Visfatin and insulin levels and cigarette smoking are independent risk factors for hidradenitis suppurativa: a case-control study

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease. HS has been associated with obesity, adipokine imbalance, dyslipidemia, pro-inflammation, and metabolic syndrome (MS). The aim of this study was to determine the association between HS, and serum visfatin levels (SVLs), small-dense low-density lipoprotein cholesterol (sdLDL-C), and ischemia-modified albumin (IMA), as well as the association between HS, and smoking, alcohol consumption, anthropometric measurements, blood pressures (BPs), fasting blood glucose (FBG) and lipids, inflammatory markers, homocysteine, uric acid (UA), serum insulin levels (SILs), insulin resistance (IR) and MS, so as to identify relevant risk factors for HS. This case-control study included 40 patients (M/F: 23/17) and 40 age- and gender-matched controls (M/F: 23/17). Demographic data, smoking status and alcohol consumption, personal and family medical history, previous and current treatments were noted. Anthropometric data, BPs, FBG and lipids, homocysteine, UA, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and high-sensitivity CRP (hs-CRP), hemoglobin A1c (HbA1c), SILs, SVLs, IMA and sdLDL-C were measured. Homeostasis model assessment for IR (HOMA-IR) was calculated. The associations were made by univariate and multivariate analyses. Univariate analysis showed that there was a significant association between HS and smoking, pack-years of smoking, weight, body mass index (BMI), waist circumference (WC), triglycerides (TGs), high-density lipoprotein cholesterol, very low-density lipoprotein cholesterol, SILs, CRP, hs-CRP, homocysteine, UA, ESR, HOMA-IR, SVLs, and MS. After adjusting for BMI and smoking status, the SVLs, SILs, and hs-CRP levels remained higher in the patients than in the controls (P = 0.02, P = 0.01, and P = 0.02, respectively). Multivariate analysis showed that there was a significant association between HS, and the SVLs and SILs, and smoking. Each unit increase in the SVL (P = 0.003, 95% CI 1.16-2.11) and SIL (P = 0.03, 95% CI 1.01-1.17) increased the risk of HS 1.56- and 1.09-fold, respectively. Furthermore, smoking was associated with a 14.87-fold increase in the risk of HS (P = 0.001, 95% CI 2.82-78.56). This study indicates that HS patients have higher SVLs, SILs, and hs-CRP levels than healthy controls-independent of BMI and smoking status. The SVL and SILs and smoking were independent risk factors for HS.

Rosacea associated with increased risk of generalized anxiety disorder: a case-control study of prevalence and risk of anxiety in patients with rosacea

BACKGROUND

Rosacea may result in emotional distress and anxiety. However, data on the presence of generalized anxiety disorder in rosacea patients are scarce.

OBJECTIVE

The aim of the study was to detect the frequency and level of anxiety and depression in patients with rosacea.

METHODS

A total of 194 consecutive rosacea patients and 194 age- and sex-matched controls were enrolled. Severity of rosacea was assessed in patients according to the criteria of the National Rosacea Society Ethics Committee. Both patients and controls were evaluated by the Generalized Anxiety Disorder 7-item scale, and severity was measured by the Generalized Anxiety Disorder-Adult.

RESULTS

Individuals who were diagnosed with an anxiety and/or depressive disorder were more common in patient group (24.7% vs. 7.2%, p<0,01). Female patients were particularly at risk for having generalized anxiety disorder (OR=2.8; 95% CI 1.15-7.37; p=0.02).

STUDY LIMITATIONS

Single center study and limited sample size.

CONCLUSIONS

Rosacea patients show greater risk of having anxiety disorders, including generalized anxiety disorder. Female patients, those with lower educational levels, those with phymatous subtype, untreated patients, and patients with prior psychiatric morbidity may be at particular risk for anxiety. It is essential to consider the psychological characteristics of patients to improve their well-being.

The effect of COVID-19 on patients with chronic spontaneous urticaria treated with omalizumab and antihistamines: A cross-sectional, comparative study

Introduction

Chronic spontaneous urticaria (CSU) is defined as recurrent attacks of urticaria present for more than six weeks. The monoclonal anti‐immunoglobulin E antibody, omalizumab, was approved for the treatment of CSU in patients who remain refractory to H1‐antihistamines. Biologic agents are shown not to increase the risk of COVID‐19 infection in different studies.

Objective

In the present study, we aimed to determine the prevalance of COVID‐19 infection in relation to the age, gender, presence of other comorbidities, and treatment given for CSU.

