Retrospective analysis of methylprednisolone treatment alone and in combination with methotrexate in patients with extensive alopecia areata.

Alopecia areata (AA) is a chronic autoimmune disorder that primarily affects the hair follicle. Systemic corticosteroids and methotrexate (MTX) are among the therapeutic options in severe cases. This study aimed to show whether the combination therapy of methylprednisolone (MP) and MTX was superior to MP alone in the management of extensive AA. A total of 26 patients with extensive AA, 14 treated with MP alone and 12 treated with the combination of MP and MTX, were retrospectively evaluated in terms of gender, age, severity of disease, clinical characteristics, disease duration, dose and duration of medications, therapy response, and side effects. Of the 26 patients with extensive AA, 14 were male and 12 were female, and the average age was 17.02 ± 10.70 years. All patients had more than 50% hair loss, 23 had extensive multifocal AA, and three had alopecia totalis. A total of 14 patients were treated with MP alone (starting dose: 0.3-0.5 mg/kg, maximum 32 mg/day), and 12 were treated with MP + MTX (starting dose: 5-15 mg/week, maximum 20 mg/week). A total of 12 of the 14 patients (85.7%) who were treated with MP alone showed a complete response, with the response rate of the patients who showed more than 50% response being 92.85%. Seven of the 12 patients (58.3%) who were treated with MP + MTX achieved complete healing, and all patients on this regimen had more than 50% treatment response. Our results showed that the combination therapy of MP and MTX was not superior to MP alone in the management of extensive alopecia areata.

Sun-protective behaviours of Turkish young adults.

BACKGROUND: The prevalence of skin cancers, including melanoma, has increased significantly in the past five decades. The main environmental factor implicated in their development is excessive sun exposure. Data on sun-protective behaviours in the Turkish population are very limited. OBJECTIVES: We aim to assess sun protection behaviours and the prevalence of exposure through broad participation among a young adult population in a national university in Turkey. METHODS: A multiple-choice questionnaire including 27 questions to evaluate sun protection behaviours was sent to e-mail addresses of all undergraduates. From 40 000 undergraduates, 17 769 of them were included in the study, with a response rate of 44.4%. RESULTS: Sunscreen usage was the most preferred sun protection method, used by 64% of the study population, followed by the use of sunglasses (60%), tending to remain in the shade (49%), the use of a hat (34%) and wearing long-sleeved clothing (23%). Forty-four percentage of the students used at least two methods, whereas 7% did not use any sun protection method. The prevalence rates of the use of sunscreen, sunglasses, wearing long-sleeved clothing and preferring to remain in the shade in the summer were all significantly higher among women. In addition, the prevalence rates of the use of sunscreen and preferring to remain in the shade were higher among students in the faculty of medicine. CONCLUSION: We found that when compared to the countries with the highest incidences of skin cancer, such as Australia and the United States, young adults in Turkey are protecting themselves more from the sun. This rate was even higher among women and faculty of medicine undergrads.

The prevalence of sacroiliitis in patients with acne vulgaris using isotretinoin.

BACKGROUND/OBJECTIVE: Acne vulgaris is a chronic inflammatory disease affecting the pilosebaceous unit in the skin. Isotretinoin is a synthetic vitamin A derivative regarded as the most effective agent in the treatment of acne. There have recently been increasing reports of adverse effects of isotretinoin on the skeletal system. Our aim in this study was to evaluate the rheumatic side-effects triggered by this drug, and particularly the prevalence of sacroiliitis. MATERIALS AND METHODS: A total of 73 patients receiving isotretinoin due to moderate or severe acne vulgaris were included. All patients were questioned about inflammatory low back pain and musculoskeletal pains during the treatment process. Inflammatory low back pain was evaluated using Assessment of Spondyloarthritis International Society (ASAS) criteria. Patients meeting ASAS criteria were evaluated with radiography and when necessary with sacroiliac magnetic resonance. RESULTS: The dose range for isotretinoin was between 0.4 and 0.8 mg/kg/day (mean 0.53 mg/kg/day). Treatment lasted for 6-8 months (mean 6.8 months). Lethargy was determined in 37 (50.7%) patients, myalgia in 31 (42.5%) and low back pain in 36 (49.3%). Mechanical low back pain symptoms were present in 20 of the patients describing low back pain and inflammatory low back pain in 16. Acute sacroiliitis was determined in six patients (8.2%) following a sacroiliac magnetic resonance imaging (MRI). Five (83.3%) of the patients with sacroiliitis were female and one (16.7%) was male. No statistically significant difference was determined between male and female patients in terms of prevalence of sacroiliitis (p = 0.392). CONCLUSION: The incidence of sacroiliitis in patients using isotretinoin is quite high. Patients using isotretinoin must be questioned about sacroiliitis findings and must be subjected to advanced assessment when necessary. Further studies regarding the development of sacroiliitis under isotretinoin therapy are now needed.

