Safety and efficacy of tofacitinib in 97 alopecia areata patients.

BACKGROUND: Alopecia areata (AA) is a recurrent immune-mediated disorder causing hair loss without any scarring being present. It affects hairs on the head or other parts of the body and can occur at any age and in both genders. It seems that AA is associated with a higher rate of psychological disorders resulting from hair loss and the esthetic and social repercussions of it. Common treatments like corticosteroids do not work for every patient and recent treatment options focusing on the immunologic mechanisms like tofacitinib have shown some promising results. METHODS: It's a retrospective study on patients with AA, AT, AU taking oral tofacitinib as a treatment for at least 6 months. Scalp hair loss was assessed before treatment and at each visit using the Severity of Alopecia Tool (SALT) score. RESULTS: Of 97 cases, 69.1% demonstrated over 50% SALT score improvement, with 44.3% having 90% or more decrease in SALT score. Patients who suffered from patchy AA were more responsive compared to patients with AT and AU subtypes and had a greater percent change in SALT score. Tofacitinib was tolerated quite well and no significant adverse events were reported. CONCLUSIONS: Tofacitinib should be taken into consideration as an efficacious treatment option for patients with AA, AT and AU.

The effect of vitamin C on oxidative stress indices and skin regimentation of vitiligo patients.

It has been suggested that vitamin C is involved in suppressing stress oxidation signaling in vitiligo disease. However, the effect of vitamin C supplementation on stress oxidative factors has not been investigated in vitiligo subjects. This study was designed to examine the effects on vitamin C supplementation on serum levels of stress oxidative factors and regimentation in vitiligo patients. Forty-four vitiligo patients will be recruited in this study. After block matching for sex and number of phototherapy sessions, they will be randomly assigned to receive 1000 mg/d vitamin C or placebo for 8 weeks. The weight, height, and waist circumference of participants will be measured. Determination of serum stress oxidative indices (CAT, SOD, GPX, MDA, TOS, TAC) will be done at study baseline and at the end of the trial. Also, the regimentation will be determined using the VASI score. This is the first randomized controlled trial that will determine the effect of vitamin C supplementation on serum levels of stress oxidative indices and regimentation in vitiligo patients. The results of this trial will provide clinical evidence on the effectiveness of vitamin C supplementation in controlling oxidative stress in vitiligo patients. Trial registration number: This study is registered in the Iranian Registry of Clinical Trials website (available at http://www.irct.ir , identifier: IRCT20230123057193N1), Registration date: 2023/04/17.

Nail abnormalities in subepidermal blistering diseases: a cross-sectional study.

BACKGROUND: Nail involvement in subepidermal autoimmune blistering diseases (SEABD) is not common. Although these changes can be transient, permanent changes can also occur. This study addresses nail involvement manifestations and their associated factors in patients with SEABD. METHODS: From March 2020 to March 2021, we enrolled 56 patients with SEABD who were being examined at a tertiary skin hospital and checked their nail changes. We investigated the association between the SEABD subtypes and treatments that patients were receiving and the nail abnormalities. Additional factors including age, gender, duration since diagnosis, presence of mucosal involvement, and anti-bp230 and anti-bp180 IgG antibody quantitative levels (in those patients with bullous pemphigoid) were analyzed. RESULTS: The most common nail abnormalities were ridging, onycholysis, and onychoschizia. We observed a lower prevalence of onycholysis in EBA, a lower prevalence of periungual bullae in MMP, and a higher prevalence of scarring loss in EBA. Rituximab and dapsone were effective in preventing onycholysis as well as prednisolone in preventing subungual hematoma. Multiple lesions were found to be more common in the foot digits including great toes, probably because of higher exposure to trauma. CONCLUSIONS: In summary, in patients with SEABD and concomitant nail involvement, the underlying disease control, proper treatment, and avoidance of trauma may be helpful.

The Relationship Between ABO and Rh Blood Groups with Alopecia Areata.

INTRODUCTION: Alopecia areata (AA) is a common non-scaring hair loss disease. Genetic susceptibility and environmental factors can develop the disease. OBJECTIVES: We investigated the association between AA and ABO and Rh blood groups. METHODS: This cross-sectional study was done on 200 patients with AA and 200 healthy controls (HCs) between March 2021 and September 2021. RESULTS: The prevalence of blood groups O, A, B, and AB in patients with AA was 30%, 30.5%, 10.5%, and 29%, respectively. A significant difference was detected between the two groups in the frequency of the ABO and ABO*Rh blood groups (p-value < 0.05). Compared to the HCs, the prevalence of the AB and AB+ blood group was higher in AA patients. No significant relationship was detected between sex, BMI, duration of disease, age at onset, severity of alopecia tool (SALT) score, hair loss pattern, and nail involvement with ABO and Rh blood groups (p-value > 0.05). CONCLUSION: In conclusion, the highest difference was related to the AB+ blood group, so compared to HCs, the AB+ blood group frequency was higher in patients with AA. However, more studies with larger sample sizes on different ethnicities should be performed to verify the results of this study.