Methods

We conducted a descriptive cross‐sectional study of 233 patients diagnosed with CSU in a tertiary referral hospital. Demographical data, treatment given for CSU, the presence of COVID‐19‐related symptoms, history of close contact to a person with COVID‐19 and COVID‐19 real‐time polymerase chain reaction (RT‐PCR) results were determined via a telephone survey and checked from medical data records.

Results

One hundred sixty patients were female; whereas 73 were male. The mean age was 44.76. Out of 233 patients with chronic urticaria, 125 had symptoms related to COVID‐19 infection. RT‐PCR testing for COVID‐19 was performed in 156 patients. Of 156 patients with COVID‐19 RT‐PCR test, RT‐PCR result was positive in 15 cases.

Conclusions

No statistically significant relationship was found between COVID‐19 RT‐PCR positivity and the type of treatment administered for chronic urticaria when the patients are divided into omalizumab ± oral antihistamines and only oral antihistamines treatment groups (p = 0.150). Omalizumab seems to be safe in the era of COVID‐19.

Assessment of Metabolic Profile and Ischemia-modified Albumin Level in Patients with Alopecia Areata: A Case-Control Study

Background:

Alopecia areata (AA) is an autoimmune-mediated hair follicle disorder. In the literature, there is no study evaluating metabolic syndrome and levels of ischemia-modified albumin (IMA) which is proposed as an oxidative stress biomarker in patients with AA.

Aims:

The aim was to investigate the presence of metabolic syndrome and the levels of IMA, small dense low-density lipoprotein (sd-LDL), and visfatin levels in AA patients.

Settings and Design:

A hospital-based cross-sectional study was undertaken among AA patients and controls.

Subjects and Methods:

Thirty-five patients with AA and 35 sex-, age-, and body mass index-matched healthy controls were enrolled. Clinical and laboratory parameters of metabolic syndrome were examined in all participants. Furthermore, IMA, sd-LDL, and visfatin levels were assessed and analyzed with regard to disease pattern, severity and extent, severity of alopecia tool score, duration, and recurrence.

Results:

The median IMA and adjusted IMA levels were significantly increased compared with controls (P<0.05 and P=0.002, respectively). Patients with pull test positivity displayed higher levels of adjusted IMA levels (P<0.05). In AA group, there was a positive correlation between adjusted IMA and waist circumference (r=0.443, P=0.008), adjusted IMA and triglyceride levels (r=0.535, P=0.001), and adjusted IMA and sd-LDL levels (r=0.46, P<0.05). We observed no statistically significant difference in fasting blood glucose and lipid profile, sd-LDL, and visfatin levels of the patients and healthy controls.

Conclusions:

AA patients and controls have similar metabolic profile. Raised levels of adjusted IMA levels may be associated with antioxidant/oxidant imbalance and with risk of cardiovascular disease.

Experience with oral tofacitinib in two adolescents and seven adults with alopecia areata

Alopecia areata (AA) is a common disease that results in nonscarring hair loss. Recently, tofacitinib (TOFA) has been a novel promising therapy for AA. The aim of this study is to determine the efficacy of oral TOFA treatment for alopecia areata (AA), and alopecia universalis (AU). Data of nine patients treated with oral TOFA with either AA or AU were retrospectively evaluated. Treatment outcome, disease severity, and therapeutic response were evaluated by Severity of Alopecia Tool (SALT) scores along with regular photographic surveillance done at third and sixth months. Treatment response was established on four categories: complete response (90% change in latest SALT score), intermediate response (51-90% change), moderate response (6-50% change), and nonresponse (<5% change). Nine patients aged 13-33 years were reviewed. Four patients (44.4%) did not respond to oral TOFA therapy, three patients (33.3%) were moderate responders, 1 (11.1%) was intermediate responder, and 1 (11.1%) was complete responder at the end of 6 months. The clinical response rate (those who achieved ≥5-100% change in SALT score) was 41.4% for all patients. Most of the patients who responded to TOFA had AA instead of AU. Adverse effects were mild. The clinical response rate of TOFA seems reasonable and TOFA was well-tolerated in this cohort. However, to truly evaluate efficacy, future studies are needed to assess the efficacy, adverse effects, and durability of treatment with TOFA in randomized controlled trials.