Assessment of demodex presence in acne-like rash associated with cetuximab.

CONTEXT: Cetuximab is an epidermal growth factor receptor inhibitor. It is frequently used in the treatment of solid tumors. However, it has a high potential to cause acne-like rash. Demodex mites, which are known to increase in number in immunosuppressive circumstances, are closely related to the acneiform lesions. OBJECTIVE: The aim of this study is to evaluate the presence of demodex mites in acne-like rash that appears under the treatment of Cetuximab. METHODS: We reviewed the medical records of patients who applied to our clinic with cetuximab induced papulopustular rashes between November 2014 and March 2016. Demodex sampling was performed by standardized skin surface biopsy (SSSB) in a total of 11 patients (eight males and three females). Infestation was defined as at least 5 living parasites/cm2 of skin. RESULTS: Upon the SSSB examination in 10 out of the 11 patients, no demodex mites were detected. Demodex mites were found in only one of the patients. This patient, in whom two dead Demodex folliculorums were found through facial sampling, was also regarded as negative since his demodex density was under the threshold limit value. CONCLUSION: In this study, it has been concluded that acne-like rash that develops under the treatment of cetuximab is not related to the presence of demodex mites. Papulopustular eruptions that develop under cetuximab treatment should not be directly correlated with the presence of demodex; first SSSB and demodex presence should be evaluated.

Spitz nevus arising upon a congenital glomuvenous malformation.

There are several reports of the collision of vascular and pigmentary anomalies (e.g., phakomatosis pigmentovascularis) and the association between congenital melanocytic nevi and infantile hemangiomas. We report a case of Spitz nevus arising in skin overlying a congenital plaque-like glomuvenous malformation (GVM). This is the first report of a Spitz nevus arising in direct contiguity to a GVM.

Environmental risk factors in pediatric psoriasis: a multicenter case-control study.

To analyze the effect of possible risk factors, including breastfeeding, on the development of childhood-onset psoriasis, a multicenter case-control study with prospective collection of data was performed. Using a standard questionnaire, personal and specific variables including family history of psoriasis, maternal and environmental tobacco smoke exposure, body mass index (BMI), exclusive and partial breastfeeding for at least 3 and 12 months, cow's milk intake before 1 year, birth delivery method, and stressful life events were collected during 2009 from 537 patients with psoriasis and 511 controls younger than 18. Overall, patients more frequently reported exposure to environmental tobacco smoke at home and stressful life events in the year preceding the diagnosis than controls. The odds ratios (OR) for smoking and stressful life events were 2.90 (95% confidence interval [CI]=2.27-3.78) and 2.94 (95% CI=2.28-3.79), respectively. In addition, children with psoriasis were more likely to have a higher BMI (>26) than controls (OR=2.52; 95% CI=1.42-4.49). High BMI, environmental tobacco smoke exposure at home, and stressful life events may influence the development of pediatric psoriasis.

Evaluation of factors that may affect disease development and severity in childhood atopic dermatitis.

BACKGROUND: Atopic dermatitis is a chronic, relapsing, inflammatory disease. Data concerning the role of perinatal conditions in the development of the disease are few and inconsistent. The purpose of this study was to investigate the effects of skin care on the severity of the disease, also to evaluate the relations of perinatal conditions with disease development and severity. METHODS: Seventy-five patients with atopic dermatitis aged 2-10 years, their parents and 65 healthy age-compatible volunteers and their parents were included in the study. The Scoring Atopic Dermatitis (SCORAD) score was used to assess the severity of the disease. RESULTS: Emollient use (regular/irregular) was higher in patients with severe disease compared to those with mild and moderate disease, but no significant difference was determined in regular use rates (P=0.029, and P=0.504, respectively). Topical corticosteroid use and sleep disturbance rates in the previous three months in the subjects regularly using emollients were low (P=0.032, and P=0.005, respectively). The incidence of severe disease was higher in the patients born in the winter (P=0.033). Severe disease rates were significantly high in the subjects in the patient group with advanced maternal age, a history of cesarean delivery and incubator use (P=0.017, P=0.046, and P=0.025, respectively). CONCLUSIONS: Low topical corticosteroid requirement and sleep disturbance rates in the subjects regularly using moisturizers emphasize the importance of emollient use in treatment. The association of cesarean delivery, history of incubator, and birth in winter with severe disease suggests that disease severity is related to less exposure to environmental allergens in the hygiene hypothesis.

