Evaluation of systemic oxidative stress in patients with melasma.

BACKGROUND: The significance of oxidative stress has been assessed and proven in the etiopathogenesis of many cutaneous disorders, but there are few studies that evaluated the role of only some factors involved in oxidative stress in patients with melasma. OBJECTIVE: This study aimed to examine the role of oxidative stress in melasma and assess the relationship between systemic oxidative stress and the severity and extension of this disease. METHODS: In this study, the serum levels of superoxide dismutase (SOD), glutathione peroxidase (GPX), catalase (CAT), malondialdehyde (MDA), protein carbonyl (PC), selenium (Se), vitamin E (vit E), and vitamin C (vit C) of fifty patients with melasma were compared with those of fifty controls. RESULTS: The serum level of MDA was significantly higher in the melasma group (3.08 vs. 2.35 U/mL; p < 0.05), and it was positively correlated with the severity (r = 0.4; p < 0.001) and extension (r = 0.3; p < 0.05) of the disease. Furthermore, the serum level of vit C was significantly lower in melasma patients (2.16 vs. 2.57 µg/mL; p < 0.001). CONCLUSION: Systemic oxidative stress has a key role in the etiopathogenesis of melasma. Serum concentrations of MDA and vitamin C are indicators of this impairment.

Bilirubin as a new antioxidant in melasma.

BACKGROUND: Oxidative stress and its role in the pathogenesis of cutaneous diseases have been widely investigated. However, there are few studies that have solely assessed the contribution of intracellular antioxidants in the etiopathology of melasma. Furthermore, there are convincing reports about antioxidant properties of bilirubin (Bil) and uric acid (UA) in some skin disorders but not melasma. OBJECTIVE: This study aimed to determine serum levels of two major extracellular antioxidants (Bil and UA) levels in patients with melasma and their correlation with the severity and extent of the disease. METHODS: In this case-control study, the serum levels of bilirubin and uric acid of 50 melasma patients were compared with 50 healthy controls. Moreover, the correlation of serum concentrations of these antioxidants with the extent and severity of the disease were assessed. RESULTS: The serum concentration of Bil was significantly higher in the case group (p < 0.05). Furthermore, serum Bil level had a positive correlation with the extent of the melasma (correlation coefficient, +0.3; p < 0.05). No significant difference was found between the serum concentrations of UA between the study and control group. Neither Bil nor UA had a significant correlation with the severity of the disease. CONCLUSION: Oxidative stress may play a major role in the etiopathology of melasma and bilirubin, as an antioxidant, could be involved in the process of oxidative stress.

Acral fibromyxoma: a rare plantar nodule.

Acral fibromyxomas are benign tumours ranging in size between 0.6 and 5 cm, commonly found around the nailbed. The often asymptomatic presentation of acral fibromyxomas means that there is often a delay in their diagnosis and subsequent treatment. The objective of this paper is to present the unique case of a fibromyxoma present in the acral region, as well as a review of the literature.

Painful ulcerations: the sole clinical sign of mixed cryoglobulinaemia secondary to marginal zone lymphoma.

A man in his 70s with background vascular disease presented with 7 months of painful non-resolving lower leg ulcers with eschar and petechiae, left lower ear lobe ulceration and dusky inflammation of the right ear. He demonstrated good bilateral pedal pulses and no peripheral oedema. No lymphadenopathy was palpated.Biopsy suggested leucocytoclastic vasculitis on chronic stasis changes. Blood investigations showed elevated rheumatoid factor and mixed polyclonal IgG and monoclonal IgM cryoglobulins. He was diagnosed with mixed cryoglobulinaemia, and consequent conducted flow cytometry revealed CD5 +marginal zone lymphoma with elevated serum free light chains and kappa/lambda ratio.One-month following rituximab and chlorambucil therapy, the patient's pain had much improved, ear ulcers had healed and several leg ulcers had reduced in width and depth. The petechial eruption had also resolved.

