Expression of immune checkpoints in active nonsegmental vitiligo: a pilot study.

BACKGROUND: Vitiligo is a depigmentary skin disfigurement resulting from destruction of melanocytes caused by a possible malfunctioning immunity. This destruction could be linked to an aberrant T-cell-mediated immune response. Cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) and programmed death-1 (PD-1) are immune checkpoints capable of downregulating T-cell immune functions. OBJECTIVES: To evaluate the pattern of expression of PD-1 and CTLA-4 in active vitiligo skin. METHODS: Thirty nonsegmental vitiligo (NSV) patients had been included in this pilot study. Marginal, lesional, and nonlesional skin biopsies were obtained. PD-1 and CTLA-4 immunohistochemistry expression in the mononuclear inflammatory infiltrates were evaluated using digital images. RESULTS: The marginal and lesional inflammatory infiltrates were significantly abundant when compared to nonlesional ones. The marginal infiltrates were significantly abundant when compared to the lesional ones. PD-1 and CTLA-4 were significantly expressed in the marginal and lesional infiltrates when compared to nonlesional skin. Moreover, the marginal expression of PD-1 was significantly higher than the lesional expression. However, no similar significant difference in CTLA-4 expression was found between the marginal and lesional infiltrates. Significant positive correlations were found between the expressions of PD-1 and CTLA-4 in marginal and lesional infiltrates. CONCLUSION: Programmed death-1 and CTLA-4 are expressed within the inflammatory infiltrate of active NSV. Further studies are required to confirm their significance in the development or limitation of the disease.

Management of resistant halo nevi.

BACKGROUND: Halo nevus (HN) is a rare dermatologic disorder characterized by typical whitish rim surrounding an existing melanocytic nevus resembling halo. It is a cosmetic problem that may be linked to vitiligo, and it is advised to remove these nevi in order to avoid development of vitiligo. OBJECTIVES: The aim of the present study is to evaluate the cosmetic outcome after nevus removal and leukoderma dermabrasion with epithelial graft followed by narrow-band ultraviolet B (NB-UVB) phototherapy as management of resistant halo nevi and avoidance of development of vitiligo. PATIENTS AND METHODS: Ten patients with persisting halo nevi were selected as candidates in this study. Superficial dermabrasion was carried out using proper diamond fraises on depigmented rim and then punch biopsy probes with suitable size were used to harvest the nevus. Thiersch graft was prepared and applied on the dermabraded depigmented area. After 1 week of the procedure, patients were exposed to NB-UVB twice weekly and were followed up for 3 months. RESULTS: Repigmentation was noticed in 2 weeks and was nearly fully accomplished in all 10 patients within the 3-month period. No other vitiligo lesions developed during this period in all patients except for one case. CONCLUSION: Excision of Sutton's nevus with combined dermabrasion and Thiersch grafting followed by phototherapy is a good aesthetic maneuver in treating halo nevi and helps in avoiding further vitiligo depigmentation.

Epithelial expression of cytokeratins 15 and 19 in vitiligo.

BACKGROUND: Cytokeratins (CK) belong to the family of intermediate filament proteins, and among them specific epithelial keratins are considered markers for stem cells activation. OBJECTIVES: This study aims to investigate the expression of CK15 and CK19 as possible stem cell markers in vitiligo during phototherapy. METHODS: The study was conducted on vitiligo patients receiving narrow-band ultraviolet therapy. Immunohistochemical staining for CK15 and CK19 was carried out, and clinical follow-up continued for 4 weeks. RESULTS: Of 28 patients, CK15 expression was demonstrated in 17 cases (61%) while CK19 expression was demonstrated in 11 cases (39%). Cells expressing positive staining were demonstrated in follicular and interfollicular epithelium. Expression was clearly demonstrated in patients younger than 20 years old, with shorter disease duration, with disease stability, and with normally pigmented hairs. Expression of cytokeratins was significantly correlated to improvement of vitiligo lesions. CONCLUSION: CK15 and CK19 are expressed in vitiligo during UV repigmentation in the follicular and interfollicular epithelium. This expression of cytokeratins was significantly correlated to improvement and can be considered valuable tool to monitor stem cells stimulation for the sake of the repigmentation process in vitiligo.

Linear neutrophilic dermatitis: a seasonal outbreak of Paederus dermatitis in upper Egypt.

