Skin necrosis after intradermal injection of lyophilized exosome: A case report and a review of the literature

BACKGROUND

Exosomes have gained attention for their potential in skin rejuvenation. Currently, most exosome products are available for topical administration, and the use of subdermal injection as a route of administration has not been approved.

AIMS

The purpose of this case report is to describe a case of skin necrosis that occurred following an intradermal injection of lyophilized exosomes.

MATERIALS AND METHODS

We hereby report a case of a middle-aged man who experienced adverse effects after receiving an intradermal injection of lyophilized exosomes. Multiple injections of an exosome product were administered to treat enlarged facial pores. Shortly after the injection, the patient felt pain and noticed several dark red bumps. Three days after injection, the lesions transformed into palpable, painful, non-blanchable purplish papules and nodules, accompanied by central, tiny crusted erosions. The residual product was injected into the upper arm using an intradermal method. Similar lesions also appeared, and a skin biopsy showed necrotic keratinocytes, leukocytoclastic vasculitis, and eccrine necrosis.

RESULTS

There are few reports available regarding complications, especially those related to intradermal exosomes. These complications include multiple foreign-body granulomatous reactions at the injection sites. In our case, oral prednisolone was administered for a duration of 7 days. After the treatment, the lesions exhibited notable improvement, eventually leaving post-inflammatory hyperpigmentation.

CONCLUSION

Utilizing exosomes through unapproved methods should be avoided due to the possibility of adverse reactions that could cause aesthetic issues.

Chicago sky blue gel for better visualization of Demodex in patients with Demodex blepharitis

Background

Demodex blepharitis is a common chronic disease. The number of mites is associated with ocular discomfort. The accurate number derived from well-stained specimens is, hence, in favor of diagnosing, monitoring, and determining treatment responses.

Methods

A cross-sectional study was conducted between April and July 2022 at the dermatology and ophthalmology clinic, Walailak University, Thailand. Adult participants with clinical suspicion of Demodex blepharitis were recruited. We examined eyelashes under light microscopy to quantify the number of Demodex mites before and after adding CSB gel. The mite counts, evaluated by an untrained investigator and an experienced investigator, were recorded and compared.

Results

A total of 30 participants were included for final analysis, among which 25 (83.3%) were female. The median age was 64.0 years (IQR, 61.0-68.0). The median Demodex counts evaluated by the experienced investigator before and after adding CSB gel were 1.0 (IQR, 0.0-1.0) and 2.5 (IQR, 2.0-3.0), respectively (p < 0.001). Moreover, the median Demodex counts evaluated by the untrained investigator before and after adding CSB gel were 1.0 (IQR, 0.0-1.0) and 2.0 (IQR, 1.0-3.0), respectively (p < 0.001). The correlation coefficient between Demodex counts after the addition of CSB counted by the experienced investigator and those counted by the untrained investigator was 0.92 (p < 0.001). CSB gel is a promising product to identify and quantify the number of Demodex mites. The findings supported the consideration of CSB gel as one of the diagnostic stains.

Low-Dose OnabotulinumtoxinA using Seven-Point Pattern Intradermal Injections in Patients with Moderate-to-intolerable Primary Axillary Hyperhidrosis: A Single-Blinded, Side-by-Side Randomized Trial

Background

The axilla is the most common site for primary hyperhidrosis (HH) affecting quality of life. No consensus on the optimal doses of botulinum toxin (BTX) has been established.

Objective

This study aimed to scrutinize the effectiveness of 25- and 50-U onabotulinumtoxinA in patients with moderate-to-intolerable primary axillary HH as well as pain scores after BTX injection.

Methods

A single-blinded, side-by-side randomized trial was conducted between January and June 2022. Participants were randomly treated with 25-unit (U) onabotulinumtoxinA in one axilla and 50-U onabotulinumtoxinA in the other. The Minor starch-iodine test and gravimetric testing, the Hyperhidrosis Disease Severity Scale (HDSS), Hyperhidrosis Quality of Life Index (HidroQoL), global self-assessment scale (GSAS), and satisfaction scores were collected and analyzed.

Results

A total of 12 participants were included in the final analysis; six (50.0%) were female. The median age was 30.3 (interquartile range: 28.7-32.3) years. No statistically significant differences were noted in the sweat rate production, hyperhidrotic area, HDSS, HidroQoL, GSAS, and satisfaction scores between 25- and 50-U BTX at any follow-up visit. No significant difference was noted in pain scores between the two groups (p=0.810).

Conclusion

Low-dose onabotulinumtoxinA is associated with similar efficacy and safety outcomes in primary axillary HH treatment as is conventional-dose onabotulinumtoxinA. No difference was noted in injection site pain between the two groups.