Drug induced vitiligo-like depigmentation from a CDK 4/6 inhibitor.

Ribociclib is an inhibitor of cyclin-dependent kinases 4 and 6 (CDK 4/6) that is used in combination with an aromatase inhibitor in the first-line setting for advanced or metastatic hormone receptor positive and human epidermal growth factor receptor 2 (HER2)-negative breast cancer. We report two cases of drug-induced vitiligo-like depigmentation (DI-VLD) associated with ribociclib. The awareness of this side effect is important given the increasing use of this drug and others with a similar mechanism of action.

Public Stroke Knowledge, Awareness, and Response to Acute Stroke in Isfahan Iran: What is Less or Misinterpreted in Developing Countries.

BACKGROUND: Considering the high burden of stroke in developing countries, it is important for the community to have adequate information and awareness of this disease. In this study, the baseline knowledge of an Iranian population towards stroke has been evaluated. METHOD: This study was conducted in a governmental hospital in Isfahan, Iran. The participants were selected from the companions of non-cardio-vascular hospitalized patients. A self-administered questionnaire was designed for gathering information RESULTS: A total of 630 questionnaires were analysed. Hypertension and stress were the most frequently identified risk factors (recognised by 83.7% and 75.8% respectively), while pregnancy, oral contraceptives, and anti-coagulants were the least (recognised by 3.5%, 14.2% and 15.8% respectively). Knowledge of other important risk factors such as cardiac diseases was also relatively low (39.4%). Sudden visual difficulties and irrelevant speech were the least identified warning signs of stroke (45.3% and 34.6% respectively), however, knowledge towards all other warning signs was moderately good (each identified by 60-70%). Importantly only 44.2% of respondents were aware that stroke treatment should be started within the first 3 hours. Participants tended to have moderately good insight of most stroke complications and rehabilitation (60-70%). Urban residence, high level of education and knowing someone with a history of stroke were significant predictors of a higher level of stroke awareness. CONCLUSION: The findings of this study indicate that there is a need to improve general knowledge of cardiac and hypercoagulable related risk factors. Furthermore, understanding of the importance of time critical stroke management and the ineffectiveness of traditional medicine needs to be raised in the general community.

Realistic hair simulator for skin lesion images: A novel benchemarking tool.

Automated skin lesion analysis is one of the trending fields that has gained attention among the dermatologists and health care practitioners. Skin lesion restoration is an essential pre-processing step for lesion enhancements for accurate automated analysis and diagnosis by both dermatologists and computer-aided diagnosis tools. Hair occlusion is one of the most popular artifacts in dermatoscopic images. It can negatively impact the skin lesions diagnosis by both dermatologists and automated computer diagnostic tools. Digital hair removal is a non-invasive method for image enhancement for decrease the hair-occlusion artifact in previously captured images. Several hair removal methods were proposed for skin delineation and removal without standardized benchmarking techniques. Manual annotation is one of the main challenges that hinder the validation of these proposed methods on a large number of images or against benchmarking datasets for comparison purposes. In the presented work, we propose a photo-realistic hair simulator based on context-aware image synthesis using image-to-image translation techniques via conditional adversarial generative networks for generation of different hair occlusions in skin images, along with ground-truth mask for hair location. Hair-occluded image is synthesized using the latent structure of any input hair-free image by deep encoding the input image into a latent vector of features. The locations of required hair are highlighted using white pixels on the input image. Then, these deep encoded features are used to reconstruct the synthetic highly realistic hair-occluded image. Besides, we explored using three loss functions including L1-norm, L2-norm and structural similarity index (SSIM) to maximize the image synthesis visual quality. For the evaluation of the generated samples, the t-SNE feature mapping and Bland-Altman test are used as visualization tools for the experimental results. The results show the superior performance of our proposed method compared to previous methods for hair synthesis with plausible colours and preserving the integrity of the lesion texture. The proposed method can be used to generate benchmarking datasets for comparing the performance of digital hair removal methods. The code is available online at: https://github.com/attiamohammed/realhair.

