7%, 83.3% and 79.2% respectively in the pulse group versus 100% (all parameters) in the continuous group (no significant difference). In general, both regimens were well tolerated and few side effects were reported.

CONCLUSION

The pulsed regimen is at least as effective as continuous dosing and thus, at 50% less cost and more convenience, is preferable to a continuous regimen.

The Y152X MC1R gene mutation: occurrence in ethnically diverse Jewish malignant melanoma patients

MC1R sequence variants are associated with malignant melanoma risk, and most commonly are missense mutations. Few (n=9) truncating mutations have been described in this gene as predisposing to malignant melanoma. In this study, three Jewish individuals were found to harbor an identical truncating MC1R mutation--Y152X: an Ashkenazi patient with two malignant melanomas, a non-Ashkenazi malignant melanoma patient with familial malignant melanoma and her asymptomatic mother. Both malignant melanoma patients carried additional, seemingly pathogenic MC1R variants. Haplotype analysis revealed that all three mutation carriers shared the same haplotype. This sequence variant was previously described in ethnically diverse, non-Jewish individuals and in all likelihood represents an error-prone domain that, in conjunction with other genetic and environmental factors, increases malignant melanoma risk.

UVB in the management of early stage mycosis fungoides

BACKGROUND

Several options for treatment of early mycosis fungoides (MF) offer similar success rates. Previous small studies have shown UVB to be at least as effective as PUVA.

OBJECTIVE

To summarize our experience with UVB treatment of early MF.

METHODS

A retrospective analysis of early-stage MF patients treated by narrow band (NB) or broad band (BB) UVB in our institution between 1996 and 2002. Most patients achieving complete response (CR) were put on maintenance until natural sun exposure was possible and followed up every 3-6 months. The results were compared to those previously reported regarding PUVA.

RESULTS

Sixty-eight and 43 patients were treated by NB and BB UVB, respectively. Eighty-six per cent (84 and 89% in NB and BB UVB groups, respectively) of IA and 71% (78 and 44% in NB and BB UVB groups, respectively) of IB patients achieved CR within a mean of 12.8 and 10.6 weeks, respectively. When maintenance was stopped, 65 and 30% had not relapsed after an average follow up of 27 and 222 weeks, respectively. Non-relapse rate was 33 and 48% for those having had vs. those not having had maintenance, respectively.

CONCLUSIONS

Our results are comparable to all previously reported for skin-targeted treatments, including PUVA and, to our belief, reflect the nature of early MF, in which CR can probably be achieved in most of the patients. Among the responding patients there is no relapse during prolonged follow-up in about one third of the cases. Thus, we believe treatment should be stopped completely following first CR induction and maintenance treatment should be considered for relapsing patients only. Both broad and narrow UVB options are good and future choices should be made on the basis of short- and long-term side-effects.

UVB therapy of pityriasis lichenoides - our experience with 29 patients

BACKGROUND

Pityriasis lichenoides comprises a clinical and pathological spectrum of disorders. So far no highly effective treatment has been reported. Previous small studies have suggested that ultraviolet B (UVB) is a good alternative.

METHODS

This is a retrospective analysis of 29 pityriasis lichenoides patients treated in our institution with broad- or narrow-band UVB during the period 1996-2002. Twenty-one of these patients had one or more previous unsuccessful treatments.

RESULTS

Complete response was achieved in 93.1% in both treatment groups, with 73% of them still relapse free after a mean follow-up of 58 and 38 months in broad- and narrow-band UVB treatment groups, respectively. Mild side-effects were observed in about one-third of the patients.

CONCLUSION

We believe both forms of UVB are a good option for pityriasis lichenoides and should be considered as the first line in generalized cases interested in treatment.

Search for germline alterations in CDKN2A/ARF and CDK4 of 42 Jewish melanoma families with or without neural system tumours

To gain insight into the molecular mechanisms involved in the inherited predisposition to melanoma and associated neural system tumours, 42 Jewish, mainly Ashkenazi, melanoma families with or without neural system tumours were genotyped for germline point mutations and genomic deletions at the CDKN2A/ARF and CDK4 loci. CDKN2A/ARF deletion detection was performed using D9S1748, an intragenic microsatellite marker. Allele dosage at the p14^ARF locus was analysed by quantitative real-time PCR employing a TaqMan probe that anneals specifically to exon 1β of the p14^ARF gene. For detecting point mutations, dHPLC and direct sequencing of the coding sequences of CDKN2A/ARF and CDK4 was used. No germline alterations in any of the tested genes were detected among the families under study. We conclude that in the majority of Ashkenazi Jewish families, the genes tested are unlikely to be implicated in the predisposition to melanoma and associated neural system tumours.