Long-term effects of omalizumab on peripheral blood cells and C-reactive protein levels in patients with chronic spontaneous urticaria

Omalizumab's mechanism of action is not well-understood yet despite its strong therapeutic efficacy in chronic spontaneous urticaria (CSU). To determine the overall effect of omalizumab on peripheral blood cell counts and serum C-reactive protein levels (sCRP) during a 1-year follow-up in patients with CSU. Data of 74 patients (male/female: 20/54) were reviewed from medical charts. Leucocyte counts, percentages of peripheral blood cells(lymphocyte, monocyte, neutrophil [PPBN], eosinophil, basophil [PPBB]) and sCRP were recorded at baseline, 3rd, 6th, 12th months of omalizumab treatment. Although a dramatic increase in the mean PPBB (±SD) was observed at the 3rd month, PPBB (%) gradually decreased after the 3rd month (PPBB: 0.38 ± 0.21 [baseline] vs. 0.59 ± 0.3 [3rd month], p = .002). However, 12th month PPBB remained higher than baseline (PPBB:0.38 ± 0.21 [baseline] vs. 0.46 ± 0.27 [12th month], p = .03). A dramatic decrease in the mean PPBN (%) was noticed within the first 3 months (PPBN:62.85 ± 8.97 [baseline] vs. 58.37 ± 9.07 [3rd month], p = .04), and 12th month PPBN remained lower than baseline values (PPBN: 62.85 ± 8.97 [baseline] vs. 60.31 ± 8.02 [12th month], p = .045).Mean sCRP (mg/dL) decreased rapidly within the first 3 months (sCRP: 1.09 ± 1.53 [baseline] vs. 0.56 ± 0.45 [3rd month], p = .17) and 12th month sCRP still remained lower than baseline levels (sCRP: 1.09 ± 1.53 [baseline] vs. 0.83 ± 1.06 [12th month], p = .01). Omalizumab substantially increases PPBB,and reduces PPBN accompanied by a reduction in sCRP especially in the first 3 months; however, these effects may continue in the long-term. The alterations in peripheral blood cell ratios and sCRP may contribute to the therapeutic effect of omalizumab in CSU.

Role of serum 25-hydroxyvitamin D levels and vitamin D receptor gene polymorphisms in patients with rosacea: a case-control study

BACKGROUND

Vitamin D has significant effects on the immune system and thereby on the pathogenesis of rosacea. However, there is a lack of information on the vitamin D status and vitamin D receptors (VDRs) of patients with rosacea.

AIM

To evaluate the role of vitamin D in rosacea susceptibility.

METHODS

A case-control study was conducted, enrolling patients with rosacea and healthy controls (HCs). Five VDR gene single nucleotide polymorphisms (SNPs) (Cdx2, FokI, ApaI, BsmI and TaqI) and serum 25-hydroxyvitamin D₃ [25(OH)D₃ ] levels were compared between patients and HCs.

RESULTS

The study enrolled 60 patients (M/F: 14/46) and 60 age- and sex-matched HCs (M/F: 14/46). Age (mean ± SD) was 48 ± 11 years for both groups. The serum 25(OH)D₃ levels (median ± interquartile range) were higher in patients with rosacea (12.9 ± 6.8 ng/mL) than in HCs (10.5 ± 3.7 ng/mL) (P < 0.001). Subjects with high serum 25(OH)D₃ levels had a 1.36-fold increased risk of rosacea (95% CI 1.17-1.58). Heterozygous and mutant ApaI polymorphisms increased rosacea risk by 5.26-fold (95% CI 1.51-18.35) and 3.69-fold (95% CI 1.19-11.48), respectively, whereas mutant TaqI polymorphisms decreased the risk by 4.69 times (95% CI 1.37-16.67). Heterozygosity for Cdx2 alleles increased rosacea risk, whereas wildtype ApaI and mutant TaqI alleles decreased it.

CONCLUSIONS

The present study suggests that an increase in vitamin D levels may contribute to the development of rosacea. ApaI and TaqI polymorphisms, and heterozygous Cdx2, wildtype ApaI and mutant TaqI alleles were significantly associated with rosacea. These results indicate a possible role of vitamin D and VDR pathways in the pathogenesis of rosacea, although causality could not be assessed.

Early recognition of chronic rejection in a face allotransplant patient with alopecia

The features of chronic rejection (CR) in full-face vascularized composite allotransplantation (VCA) are not well-known. Herein, we report a full-face transplant patient that experienced two episodes of acute rejection (AR) and three episodes of AR/CR over the course of 6-years. The patient noticed a small, round patch of hair loss in his beard 9 months after the second AR episode, which occurred 21 months post-transplantation. Biopsy of the alopecic patch showed lichen-planopilaris-like features, which was suggestive of early CR. Despite an increase in immunosuppressive dosages, the alopecia progressed. Following the second and third AR/CR episodes, the alopecia became more pronounced, with the addition of hyperpigmentation as well as sclerosis and telangiectasia. The findings of multiple biopsies showed CR. Based on these findings we think that alopecia with lichen-planopilaris-like histopathological features similar to grade III AR features, particularly in hair follicles appears to be an early finding of CR in the presented patient. The findings further indicate that follicular involvement may be a significant feature of CR in VCA patients and that it can present prior to sclerosis, vasculopathy, or loss of adnexa. The present case is uniquely important because of the distinctive presentation of CR, with hair follicles clinically and histopathologically affected, leading to progressive and irreversible alopecia with lichen-planopilaris-like histopathology.