Subcutaneous Panniculitis-like T-Cell Lymphoma with a Transformation to Lupus Erythematosus Panniculitis: A Case Report

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare primary cutaneous lymphoma characterized by infiltration of the subcutaneous tissue by neoplastic cytotoxic T cells mimicking panniculitis. There is a strong association between SPTCL and lupus erythematosus panniculitis (LEP). However, patients who were diagnosed with LEP with a preceding diagnosis of SPTCL have been scarcely reported. We herein reported a 21-year-old Thai woman presenting to a dermatology clinic for evaluation of a 1-month history of a painful mass on the right buttock and bilateral upper eyelid swelling. A subcutaneous mass which was 5 by 2 cm in diameter, tender, firm, and fixed with a smooth surface was palpated over the upper outer quadrant of her right gluteal area. After a diagnosis of SPTCL had been made based on the histological and immunohistochemical studies, treatment with oral dexamethasone and ciclosporin A was initially started. Because of intolerance to adverse reactions of dexamethasone, only ciclosporin A was given. Improvement was not achieved at 6-month follow-up. She then underwent the re-incisional biopsy at the same gluteal area and the histological features were consistent with LEP. After hydroxychloroquine was given, the lesion resolved within 3 months, and no recurrence was detected during the following 6-month follow-up. We emphasize that long-term follow-up of patients with SPTCL is required. Additionally, in case of poor response to the given treatment, a repeat skin biopsy should be considered in order to determine the proper management.

Exfoliative Erythroderma: An Unusual Presentation of Paraneoplastic Pemphigus Associated with Castleman's Disease

We report a 23-year-old woman who presented with generalized scaly erythematous rash predominately on the upper trunk and hemorrhagic stomatitis. The histopathologic and immunopathologic findings were consistent with the diagnosis of paraneoplastic pemphigus. Castleman's tumor was diagnosed with computed tomography and exploratory laparotomy. A partial clinical improvement was observed after complete tumor removal and intravenous immunoglobulin administration. However, the patient died as a result of septicemia.

Methimazole-Induced Leukocytoclastic Vasculitis: A Case Report

Major identifiable causes of leukocytoclastic vasculitis include certain infections and medications. Amongst antithyroid drugs, methimazole (MMI) is rarely implicated as a culprit drug. We report the first case, in Thailand, of MMI-induced leukocytoclastic vasculitis in a 41-year-old Thai female who had received MMI for relapsed Graves' disease. MMI was discontinued and cholestyramine at a dose of 4 g four times daily was given instead. Her rashes on both legs resolved dramatically at 1-week follow-up. However, thyroid function test revealed unimproved thyrotoxicosis. She subsequently underwent radioiodine ablation as a definitive treatment. There were neither recurrent skin lesions nor other systemic involvements during the 3-month follow-up period. Notably, the most crucial step in the management of drug-induced leukocytoclastic vasculitis is the discontinuation of the offending drug in order to avoid further progression of the disease. The administration of immunosuppressive agents may not be necessary in patients with mild severity and non-vital organ involvement.

Reflective and feedback performances on Thai medical students' patient history-taking skills

BACKGROUND

Reflective practice (RP) plays a crucial role in encouraging learners to think critically and consciously about their performances. Providing constructive feedback can further enhance RP. But non-Western learners might face different learning barriers compared to learners in the West, where RP originated.

METHODS

In this retrospective study, we assessed RP and feedback performances on Thai medical students' patient history-taking skills. We applied RP and peer feedback, along with feedback from the instructors, during the history-taking sessions of the ten-week introduction course for fourth-year medical students. Twelve history-taking sessions were used for the analysis. Two instructors assessed students' reflective performance and categorised them into one of the six stages of Gibbs' reflective cycle; their feedback performances were analysed using Pendleton's model. We investigated the correlations between students' overall grade point average (GPAX) and patient history-taking scores on the Objective Structured Clinical Examination (OSCE). Students' opinions of the RP teaching method were also collected.

RESULTS

All (n = 48) students participated in our study. The students' mean age was 21.2 ± 0.5 years. The majority of the students were female (64.6%). The data indicated that 33 and 4% of the participants were categorised into the evaluation stage and action plan stage of Gibbs' reflective cycle, respectively. In addition, 22 and 15% of the participants were able to state what their peers did well and suggest how peers could improve their skills, respectively. All students passed the minimum passing level of four history-taking OSCE stations. Participants agreed that RP was a useful tool (mean 9.0, SD 0.1), which enhanced their thought processes (mean 8.4, SD 0.2) and future performances (mean 8.2, SD 0.2). However, there was no correlation between the students' highest Gibbs' reflection levels and their history-taking OSCE scores.

CONCLUSIONS

RP, together with feedback, proved to be a useful technique to help fourth-year Thai medical students improve their reflection skills, enhance their medical knowledge, and improve patient history-taking skills. Further study with longer monitoring is required to further explore negative and positive influential factors affecting students' achievement of better reflection performances.