In this retrospective study, we investigated a mysterious acute linear eruption that was reported yearly in 300 Egyptian patients, with peaks in June and September, without a clear diagnosis. The lesions evolved suddenly in all patients and presented as an erythematous linear eruption with a grayish center and vesicles and/or pustules located in the middle of the plaques. Only areas that were not covered by clothing were affected. Microscopic examination of skin biopsies revealed striking neutrophilic spongiotic lacunae within a degenerated epidermis and moderate dermal infiltrate. After excluding other possible differential diagnoses associated with linear lesions, the Paederus beetle was concluded to be the initiator of this irritant dermatitis reaction. An outbreak of acute linear neutrophilic dermatitis may develop due to exposure to the Paederus beetle with no sex or age predilections.

Repigmentation of poliosis after epithelial grafting for vitiligo.

BACKGROUND: Vitiligo is a disease of color loss from skin and possibly also from hair. The presence of white hair follicles is known to be a bad prognostic sign. OBJECTIVES: To evaluate the possibility of repigmentation of white hair follicles after epithelial grafting. METHODS: Patients with recalcitrant vitiligo with loss of hair pigment were treated using Chinese cupping blisters or ultrathin Thiersch grafting after de-epithelialization of vitiliginous patches by dermabrasion. Phototherapy was used afterward to enhance success. RESULTS: Repigmentation of the skin surface was obtained with as little as 1 to 2 months of phototherapy, as expected, and further follow-up of cases revealed the re-coloring of hair follicles after 4 to 11 months. CONCLUSION: Re-coloring of poliosis with vitiligo is possible but was unexpected because of the difference in mechanism and signaling required between hair bulb melanization and the surface skin. One likely mechanism to explain this change is that melanocyte stem cells are stimulated and migrate to supply hair bulbs with new mature melanocytes. Epithelial grafting of vitiligo with poliosis in hairy areas should be a treatment of choice when white hair tufts cause cosmetic disfigurement.

Loose anagen hair syndrome in children of Upper Egypt.

BACKGROUND: Loose anagen hair (LAH) syndrome is a phenomenon in early childhood characterized by the presence of easily pluckable hair, where hair tufts can be pulled out easily and painlessly. AIMS: All reports in the English literature described mainly white patients with blond hair. We present the first report of LAH syndrome in dark-skinned children of Upper Egypt. PATIENTS AND METHODS: Twenty-eight children with LAH were diagnosed and examined from 1996 to 2007. The main complaints were patchy or diffuse alopecia and/or slow growth of hair. Clinical examination, hair pull test, trichogram, and scanning electron microscopy (SEM) were performed. RESULTS: Children with LAH included 21 girls (75%) and seven boys (25%). Light microscopy of hair pull tests and trichograms disclosed a striking predominance of anagen hairs (90-100%) with misshapen hair bulbs and absent inner and outer root sheaths. SEM confirmed the misshapen anagen bulbs with ruffled appearance of cuticle and the longitudinal groove parallel to the long axis of the hair shaft. Most children improved spontaneously within few years, however, hair shed continued. CONCLUSION: LAH syndrome occurs in dark-skinned children and could be under-diagnosed. The condition is of cosmetic concern and does not affect the general health.

Epithelial grafting for vitiligo requires ultraviolet A phototherapy to increase success rate.

BACKGROUND: Phototherapeutic techniques were introduced into medical practice by the ancient Egyptians. It is considered a cornerstone in the management of resistant vitiligo; yet, failures are very well known. Recently, the introduction of surgical techniques provided a major development in the management of vitiligo and replaced other conventional unsuccessful therapies. OBJECTIVES: The aim of this work is to find out if phototherapy, which failed to resolve the vitiligo problem in patients, is still required in the treatment strategy after epithelial grafting of the same cases. METHODS: Twenty-five vitiligo patients, nonresponding to classic phototherapy, were treated surgically. Ultrathin Thiersch grafts and suction blister grafts were used. Phototherapy using ultraviolet A (UVA) bulbs in combination with psoralen or khellin was used postoperatively immediately after take of grafts onto recipient sites. RESULTS: In spite of reactivation of depigmentary effects at grafted areas, phototherapy acted as a stimulator for melanocytic proliferation and function and as an immunosuppressant, halting the melanocytic destructive process. The application of UVA phototherapy resulted in successful treatment in the patients receiving it. CONCLUSION: The success of epithelial grafting in patients with vitiligo can be increased by UVA phototherapy.