Artificial Intelligence in Dermatology-Where We Are and the Way to the Future: A Review.

Although artificial intelligence has been available for some time, it has garnered significant interest recently and has been popularized by major companies with its applications in image identification, speech recognition and problem solving. Artificial intelligence is now being increasingly studied for its potential uses in medicine. A sound understanding of the concepts of this emerging field is essential for the dermatologist as dermatology has abundant medical data and images that can be used to train artificial intelligence for patient care. There are already a number of artificial intelligence studies focusing on skin disorders such as skin cancer, psoriasis, atopic dermatitis and onychomycosis. This article aims to present a basic introduction to the concepts of artificial intelligence as well as present an overview of the current research into artificial intelligence in dermatology, examining both its current applications and its future potential.

Mammalian target of rapamycin (mTOR) inhibitors and skin cancer risk in nonrenal solid organ transplant recipients: systematic review and meta-analysis.

BACKGROUND: Solid organ transplant recipients have an increased risk of malignancy compared with the general population. Mammalian target of rapamycin (mTOR) inhibitors have been used as immunosuppressants in transplant recipients. There remains a lack of evidence of this treatment in nonrenal solid organ transplantation. We aimed to perform a systematic review and meta-analysis to assess the effects of mTOR inhibitors on secondary nonmelanoma skin cancer (NMSC) malignancies in nonrenal transplant recipients. METHODS: A systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies for the present systematic review and meta-analysis included those in which patient cohorts underwent heart, liver, lung, and pancreas (i.e. nonrenal solid organ) transplantation, with treatment group being those treated with an mTOR inhibitor such as sirolimus or everolimus, and control group being placebo, or alternative non-mTOR inhibitor treatment such as calcineurin inhibitors or as per standard treatment protocol. RESULTS: From the six included studies, we found no significant difference in the odds of either primary or secondary NMSC (OR 0.73, 95% CI 0.41-1.29, P = 0.28). Pooled analysis of patients with secondary NMSC demonstrated a trend toward significant benefit with mTOR inhibitor treatment (OR 0.61, 95% CI 0.37-1.02, P = 0.06) but no protective effect for primary NMSC (OR 0.53, 95% CI 0.03-9.96, P = 0.67). CONCLUSIONS: Our results suggest that in nonrenal transplant recipients, mTOR inhibitors may have a protective effect against secondary NMSC but not primary NMSC posttransplantation. Extrapolating the findings of reduced NMSC in renal transplant populations to nonrenal transplant cases should be cautioned.

Recurrence rates following surgical excision of periocular basal cell carcinomas: systematic review and meta-analysis.

Background: Basal cell carcinomas (BCCs) remain one of the most common non-melanoma skin cancers (NMSCs). Surgical options include primary excision with predetermined margins, frozen section controlled excision, and Mohs micrographic surgery (MMS). There is no randomized study comparing recurrence rates between different surgical techniques for periocular BCCs.Methods: A meta-analysis of proportions was conducted for recurrence rates. Meta-regression was used for subgroup analysis to compare results in those undergoing MMS versus FSE or paraffin controlled sections (WLE).Results: The pooled recurrence rate for periocular BCCs excised via MMS was 2.9% (95% CI 1.9-4.4%) over an average of 48.8 ± 14.9 months. The pooled recurrence rate for FSE was 1.9% (95% CI 1.9-2.4%) over an average of 70.7 ± 48.0 months. By comparison, the pooled recurrence rate following WLE was 5.9% (95% CI 3.9-8.9%) over an average of 49.2 ± 29.3 months. Meta-regression demonstrated that the recurrence rate for WLE was significantly higher compared to MMS and FSE techniques (p<.001) but similar for MMS and FSE (p=.65).Conclusions: Our results highlight the importance of intraoperative margin assessment in the management of BCCs in order to reduce recurrence. These factors should be taken into consideration in the workup and management of patients with periocular BCCs.