Recurrent erysipelas: risk factors. Risikofaktoren fur Rezidiverysipele

BACKGROUND

Several systemic and regional risk factors have been described for erysipelas. However, those predisposing for recurrent episodes are not well defined.

MATERIALS AND METHODS

We performed a retrospective analysis of 574 patients hospitalized in our institution during a 3 year period. The analysis included demographic, epidemiologic, and medical chart review data with special attention to background disorders. The patients with single and recurrent episodes of erysipelas were compared.

RESULTS

The recurrent cases occurred mainly in the lower limb with several risk factors that were statistically more common than in the single episode group including overweight, venous insufficiency, lymphedema, tinea pedis, and previous regional surgical intervention or trauma.

CONCLUSIONS

Patients with erysipelas, especially when it involves the lower limb, should be instructed to reduce weight, control venous insufficiency and/or lymphedema and to emphasize prevention and treatment of tinea pedis. The role of prophylactic antibiotics requires further study.

Use of sunscreen is linked with elevated naevi counts in Israeli school children and adolescents

Epidemiological evidence indicates that a fair complexion and exposure to solar radiation in early years contribute to the proliferation of naevi and subsequent melanoma risk. To determine whether protection from sunlight is associated with lower naevi counts, we examined the prevalence and risk factors of naevi in a sample of Israeli school pupils. Whole body counts of naevi were recorded in 974 out of 1312 (74.2%) recruited pupils (7 and 12 year olds) from Ramat-Gan and Jerusalem. Host characteristics and habits of sun exposure were obtained using questionnaires. In each age group and geographic area, the mean whole body naevi counts, adjusted for confounders, were higher among males, pupils of European-American descent, and those susceptible to sunburn. The contributions to naevi risk of fair skin colour and frequent recreational sun exposure were higher among 7 year olds. Regular sunscreen use contributed to the naevi risk for both age strata in Ramat-Gan (at age 7, rate ratio [RR] = 1.7, 95% confidence interval [CI] = 1.3-2.2; at age 12, RR = 1.5, 95% CI = 1.1-2.1). Among the younger age group in Ramat-Gan, even seldom compared with no use of sunscreen was associated with higher naevi counts (RR= 1.5, 95% CI = 1.2-2.0). Similar patterns were noted with the pupils from Jerusalem. In conclusion, the elevated naevi count with increased sunscreen use indicates that sunscreens apparently do not modify the genetic predisposition to naevi proliferation. For better protection of children and adolescents, including those who use sunscreens, from the naevogenic effect of solar radiation, they should be encouraged to limit their exposure and wear protective clothing when in the sun.

A graded work site intervention program to improve sun protection and skin cancer awareness in outdoor workers in Israel

OBJECTIVES

A graded worksite intervention program to improve sun protection and skin cancer awareness of outdoor workers was implemented and evaluated longitudinally over a period of 20 months.

METHODS

Outdoor male workers (144/213 recruits) from geographically separated units of the Israel National Water Company were allocated to complete (n = 37), partial (n = 72) or minimal (n = 35) intervention groups. Subsequent to the assignment and training of local safety officers, an educational and medical screening package was provided to the corresponding groups either once, or repeatedly a year later. Personal sun protective gear was provided upon repeated intervention. Outcome measures were evaluated through self-response questionnaires administered prior to the first intervention pulse, and 8 months after the first and second interventions.

RESULTS

A 15-61% improvement in sun-protection habits was noted in the entire study population 8 months after initialization, compared to no sunscreen use, 20% sun-exposed skin area and highest mean occupational exposure dose of 1.68 MED/day at pre-test. An even greater use of sunscreen was evident 1 year later in the complete and partial intervention groups, + 80% and + 52%, respectively. The baseline rate of self-examination of the skin in the same two groups (49%) increased significantly at post-test (+ 71% and + 53%, respectively).

CONCLUSIONS

This integrated intervention program led to significantly improved sun protection and skin cancer awareness. Repeated intervention combined with the supply of sun-protective gear contributed to an even greater impact.