Serum Sickness after Equine Rabies Immunoglobulin in Identical Male Twins: Two Case Reports

We, hereby, report two cases of serum sickness in adult male identical twins who had received equine rabies immunoglobulin as a postexposure rabies treatment after cat scratches. The younger brother developed low-grade fever, polyarthritis, and multiple erythematous maculopapular eruptions, whereas low-grade fever and urticaria-like eruptions were detected in the elder brother. Both patients received a 7-day course of low-dose prednisolone and achieved good responses without recurrent attacks.

Retained mind mapping skills and learning outcomes in medical students: a mixed methods study

This article was migrated. The article was not marked as recommended. Background: Mind maps (MM), is a learning method assisting learners in the visualisation of relationships between theoretical concepts. Studies showed the enhancement of data retention, overall comprehension, and creativity in MM users. Thus, MM has been implemented in many medical schools to facilitate medical students' learning experiences. However, retained mind mapping skills and its effect on the learning outcomes in the long-term follow-up remain unknown. Methods: A concurrent mixed-methods design with convenience sampling method. All (48) second-year medical students joined a three-day MM workshop in 2016. One year later, we surveyed the students who still use MM and those who did not. Mind Map Assessment Rubric (MMAR) and Grade Point Average (GPA) were compared between the two groups. Content analysis with data triangulation method was used to explore their preferences and MM skills. Results: We achieved a 100% response rate. 39 (81.2%) of participants were female. The mean age of participants was 20.6 years (SD = 0.5). 37 students still use MM (77.1%). With MMAR, participants in the MM group scored 28.9 higher than participants in the MM-free group significantly (p = 0.01). There were no differences in the median GPAs to both groups. However, there was a significant correlation between using MM in learning and the second trimester (year1) (r=0.29, p<0.05). Majority of participants in the MM groups stated the advantages of using MM to help to organise data and their thought process. But the students in MM-free group saw the disadvantages of MM as a time-consuming process and the potential of missing information from lectures. Conclusions: Without revision in MM, participants' skills deteriorated immensely. There was a non-statistically significant trend toward increased learning outcomes with MM group. Further studies to examine whether more frequent MM use or workshop revision can boost their learning outcomes or not is recommended.

Retained mind mapping skills and learning outcomes in medical students: a mixed methods study

This article was migrated. The article was not marked as recommended. Background: Mind maps (MM), is a learning method assisting learners in the visualisation of relationships between theoretical concepts. Studies also showed enhancement of data retention, overall comprehension, and creativity in MM users. Thus, MM has been implemented in many medical schools to facilitate medical students' learning experiences. Nevertheless, retained mind mapping skills and its effect on the learning outcomes in long-term follow-up remain unknown. Methods: A concurrent mixed-methods design with convenient sampling method. All (48) second-year medical students joined a three-day MM workshop. One year later, we surveyed the students who still use MM and those who did not. Mind Map Assessment Rubric (MMAR) and Grade Point Average (GPA) were compared between two groups. Content analysis with data triangulation method was used to explore their preferences and MM skills. Results: We achieved a 100% response rate. 39 (81.2%) of participants were female. The mean age of participants was 20.6 years (SD = 0.5). 37 students still use MM (77.1%). With MMAR, participants in MM group scored 28.9 higher than participants in MM-free group significantly (p = 0.01). There were no differences in the median GPAs to both groups. However, there was a significant correlation between using MM in learning and the second trimester (year1) (r=0.29, p<0.05). Majority of participants in MM groups stated the advantages of using MM as a tool helping those organising data and their thought process. On the contrary, students in MM-free group declared the disadvantages of MM as a time-consuming and missing data from lectures. Conclusions: Without revision in MM, participants' skills deteriorated immensely. There was a non-statistically significant trend toward increased learning outcomes with MM group. Further studies to examine whether more frequent MM use or workshop revision can boost their learning outcomes or not is recommended.

A small group learning for evidence-based medicine in pre-clinical medical students

This article was migrated. The article was not marked as recommended. Background Evidence-based medicine (EBM) is the application of current, best-available clinical evidence to health care decisions for individual patients. Many medical schools put EBM courses in their curriculum as they considering it is important. However, to teach the EBM course in pre-clinical year medical students is challenging owning to their clinical inexperience. Methods A prospective study of the third-year medical students of Walailak University located in the southern part of Thailand. They participated in a two-week course of evidence-based medicine. The effectiveness of the course organization was assessed by percentage of students whose scores reached the minimal passing level and using pre-study and post-study self-reported evaluation. Results The percentage of students whose scores reached the minimum pass level (70%) was 100%. The scores are normally distributed with a mean of 88.59 (SD 3.33). Self-reported evaluation of knowledge and skills increased 4.28 scores (SD 2.06, p-value <0.001) and 4.24 scores (SD 2.08, p-value<0.001), respectively. Conclusion Using small group learning for evidence-based medicine in pre-clinical medical students achieved remarkable learning outcome regardless of clinical experiences. However, the role of the facilitator was of crucial importance as student learning depended on the facilitator's proper guidance and evaluation in the small group sessions.