Digital hair segmentation using hybrid convolutional and recurrent neural networks architecture.

BACKGROUND AND OBJECTIVE: Skin melanoma is one of the major health problems in many countries. Dermatologists usually diagnose melanoma by visual inspection of moles. Digital hair removal can provide a non-invasive way to remove hair and hair-like regions as a pre-processing step for skin lesion images. Hair removal has two main steps: hair segmentation and hair gaps inpainting. However, hair segmentation is a challenging task which requires manual tuning of thresholding parameters. Hard-coded threshold leads to over-segmentation (false positives) which in return changes the textural integrity of lesions and or under-segmentation (false negatives) which leaves hair traces and artefacts which affect subsequent diagnosis. Additionally, dermal hair exhibits different characteristics: thin; overlapping; faded; occluded and overlaid on textured lesions. METHODS: In this presented paper, we proposed a deep learning approach based on a hybrid network of convolutional and recurrent layers for hair segmentation using weakly labelled data. We utilised the deep encoded features for accurate detection and delineation of hair in skin images. The encoded features are then fed into recurrent neural network layers to encode the spatial dependencies between disjointed patches. Experiments are conducted on a publicly available dataset, called "Towards Melanoma Detection: Challenge". We chose two metrics to evaluate the produced segmentation masks. The first metric is the Jaccard Index which penalises false positives and false negatives. The second metric is the tumour disturb pattern which assesses the overall effect over the lesion texture due to unnecessary inpainting as a result of over segmentation. The qualitative and quantitative evaluations are employed to compare the proposed technique with state-of-the-art methods. RESULTS: The proposed approach showed superior segmentation accuracy as demonstrated by a Jaccard Index of 77.8% in comparison to a 66.5% reported by the state-of-the-art method. We also achieved tumour disturb pattern as low as 14% compared to 23% for the state-of-the-art method. CONCLUSION: The hybrid architecture for segmentation was able to accurately delineate and segment the hair from the background including lesions and the skin using weakly labelled ground truth for training.

Isotretinoin and night blindness.

Isotretinoin is an effective and increasingly popular treatment for acne vulgaris. There have been reports of night blindness as a side-effect of treatment although the evidence does not demonstrate a clear causal relationship between isotretinoin therapy and the risk of night blindness. Nevertheless, considering the lack of evidence in this area, it is important to educate patients about this potential consequence, which may become longstanding and even irreversible, and encourage them to promptly report changes in their night vision.

Miniaturized Hairs Maintain Contact with the Arrector Pili Muscle in Alopecia Areata but not in Androgenetic Alopecia: A Model for Reversible Miniaturization and Potential for Hair Regrowth.

BACKGROUND: Hair follicle miniaturization is the hallmark of male pattern hair loss (MPHL), female pattern hair loss (FPHL), and alopecia areata (AA). AA has the potential for complete hair regrowth and reversal of miniaturization. MPHL and FPHL are either irreversible or show only partial regrowth and minimal reversal of miniaturization. HYPOTHESIS: The arrector pili muscle (APM) attachment to the hair follicle bulge, a recognized repository of stem cells may be necessary for reversal of hair follicle miniaturization. MATERIALS AND METHODS: Sequential histological sections from MPHL, FPHL, AA, and telogen effluvium were used to create three-dimensional images to compare the relationship between the APM and bulge. RESULTS: In AA, contact was maintained between the APM and the bulge of miniaturized follicles while in MPHL and FPHL contact was lost. DISCUSSION: Contact between the APM and the bulge in AA may be required for reversal of hair follicle miniaturization. Maintenance of contact between miniaturized follicles in AA could explain the complete hair regrowth while loss of contact between the APM and the bulge in MPHL and FPHL may explain why the hair loss is largely irreversible. This loss of contact may reflect changes in stem cell biology that also underlie irreversible miniaturization.