Is the severity of alopecia areata associated with arterial stiffness?

Background: This study aimed to evaluate the severity of alopecia areata (AA) associations with metabolic syndrome, body composition evaluated by bioimpedance techniques, and arterial stiffness based on pulse-wave velocity analysis. Materials and Methods: This cross-sectional study was conducted on patients referred to AA Clinic at Razi Hospital in 2021 and 2022. Patients with AA with the Severity of Alopecia Tool (SALT) score above 20% and receiving no systemic therapy were included. Patient demographic and clinical information, symptoms of metabolic syndrome, and bioimpedance factors were collected, and the relationship between disease severity, metabolic syndrome, and bioimpedance indicators was evaluated. Results: In this study, 59 patients were examined, with 26 (44.07%) being female and 33 (55.93%) being male. The mean age of the patients was 37.42 years (standard deviation [SD] =11.28). The severity of the disease was assessed using the SALT score, with the mean severity in terms of the percentage being 69.83% (SD = 28.57%). In the regression model, SALT score was independently related to the severity of vascular stiffness after adjusting for the effect of other variables (beta = 0.033, 95% CI = 0.009-0.057, P = 0.046). Moreover, SALT score was significantly related to metabolic syndrome after adjusting for the effect of other variables (OR = 1.035, 95% CI = 1.012-1.059, P = 0.002). Conclusion: This study found that AA severity is associated with a higher chance of having metabolic syndrome and arterial stiffness which may lead to cardiovascular diseases in patients with AA, and screening patients regarding cardiometabolic diseases is mandated.

Evaluating the Perception of Mycosis Fungoides Patients About Their Disease Before and After Educating Them.

Introduction: Patient-held beliefs are important for disease management and few studies have evaluated illness perception of Mycosis Fungoides (MF) patients. Objectives: Here, we aimed to determine the effect of educating MF patients on their perception of their disease. Methods: Patients with diagnosed MF were asked to fill the Illness Perception Questionnaire-Revised (IPQ-R) once before education and once 3 months later. Results: Fifty-five patients, 41 men and 14 women, with a mean age of 45.5 ± 13.9 years were enrolled. Regarding the main etiologic factor, most patients cited anxiety (91%). After education, the most significant changed belief on disease etiology was immune system dysfunction and the change was twenty-six percent which was observed more in patients with higher educational levels, shorter disease duration, and lower MF stages. Regarding the most prevalent clinical manifestations, most patients mentioned erythema (86%). After education, the greatest change in symptom perception was related to lymphadenopathy (32%) which was significantly associated with less disease duration and those treated with phototherapy. Before education, the mean perception score about the disease chronicity was 23.67 ± 3.549 that increased to 27.71 ± 1.66 (P < 0.001). This change was more observed in men (P = 0.03), those with less disease duration, and those treated with phototherapy. Conclusions: Generally, MF patients hold favorable perspectives about their disease and educating them positively improves their illness perception. Patients with higher educational levels and lower stages of the disease showed more significant changes in various aspects of illness perception. Hence, early education is recommended in patients with lower educational levels.

Corrigendum.

[This corrects the article DOI: 10.1002/hsr2.602.].

Adverse outcome and severity of COVID-19 in patients with autoimmune bullous diseases: A historical cohort study.

The ongoing COVID-19 pandemic has raised concerns regarding the outcome of this infection in patients with autoimmune bullous dermatoses (AIBDs) due to effect of drugs used to treat these disorders. This investigation was performed from the onset of the pandemic to June 1, 2021. Patients with AIBDs who contracted COVID-19 were evaluated. A generalized linear model was employed to find the predictors of severe COVID-19 among patients with AIBDs. Ninety-three patients with AIBDs with a mean age of 50.3 years were evaluated. The most COVID-19 related symptoms were tiredness (76.3%) myalgia (69%), and cough (63.4%). During follow-up, the rate of hospitalization and death were 45.2% and 4.3%, respectively. Previous comorbidities (ß = 0.61) and mean prednisolone dosage above 10 mg/day in the last 3 months (ß = 1.10) significantly increased COVID-19 severity. Also, vaccination against SARS-CoV-2 (ß = -1.50) and each passing month from the last rituximab dose decreased severity (ß = -0.02). Notably, 19.3% of the patients developed AIBD flare-ups following COVID-19 infection. Higher prednisone dose and the shorter interval from the last rituximab infusion were determinants of severe COVID-19. Physicians should assess the risk versus the benefits when prescribing the medications. Moreover, vaccination could successfully attenuate COVID-19 severity.