Nicolau Syndrome Secondary to Subcutaneous Glatiramer Acetate Injection

Nicolau syndrome, also known as embolia cutis medicamentosa, is a rare complication of injectable drugs. Patients present with pain at injection site, followed by swelling, erythema, purple, hemorrhagic patches and lastly ulcer formation. A variety of intramuscular agents have been implicated as responsible. We report a case of a 26-year-old woman with a history of a purple lesion on her thigh who was diagnosed with Nicolau syndrome due to subcutaneous administration of glatiramer acetate. The patient was followed up with topical mupirocin. On follow-up, although the patient stated that she continued using glatiramer acetate, no new lesions appeared and the existing lesion continued to shrink. Nicolau syndrome seems to have an unpredictable and unavoidable course. This case suggests that physicians should have a high index of suspicion for the presence of Nicolau syndrome in patients presenting with necrotic or ulcerative lesions with a history of using injectable drugs.

Paediatric lichen sclerosus et atrophicus: A retrospective analysis of 38 paediatric patients

BACKGROUND

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory cutaneous disease.

AIM

To evaluate the characteristics of paediatric LSA patients in Turkey.

MATERIAL AND METHODS

Data for patients aged <18 years who were diagnosed with LSA by a paediatric dermatologist were retrospectively reviewed. Patient demographic characteristics, clinical features, disease duration, the vitamin D level, accompanying diseases, presence of atopy, therapeutic approach and treatment response were recorded.

RESULTS

The study included 38 patients, of whom 35 (92.1%) were female and 3 (7.9%) were male. Mean age at onset of disease was 6.4 ± 3.3 years in females versus 3.1 ± 2.6 years in males. Mean diagnostic delay was 20.6 ± 28.9 months in females and 2 ± 1.7 months in males. In 28 (80%) patients the time from onset of lesions to diagnosis was ≥3 months. The majority (76.3%) of the patients were asymptomatic, whereas five had itching, two had itching and burning, and two had pain. Among the females, 12 (34.3%) and 23 (65.7%) presented with isolated extragenital and anogenital involvement + extragenital lesions, respectively. All three males had isolated extragenital involvement. The most commonly recommended treatments were topical calcineurin inhibitors and calcipotriol/betamethasone ointment. Accompanying diseases were as follows: alopecia areata (n = 2); atopic dermatitis (n = 2); vitiligo (n = 2); ulcerative colitis and juvenile idiopathic arthritis (n = 1); Hashimoto's thyroiditis (n = 1). Among the 28 patients whose vitamin D level was measured, 24 (85.7%) had vitamin D deficiency.

CONCLUSION

LSA can be asymptomatic in the majority of affected children. Diagnostic delay was noted in 80% of the study's LSA patients, highlighting the lack of awareness of the condition among parents and clinicians.

Hydroxychloroquine treatment for Alopecia Universalis: Report of six cases

Recent reports indicate that hydroxychloroquine is a potential new treatment option for alopecia universalis; thus, we aimed to report on the safety and efficacy of hydroxychloroquine in 6 patients with refractory alopecia universalis that were treated with 400 mg/d continuously for ≥6 months. The treatment outcome was retrospectively evaluated using the Severity of Alopecia Tool (SALT), and at the end of 6 months, patients with a ≥50% decrease in the SALT score were considered as strong responders, a 5%-50% decrease as intermediate responders and a <5% decrease as non-responders. The present findings indicate that hydroxychloroquine is not an effective treatment since in 5 of the 6 patients it was discontinued at the end of 6 months due to lack of hair regrowth, whereas only a 6-year-old boy responded with a SALT score change of 8% after the 12th month.

