Sweet's syndrome: diagnostic criteria revisited.

The diagnosis of Sweet's syndrome (SS) is based on a set of criteria that requires the presence of two major and at least two minor criteria. In some cases, however, the diagnosis is not as straightforward due to the absence of certain criteria. The objective of the present study was to review the clinical, histopathological, and laboratory features of the current diagnostic criteria for SS, and to evaluate their validity in the cases reported in the literature as well as in 40 patients treated at our institution. Our comprehensive review of the current criteria for SS reveals that the two major criteria have been consistently present in all cases - including ours - since the first description of SS in 1964. With regard to the minor criteria, on the other hand, there has been marked variability between different studies, and many cases failed to fulfill the requirement of showing two minor criteria. In order to simplify the diagnosis, avoid misdiagnosis, and allow for prompt treatment, we propose two sets of revised diagnostic criteria for SS. The first set comprises constant clinical and histopathological features that must be present and are by themselves sufficient for the diagnosis of SS to be established. The second set includes variable features whose absence does not warrant ruling out SS.

Treatment of recalcitrant warts with Bacillus Calmette-Guérin: a promising new approach.

Recalcitrant warts represent a therapeutic challenge for both patients and physicians. Recently, intralesional immunotherapy by different antigens has been proved effective in the treatment of different types of warts. We describe a case of a 48-year-old male who presented with troublesome huge common wart on the left little toe of 5 years duration and not responding to many lines of therapy. Nearby and distant common and plantar warts have also been observed. Intralesional Bacillus Calmette-Guérin (BCG) vaccine was injected into the huge wart of the little toe at 2-week intervals for five sessions. Follow-up was made every month for 6 months. A gradual decrease in the size of the injected wart was observed until reaching complete clearance by the end of the fifth session. Untreated nearby common and distant warts disappeared completely by the end of the third session. BCG injection was associated with erythema and edema with or without pustules, at the site of injection. A flu-like illness that rapidly subsided within 3 days was also observed with each injection. No recurrence was observed after the 6-month follow-up period. Intralesional immunotherapy with BCG vaccine seems to be a promising effective and safe treatment modality for recalcitrant warts.

Possible clinical efficacy and tolerability of platelet-rich plasma with atopic dermatitis.

BACKGROUND: Narrowband-ultraviolet B (NB-UVB) is a promising, effective, and safe therapeutic option for atopic dermatitis (AD), but the treating courses frequently need an extended period since they might have a possible hazard for several side effects and cases of non-compliance. OBJECTIVE: To discover the influence of platelet-rich plasma (PRP) injecting on the outcomes of short-term NB-UVB treatment for AD cases. PATIENTS AND METHODS: The present study includes 44 atopic dermatitis cases with general symmetric lesions. For every case, the left side of the body was treated with NB-UVB (control side) whereas the right side was treated with NB-UVB plus PRP intradermal injection, at 3-week interval for 3-months. RESULTS: A statistically high significant reduction was found in the EASI score, IGA score in the combined side (PRP plus NB-UVB) in comparison with NB-UVB side. CONCLUSION: Intradermal PRP injecting in addition to NB-UVB can be considered as a simple, acceptable, and economical method for treating atopic dermatitis. It decreases the NB-UVB therapeutic period and is predictable to raise case compliance. Assessments through follow-up were proposed and undertaken to rate the efficacy of treatment.

Lichen myxedematosus: diagnostic criteria, classification, and severity grading.

BACKGROUND: Lichen myxedematosus (LM) is a rare, chronic idiopathic disorder characterized clinically by waxy, closely set papules and histopathologically by diffuse dermal mucin deposition and fibroblast proliferation. The most recent classification of LM was proposed in 2001; however, it seems to be complex, confusing, and imprecise. Herein, we present seven cases of LM to evaluate the validity of the current classification, to propose new diagnostic criteria and classification, and to suggest a clinically relevant severity grading system for this rare disorder. MATERIALS AND METHODS: The study included seven patients with different presentations and severities of LM. All patients were subjected to thorough dermatological and systemic examination, routine laboratory tests, evaluation of thyroid function, protein electrophoresis, and detailed investigations to detect systemic involvement. RESULTS: The current classification does not meet the requirements of proper diagnosis of different presentations of LM. Subtyping of the studied patients differs greatly according to the old classification and the newly proposed one. New diagnostic criteria, classification, and grading are consequently suggested. CONCLUSIONS: We propose two sets of diagnostic criteria to define the disease more precisely and to avoid confusion associated with the other classification. The first set comprises constant clinical and histopathological features that are always present in every case, and the second set includes associated features that were variably reported in some patients. LM is then subclassified according to the presence or absence of systemic manifestations into a systemic severe form (scleromyxedema) and a non-disabling, pure cutaneous form.

Febrile ulceronecrotic Mucha-Habermann disease: proposed diagnostic criteria and therapeutic evaluation.