Treatment satisfaction and response in patients with severe alopecia areata under treatment with diphenylcyclopropenone.

Background and Aims: Alopecia areata (AA) is an autoimmune disease of hair follicles. Treatments currently include topical and intralesional corticosteroids and contact immunotherapy; however, the overall prognosis is usually unfavorable. In severe AA, topical immunotherapy with diphenylcyclopropenone (DPCP) is preferred. Since its effectiveness is heterogeneous and there are several side effects, we decided to measure the patients' satisfaction using the "Version II of the Treatment Satisfaction Questionnaire for Medication," which investigates satisfaction with effectiveness, side effects, convenience, and global satisfaction. Methods: We examined 100 patients under treatment with DPCP for treatment response, asked them to respond to the questionnaire, and calculated their overall scores out of 400. We then investigated the association between the patients' characteristics with their treatment response and satisfaction. Results: The overall satisfaction of patients was 257/400. We observed a significant association between patients' satisfaction scores on effectiveness and global satisfaction with their response to treatment (p < 0.001). The patients' satisfaction with the treatment's convenience had a significantly positive association with the age of receiving the diagnosis (p = 0.028). The overall treatment satisfaction was significantly associated with treatment response (276 vs. 213, p = 0.000). Conclusion: Although there are currently no gold standard treatments for severe AA, DPCP demonstrated a 71% response to treatment, and patients with response were significantly more satisfied with their treatment.

Topical treatment adherence and associated factors in patients with psoriasis: A single center, cross-sectional study.

Topical medications are one of the main treatments for psoriasis. Adherence to treatment is an important factor in achieving successful control of disease. The aim of this study was to evaluate adherence to topical drugs and identify possible associated factors in in patients with psoriasis. Ninety-three patients were evaluated by a two-part questionnaire; the first part examined demographic, socioeconomic and disease-related factors while the second part, the ECOB questionnaire (Elaboration d'un outil d'evaluation de l'observance des traitements medicamenteux), examined adherence to topical drugs. The mean self-reported adherence to topical treatment in this study, was 50.5%. Severe disease, involvement of lower extremity, and positive family history of psoriasis were associated with poor adherence to treatment. Patients with a history of diabetes mellitus had better adherence to treatment. In this study adherence to topical treatment was low and had no significant relationship with most of the studied demographic and socioeconomic factors.

Sleep disturbance in alopecia areata: A cross-sectional study.

Background: Alopecia areata (AA) is a nonscarring hair loss with autoimmune pathophysiology, which is associated with psychiatric disorders including anxiety and depression. Sleep disorders are commonly seen with anxiety and depression. Here we evaluate the sleep quality of AA patients. Methods: This cross-sectional study involved 51 AA patients and 51 age- and sex-matched healthy controls. The sleep quality and day sleepiness were evaluated by the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) questionnaires. The severity of AA was evaluated with the Severity of Alopecia Tool (SALT). Results: Unlike the ESS score, the mean PSQI score was significantly higher in the AA group compared with the controls (7 ± 4.13 vs. 3.53 ± 1.96, p < 0.001). The number of cases with ESS ≥ 11, indicating the excess daytime sleepiness, was significantly higher in the AA group compared with controls (15 vs. 6, p = 0.02). There was no significant correlation between PSQI score and age, age of onset of the disease, or SALT score (p > 0.05). Anxiety and depression were more common in the AA group versus controls (p = 0.9). PSQI score was higher in AA patients who had anxiety and depression compared with those who did not (9.9 ± 5.28 vs. 4.76 ± 3.08, p = 0.001). Conclusion: Sleep quality is impaired in AA patients. As expected, sleep would be more disturbed in AA cases with depression or anxiety. Therefore, attention to sleep quality and concomitant psychiatric diseases is essential in AA clinical management.

The efficacy of rituximab in patients with mucous membrane pemphigoid.