Decreased density of epidermal dendritic cells in melanocytic naevi: the possible role of in vivo sun exposure

Melanocytic naevi are benign skin tumours that originate in the epidermis. The pathogenesis of naevi and cutaneous malignant melanoma has been linked to sun exposure. This study evaluates alterations in the density of immunologically active epidermal dendritic cells (EDCs) in naevi in response to sun exposure. Immunohistologically stained sections of 266 naevi from patients from Israel (n=135) and Germany (n=131) were evaluated. The proportion of naevi with decreased density of HLA-DR+ (dDR+) and CD1a+ (dCD1a+) EDCs was analysed according to country, last exposure to sunlight, anatomical location and histological subtype. The risk of dDR+ was found to be linked to residence in Israel compared with Germany (odds ratio [OR] = 4.2; 95% confidence interval [CI] = 2.0-8.9), suggesting a latitude-dependent effect. Naevi removed in summer had a higher risk of dCD1a+ (OR = 4.7; 95% CI = 2.3-9.8) compared with those removed in winter. The most conspicuous dDR+ among the German cases, and dCD1a+ among the Israelis, occurred in naevi located on commonly exposed skin. The similar densities of EDCs in the lesional and perilesional skin of the majority of the naevi indicates that the underlying naevus cells have no effect on EDC density. It is not unlikely that an altered immune response due to dDR+ and dCD1a+ in sun-exposed skin in the vicinity of naevi contributes to the subsequent melanoma risk in highly susceptible individuals.

Silver-stained nucleolar organizer regions (AgNORs) as a prognostic value in malignant melanoma

The nucleolar organizer regions (NORs) are chromosomal loops of DNA and proteins involved in ribosomal synthesis. By silver staining, they can be identified as black dots (AgNORs) in the nuclei. Their size and number reflect cell and nuclear activity. Therefore, AgNOR count may correlate with the proliferative activity of tumors. In malignant melanoma, correlation between AgNOR count and the growth phase was found. However, the value of AgNORs in determining prognosis is disputable. Our purpose was to evaluate the role of AgNORs in predicting the biological behavior of melanoma. Paraffin-embedded sections of 30 cases of primary melanoma, 0.4-5 mm thick (mean, 1.6 mm) were stained with silver. Follow-up of all patients was at least 5 years. For each tumor, at least 50 cells were randomly selected for AgNOR count at a final magnification of 500, and the mean of AgNOR content was calculated. Sample parameters corresponded well to the epidemiology and the natural history of melanoma. AgNOR counts (0.78-4.26; mean, 1.42+/-0.72) correlated with tumor thickness (p = 0.01); thus, most superficial tumors had low AgNOR counts, whereas most deep tumors (> or = 1.5 mm) showed high counts. Patients who had tumors with AgNOR counts lower than the median had longer disease-free interval (DFI) than did patients who had tumors with higher counts (p = 0.02). Furthermore, in a multivariate Cox analysis, AgNOR count was independent of tumor thickness in determining DFI (p = 0.05). Therefore, AgNORs may serve as a parameter to predict more accurately the progression of melanomas (mainly thin ones). Larger studies are needed in order to consolidate these preliminary results and to characterize AgNOR value further as a prognostic factor in melanoma.

[Acquired torticollis in hospitalized children]

Torticollis results from various pathological mechanisms, and its elucidation depends on identifying diseases of musculoskeletal, neural and ocular tissues. This study characterized the underlying diseases of children hospitalized with torticollis, excluding congenital torticollis. Records of 36 children with torticollis seen during 4 years were reviewed and categorized according to presumed etiology. Most could be classified into 2 categories: in 39% it was due to trauma and in 36% to upper respiratory tract infection. Most girls were in the first group and most boys in the second group. There were 3 cases of ocular torticollis due to superior-oblique muscle palsy, 1 with a post-burn eschar, 2 with neurological disorders (intramedullary cervical astrocytoma and leukodystrophy with macrencephaly), and in 3 no associated cause was found. There was a clear seasonal trend with 58% of cases presenting from November through February, 33% from April through July, and the rest, of neurological or ocular origin, during the rest of the year. In cases of post-traumatic torticollis 21% had neurological symptoms such as weakness of the limbs, headaches or incontinence. Only a few had prior upper respiratory tract infection. All children whose torticollis was assigned to infection had had fever. Only 8% had had neurological complaints or vomiting, half of whom presented with fever exceeding 37.5 degrees C. 46% had restriction of movement and 38% had tenderness. In over 60% of those in this group there were signs of an upper respiratory tract infection, such as lymphadenopathy or a white blood cell count exceeding 15,000/microliter, 3 patients with recurrent torticollis were diagnosed as having severe neurological diseases. Mean hospitalization time was 4 days (range 1-28). Hospitalization periods were similar for all kinds of patients and treatment by traction or fixation did not affect this period.