Serial Quantiferon-TB Gold test results in 279 patients with psoriasis receiving biologic therapy

The risk of active tuberculosis is still a concern in patients receiving biologics. To determine the risk of latent tuberculosis infection (LTBI) reactivation by Quantiferon-TB Gold (QFT) assay in psoriatic patients treated with biologics in 11 years' follow-up, along with chest radiography alterations. This retrospective study included 279 patients with plaque-type and/or pustular, or nail psoriasis who were treated with biologics, and had results for ≥2 LTBI tests. The QFT outcomes were defined according to the baseline and the follow-up QFT results; seroconversion as from negative to positive, seroreversion as from positive to negative, persistently seronegative as invariantly negative, persistently seropositive as invariantly positive, and other any result was accepted as indeterminate. Demographic features, the presence and the type of any chest X-ray abnormality was noted during the follow-up. Of 279 baseline QFT tests, the vast majority were negative (n = 193; 69%), with a less of positive (n = 86; 31%). Ten (5.2%) of 193 patients converted from negative to positive QFT status after starting biologic therapy (P < 0.001) during 11 years' follow-up. Although these 10 patients exhibited seroconversion of QFT from negative to positive, only one patient was diagnosed with active TB. There was no statistically significant difference among biologics as regards with QFT seroconversion risk (P = .09). This study showed that 5.2% of patients showed seroconversion. Annual QFT testing remains a necessary and mandatory tool to prevent further TB reactivation in psoriasis patients taking biologic therapy although only one patient was diagnosed with active TB in this cohort.

Treatment of psoriasis with biologics in the early COVID-19 pandemic: A study examining patient attitudes toward the treatment and disease course

Background

Since March 2020, the coronavirus disease 2019 (COVID‐19) pandemic has been ongoing all around the world with a wide range of clinical course including asymptomatic cases to severe and fatal respiratory tract disease. Patients on immunosuppressive treatments were predicted to be more susceptible to COVID‐19.

Aims

It was aimed to assess treatment continuity, the course of psoriasis and the course and clinical features of COVID‐19 in patients treated with biological agents for psoriasis at the early initial period of COVID‐19 pandemic.

Patients/Methods

Patients treated with biological agents for psoriasis at our institute were contacted by phone between 1 and 10 July 2020 and fulfilled a questionnaire about their continuity to psoriasis treatments, clinical course of psoriasis, and any suspicion/diagnosis of COVID‐19.

Results

A total of 106 patients, 41 females and 65 males, were enrolled. Mean age of the patients was 46.1 ± 12.1 years (range: 19–77). Median duration of psoriasis was 18 years (min–max: 1 month–51 years). Twenty‐four patients (22.6%) were using tumor necrosis alpha inhibitors (ETA:1, IFX:19, ADA:4), whereas 82 patients (77.4%) were using interleukin (IL) 12/23 or IL‐17 inhibitors (UST:48, SECU:30, IXE:4). Seventy‐six patients (71.7%) continued the treatment, whereas 30 patients (28.3%) interrupted the treatment voluntarily. Twenty out of 30 patients (66.6%) who interrupted the treatment had an exacerbation of psoriasis. None of the patients were diagnosed with COVID‐19 in the study period.

Conclusion

Patients with psoriasis who received biological therapy continued their treatment at a high rate during the early period of the COVID‐19 pandemic. No COVID‐19 diagnosis was made among patients whether they continued or discontinued treatment. Recurrence and exacerbation of psoriasis in a significant proportion of patients who interrupted treatment and absence of COVID‐19 diagnosis in each group support the importance and safety of continuity of biological treatments for psoriasis in COVID‐19 era.

Educational level and job status are the most important factors affecting compliance with oral antihistamine therapy for patients with chronic urticaria

BACKGROUND

Management of chronic urticaria (CU) is often difficult with oral antihistamines (OAs) despite long-term use.

OBJECTIVE

The aim of this study was to determine the extent of medication compliance (MC) and to assess the factors affecting the MC of patients with CU toward OA therapy.

METHODS

A 43-item questionnaire was administered to 201 adult patients. A compliance score (CS) of 6 points was chosen as a cutoff point. A CS of 0-6 corresponds to poor compliance and score of 6-9, to good compliance. Subsequently, associations with compliant and poorly compliant groups were made by univariate and multivariate analyses.

RESULTS

The median age and disease duration of all patients were 47 years (range: 18-88) and 15 months (range: 1.5-480), respectively. Overall, the rate of compliant and poorly compliant patients was 53.2% and 46.8%, respectively. Educational level and job status were significantly associated with MC. To have graduated from university and high school increased MC by 9.1-fold (p = .002, 95% confidence interval (CI): 2.26-36.37) and 3.6-fold (p = .019, 95% CI: 1.26-13.47), respectively, compared with illiterates. Patients who had worked previously and were currently looking for work were 4.8-fold (p = .032, 95% CI: 1.14-19.97) more compliant than patients who had never worked.

CONCLUSION

Most patients with CU had good compliance with OAs. Educational level and job status were significant predictors of MC to OAs in CU. The impact and long-term effects of education and job status should be evaluated in different patient groups.