OBJECTIVE: Mucous membrane pemphigoid (MMP) is an autoimmune blistering disorder with tendency to scarring. Long term immunosuppressive treatment may be required to minimize the consequences of the disease. METHODS: In this retrospective study, we investigated the efficacy of rituximab (RTX) in MMP patients and compare the beneficial effects of early versus late administration of RTX. Medical records of 24 MMP patients who were treated with 500 mg RTX on day 1, then weekly for 4 consecutive weeks were reviewed. RESULTS: Twenty-one patients (87.5%) reached disease control (DC) at the mean interval of 4.95 months (SD: 5.15; range: 1-24) after RTX. Complete remission (CR) with scarring was achieved in 45.8% (n = 11) and 33.3% (n = 8) attained CR without any residual scar (total CR with or without scar 79.1%). Two patients (8.3%) reached partial remission including persistent gingivitis. Only one patient progressed from non-cicatricial to cicatricial MMP despite receiving RTX. 47.6% (n = 10) of patients experienced relapse after achieving DC at a mean interval of 15.2 months (range: 6-30, SD: 7.0). Considerably, earlier the RTX was administered, sooner the DC was obtained (Pearson r = 0.742, p-value < .001). CONCLUSIONS: These results suggest that RTX may prevent further scarring and progression in MMP patients especially if administered early.

Oral isotretinoin combined with topical clobetasol 0.05% and tacrolimus 0.1% for the treatment of frontal fibrosing alopecia: a randomized controlled trial.

BACKGROUND: Frontal fibrosing alopecia (FFA) is a scarring alopecia with no promising treatment. OBJECTIVE: To evaluate the additive efficacy of oral isotretinoin to topical treatments. METHODS: Between November 2017 and August 2018, FFA patients were randomly assigned to receive either isotretinoin (20 mg/d) plus topical treatments (clobetasol 0.05% and tacrolimus 0.1%) or monotherapy with topical treatments. Treatments' efficacy was evaluated through Frontal Fibrosing Alopecia Severity Index (FFASI) after two and 6 months. RESULTS: From 38 participants, 28 patients completed the study. Facial papules improved after 6 months (p value < .001) in the isotretinoin group. Moreover, frontotemporal hairline (p values for frontal < .001; R lateral: 0.03; L Lateral: 0.02), total scalp margins, total additional features' scores, and total combined (p value < .001 for all) improved more in the isotretinoin group than in the control group. Frontal band improved in the treatment group (p value: .02). Frontal margin (p value: .01), R lateral (p value: .01), total scalp (p value < .01), and combined total scores (p value: .01) worsened in the control group. Isotretinoin-related side-effects included lip dryness, telogen effluvium, and malaise. LIMITATIONS: Small sample size and lost to follow-up. CONCLUSION: Isotretinoin combined with topical treatments is more effective than monotherapy with clobetasol and tacrolimus for FFA. CLINICAL TRIAL CODE: (IRCT.ir) IRCT2017091736173N1.

The Serum Level of Oxidative Stress and Antioxidant Markers in Patients with Psoriasis: A Cross-sectional Study.

BACKGROUND: soriasis is a chronic, immune-mediated, inflammatory disease. Previous studies have indicated a possible role of oxidative stress in the pathogenesis of psoriasis. OBJECTIVE: We sought to compare special oxidative stress and antioxidant markers in psoriatic patients. METHODS: This study included 35 patients with psoriasis and 35 healthy controls. Serum levels of oxidant markers, including advanced glycation end products (AGEs) and advanced oxidation protein products (AOPPs), as well as antioxidant enzymes, including lecithin-cholesterol acyltransferase (LCAT), paraoxonase-1 (PON1), and ferric-reducing ability of plasma (FRAP), were measured. RESULTS: The mean age of the subjects was 39.63±13 years in the case group and 39.37±12.62 years in the control group (p=0.92). The mean Psoriasis Area and Severity Index (PASI) scores of these groups were 15.27 and 10.47. The mean levels of fasting blood sugar and C-reactive protein were significantly higher in the case group than the control group (p=0.04 and p=0.02, respectively). Moreover, the mean levels of AGEs and AOPPs in the case group were significantly higher than in the control group (p=0.001), while the mean levels of FRAP, PON1, and LCAT were significantly lower in the case group than in the control group (p=0.001). There was no significant association between PASI and oxidant or antioxidant markers, except for AOPP, which had a negative association with PASI. CONCLUSION: Our findings suggest an imbalance among oxidative stress and antioxidant markers in the pathogenesis of psoriasis. The oxidant-antioxidant enzymatic system is impaired in psoriasis as a result of increased oxidant products and reduced antioxidant activity.

A prospective comparative study of two regimens of diphenylcyclopropenone (DPCP) in the treatment of alopecia areata.