Prevalence of melanocytic nevi and freckles in young Israeli males. Correlation with melanoma incidence in Jewish migrants: demographic and host factors

The role of host and environmental factors in the pathogenesis of multiple melanocytic nevi, atypical nevi, and freckles was studied in 1989 in a random sample of 3,040 Israeli males aged 17 years. Multiple melanocytic nevi were significantly associated with family history of melanoma or multiple melanocytic nevi (odds ratio (OR) = 15.0), fair or lightly pigmented skin color (OR = 2.7 and 2.3, respectively), and affiliation to the high or heterogenous melanoma risk group, determined by the incidence rates of melanoma in Jewish migrants from corresponding origin (OR = 3.1 and 2.1, respectively). An environment-related effect may account for the increased multiple melanocytic nevi risk among second- (OR = 8.2) compared with first-generation, native-born recruits (OR = 3.0) from the high melanoma risk group whose families had been living in Israel the longest. Atypical nevi were associated with fair (OR = 6.1) and lightly pigmented (OR = 3.5) skin color, high and moderate sunburn susceptibility (OR = 4.7 and 2.5, respectively), and family history of melanoma or multiple melanocytic nevi (OR = 4.7). Freckles were significantly associated with sun-sensitive phenotype, family history of melanoma or multiple melanocytic nevi (OR = 1.5). Conservative (OR = 1.9) or nonreligious status (OR = 1.9), and high (OR = 2.4) or heterogenous melanoma risk groups (OR = 1.8). These findings indicate that environmental factors may modify the occurrence of multiple melanocytic nevi and freckles in genetically susceptible ethnic groups.

Familial cutaneous malignant melanoma and tumors of the nervous system. A hereditary cancer syndrome

BACKGROUND

Excessive risk of cutaneous melanoma as a second cancer has been associated with benign or malignant tumors of the nervous system. Cutaneous melanoma and nervous system tumors may independently aggregate in families. There are, however, no previous reports of increased likelihood of tumors of the nervous system in families of patients with cutaneous melanoma or--of cutaneous melanoma in families with tumors of the nervous system.

METHODS

The occurrence of nervous system tumors as second cancers was examined in a series of 904 patients with cutaneous melanoma and/or their family members.

RESULTS

Fifteen families with 17 members with cutaneous melanoma from this series had one or more additional relatives with tumors of the nervous system, including astrocytoma, medulloblastoma, glioblastoma multiforme, ependymoma, glioma, meningioma, and acoustic neurilemmoma. Another subgroup of 10 patients with cutaneous melanoma had either a meningioma (n = 9) or acoustic neurilemmoma (n = 1) as a second tumor. The pattern of atypical melanocytic nevi occurring in the majority (20/25) of cutaneous melanoma patients in our series and in additional first degree relatives of 9 of 11 of the affected families, has been previously associated with the Familial Atypical Multiple Mole-Melanoma syndrome.

CONCLUSIONS

This unusual familial and personal occurrence of tumors, showing differentiation toward tissues of the neural crest, neuroepithelium, and/or mesenchymal derivation, supports a putative association with a hereditary cancer susceptibility trait.

[Fabry disease: systemic deposition of a glycolipid]

A 20-year-old man was admitted with telangiectatic skin lesions over the lower abdomen, buttocks and genitals and also hypohidrosis and heat intolerance. Fabry disease was diagnosed on the basis of biochemical and histopathological analyses. The concentration of urinary trihexosyl-ceramide was increased but the activity of galactosidase in serum, urine and lymphocytes was marginal. Typical lipid inclusions, showing a concentrically arranged, lamellar osmiophilic structure were identified by electron microscopy in the cytoplasm of endothelial cells from affected skin.