Febrile ulceronecrotic Mucha-Habermann disease (FUMHD) is a rare severe variant of pityriasis lichenoides et varioliformis acuta characterized clinically by aggressive ulceronecrotic skin lesions associated with high fever and histologically by features typical of pityriasis lichenoides et varioliformis acuta. Despite the continuous addition of new case reports, no definite diagnostic criteria have been established, and an optimum treatment is still waiting. Herein, we review the different aspects of this rare entity, including pathogenesis, clinical and histopathological features, differential diagnosis, course, prognosis, and outcome. Different diagnostic and therapeutic challenges associated with FUMHD are also evaluated and discussed. We propose two sets of diagnostic criteria to define the disease more precisely and to avoid missing cases. The first comprises constant clinical and histopathological features that are always present in every case, the combination of which is necessary for diagnosis. The second set includes variable features that may be present in some cases and to which any emerging finding could be added. Although different therapeutic options have been used, there is no optimum therapy for FUMHD, and the disease still represents a therapeutic challenge.

Treatment of recalcitrant warts with intralesional measles, mumps, and rubella vaccine: a promising approach.

BACKGROUND: Recalcitrant warts represent a frustrating challenge for both patients and physicians. Although many destructive and immunotherapeutic modalities are available for the treatment of warts, an ideal, universally effective approach has not been explored to date. Recently, intralesional antigen immunotherapy has shown promising efficacy in the treatment of warts. The aim of the study was to evaluate the efficacy and safety of intralesional measles, mumps, and rubella (MMR) vaccine in the treatment of recalcitrant warts. METHODS: The study included 70 adult patients with multiple recalcitrant extragenital warts of different sizes and durations, with or without distant warts. They were directly injected, without a pre-sensitization skin test, with 0.3 intralesional MMR vaccine into the largest wart at 2-week intervals until complete clearance or for a maximum of five treatments. Follow-up was made every month for six months to detect any recurrence. RESULTS: Sixty-five patients, 35 men and 30 women, completed the study, and five patients discontinued for various reasons. Complete clearance of the lesions was observed in 41 patients (63%), partial response in 15 patients (23%), and no response in nine patients (14%). Complete response was demonstrated in 74.5% of those presenting with distant warts. Side effects were mild and insignificant in the form of pain during injection, itching, erythema, and edema at the site of injection and flu-like symptoms. Recurrence was detected in two patients only. CONCLUSIONS: Intralesional immunotherapy by MMR vaccine is a promising, effective, and safe treatment modality for recalcitrant warts.

Generalized eruptive keratoacanthoma: a diagnostic and therapeutic challenge.

BACKGROUND: Generalized eruptive keratoacanthoma (GEKA) is an extremely rare variant of keratoacanthoma that poses significant diagnostic and therapeutic challenges. PATIENTS: The study included three patients presenting with highly pruritic, generalized eruption of numerous small skin and flesh-colored follicular papules. They were mainly distributed on the face, neck, and trunk. Few larger nodules were also present. Mask-like facies, mucosal involvement, and ectropion were evident in two patients. Family history was irrelevant, and general examination was unremarkable. RESULTS: Histopathological examination revealed typical features of keratoacanthoma, particularly in the larger lesions. Routine laboratory tests were normal, and ultrasonography and computed tomography revealed no evidence of malignancy. Based on the clinicopathological correlation, the diagnosis of our cases was GEKA of Grzybowski. Acitretin 1 mg/kg per day and methotrexate 15 mg/week for three months were associated with mild or no response. Cyclophosphamide pulse therapy 1 g/month for six months was associated with complete clearance of the lesions in the first two patients, while the third was lost to follow-up after failure of acitretin therapy. CONCLUSION: Because of the extreme rarity of reported cases, the common absence of classic large lesions of keratoacanthoma, the atypical histological presentations in some cases, and absence of a uniformly effective therapeutic approach, we believe that GEKA still represents a diagnostic and therapeutic challenge. Cyclophosphamide pulse therapy is a promising alternative to oral retinoids.

Intralesional antigen immunotherapy for the treatment of warts: current concepts and future prospects.

Many destructive and immunotherapeutic modalities have been used for the management of warts; however, an optimal treatment with high efficacy and absent or low recurrence has not been explored to date. Recently, the use of intralesional immunotherapy with different antigens has shown promising efficacy in the treatment of warts. We review the different aspects of this new modality, including candidates, types of warts treated, dosage, number and interval between treatment sessions, mode of action, efficacy, adverse effects, recurrence rate, advantages, disadvantages, current place and future prospects. A literature review revealed that healthy immune subjects are the best candidates, and a pre-sensitization test is usually done before the start of therapy. The dosage, the number and interval between sessions, and the success rates varied among the different studies. The mode of action is still uncertain, but is essentially mediated through stimulation of T helper-1 cell cytokine response. Adverse effects are mild and generally insignificant, and the recurrence rate is absent or low. Intralesional antigen immunotherapy seems to be a promising, effective and safe treatment modality for viral warts. Future well-designed and controlled studies would help to more clearly define its place in the challenging field of wart therapy.