BACKGROUND: Alopecia areata (AA) is a chronic disorder and the best treatment regimen for it is unknown. Currently, one of the best documented treatment modalities for AA is topical immunotherapy. AIM: To evaluate the safety and efficacy of a novel method (multi-concentration patch test) versus standard protocol for topical immunotherapy. METHODS: A prospective randomized clinical trial was conducted on 30 patients with Alopecia areata, half of them received DPCP with a novel method using multi-concentration patch test to determine the optimal initiating concentration of DPCP (case group) and the other half experienced immunotherapy according to the standard protocol (control group). Percentage of hair regrowth after 6 months of treatment and the incidence of drug-related adverse effects were evaluated and compared between the two groups. (IRCT registration code: IRCT20141209020250N5). RESULTS: Absolute and relative hair regrowth percentages were reported 25% and 41.49% in case group and 8.2% and 14.21% in control group respectively. Considerable response (more than 75% hair regrowth) was observed in 4 (26.6%) patients in case and 1 (6.6%) patient in control group. The clinical response was initiated about 7 weeks sooner in case compared to the control group (14 versus 7.38 weeks, P: 0.001). Overall, clinical response was higher in patients received new protocol, compared to control group. Moreover, patients who experienced new protocol had a higher level of treatment satisfaction in comparison with patients having standard protocol (P: 0.012). CONCLUSION: This study revealed the effectiveness and safety of the novel multi-concentration patch test DPCP therapy for AA and its priority to conventional method, at least in terms of shortened duration of DPCP immunotherapy.

Is the severity of initial sensitization to diphenylcyclopropenone in alopecia areata patients predictive of the final clinical response?

Immunotherapy by diphenylcyclopropenone (DPCP) is generally started with 2% DPCP sensitization, however in recent years studies have questioned the necessity of sensitization that may cause patients severe reactions and troubles at the onset of therapy. The purpose of the present study was to evaluate the association between the severity of initial reaction to 2% DPCP sensitization in AA patients and clinical response. In this retrospective study, 110 AA patients who continued therapy for at least 6 months were enrolled. Hair loss and hair regrowth rates were calculated based on the Severity of Alopecia Tool (SALT) scoring system. Initial reaction to 2% DPCP sensitization after 2 weeks was graded as negative reaction (absence of any reaction), doubtful reaction (mild erythema, pruritus, and irritation for minutes after test), weak (erythema, mild edema, and scaling), and strong to extreme reaction (vesicles, bullae, ulcer, and discharge). The degrees of the initial reaction to 2% DPCP after 2 weeks were negative reaction 13 (11.81%), doubtful reaction 40 (36.36%), weak reaction 33 (30%), and strong to extreme reaction 24 (21.81%). Patients were divided into two groups: (A) patients with less than 12-month therapy (75 of 110), (B) patients with more than 12-month therapy (35 of 110). Initial reaction to 2% DPCP sensitization was not correlated with hair regrowth rate in either group (group A: Spearman's rho = 0.194, p = 0.095; group B: Spearman's rho = 0.063 p = 0.720). After 12-month treatment with DPCP, hair regrowth rate was significantly greater than 6-months therapy (group A: 17.03 ± 37.78, group B: 49.26 ± 36.34; p = 0.003). The severity of hair loss at the onset of treatment was significantly associated with the response rate in both groups (p-value <0.002). Based on our results, it is the initial severity of the disease and not the initial reaction to 2% DPCP sensitization that predicts the clinical response to DPCP immunotherapy.

A randomized trial of diphenylcyclopropenone (DPCP) combined with anthralin versus DPCP alone for treating moderate to severe alopecia areata.

BACKGROUND: Alopecia areata (AA) is a chronic autoimmune disorder. Finding the best treatment regimen for it remains a challenge. Currently, one of the best documented treatment modalities for AA is topical immunotherapy. AIM: To evaluate the safety and efficacy of combined DPCP and anthralin versus standard protocol (DPCP alone). METHODS: A prospective randomized clinical trial was conducted on 50 patients with Alopecia areata who received DPCP alone (group D) or in combination with anthralin (group D/A). Percentage of hair regrowth after 6 months of treatment and the incidence of drug-related adverse effects were evaluated and compared between the two groups. RESULTS: Complete hair regrowth was observed among three patients in each group (18.75% in Group D and 15.79% in Group D/A) after 6 months. Moreover, 25% and 31% of patients in group D and 21% and 47% of patients in group D/A had > 75% and > 50% hair regrowth respectively at the end of the study (P-value: 0.696). In addition, earlier age of onset, chronicity of lesions, nail involvement, facial hair loss and extensive lesions at baseline were associated with poor clinical outcome. CONCLUSION: DPCP and anthralin was as effective as DPCP alone and anthralin did not add to the effect of DPCP in treating AA.