Prevalence and Dermoscopic Patterns of Acral Melanocytic Nevi in Turkey.

Although nevi are frequently encountered in the acral region, very limited studies have reported their prevalence in specific populations. We aimed to determine the prevalence of acral nevi, their dermoscopic patterns, and evaluate patient awareness in a Turkish population. We prospectively examined 2644 patients admitted to the outpatient dermatology clinics between October 2016 and October 2017. The characteristics of the detected acral nevi and dermatoscopic images were recorded. A questionnaire of demographic characteristics was completed from all patients. Two hundred six of the 2644 patients had at least one acral nevus. Two hundred sixty nevi were examined. The general prevalence of acral nevi was 7.8%. Women were more likely to have acral nevi than men (8.7% vs. 6.3%; P=0.028). Moreover, darker-skinned patients were also had significantly more acral nevi (8.6% in skin type III-IV vs. 6.0% in skin type I-II; P<0.001). The prevalence of acral nevi was 9.4% before the age of 20, 9.5% in patients aged 20-40 years, and 4.6% after the age of 40. In addition, 51.5% of all nevi exhibited a parallel furrow, 13.5% were lattice-like, and 7.7% had a homogeneous pattern. The overall nevus awareness rate was 73.8% and was significantly higher in women at 78.3%. Our study is the first large-scale study of that showed the prevalence of acral nevi in Turkey. According to our study, the prevalence of acral nevi was higher in patients with female sex and darker skin type. We also found that the prevalence of acral nevi decreased over 40 years of age. The general awareness of nevi was higher in women.

Coexistence of basal cell carcinomas and multiple sebaceous gland hyperplasias in a cyclosporine (ciclosporin)-treated renal transplant recipient.

A 55-year-old man presented with multiple, asymptomatic, yellowish papules on his face with a 4-year history, and two non-healing tumoral lesions on his nose with a 7-month history. He was a renal transplant recipient and had been treated with cyclosporine (ciclosporin) for 9 years. A biopsy from the asymptomatic, yellowish papule on the face showed sebaceous gland hyperplasia, and biopsies from the lesions on the nose revealed basal cell carcinomas. The lesions on the nose were excised. Sebaceous gland hyperplasia and skin cancers are among the cutaneous neoplasms observed in renal transplant recipients receiving cyclosporine. To our knowledge, this is the third reported case of the coexistence of basal cell carcinomas and multiple sebaceous gland hyperplasias in a cyclosporine-treated renal transplant recipient.

Sun-protection habits and knowledge of patients with vitiligo.

INTRODUCTION: Vitiligo is a common chronic depigmentation disease. Patients are generally advised to protect themselves from the sun. METHODS: One hundred fifty-three patients diagnosed with vitiligo and 106 healthy volunteers with no additional dermatological disease were included in the study. We evaluated the sun-protection habits of patients with vitiligo and controls, and also assessed their knowledge and attitudes toward sun exposure. RESULTS: Rates of sunscreen use, high-factor sunscreen use, and remaining in the shade were significantly higher among patients (p = 0.004, p = 0.028, p = 0.040). We found significantly higher rates of modifying vacation habits, high sun-protection factors (SPF) sunscreen use, and preferring to remain in the shade among patients using phototherapy (p = 0.016, p = 0.019, p = 0.028). We showed higher rates of modification of vacation habits, wearing sunglasses, and remaining in the shade among patients with longer disease durations (p = 0.026, p = 0.001, and p = 0.017). CONCLUSIONS: We determined higher rates of sunscreen use, high-SPF sunscreen use, and tendencies to remain in the shade in vitiligo patients compared to the general population. We also determined that disease duration and treatment with phototherapy alters sun-protection habits, but the presence of generalized disease and lesions in visible areas such as the face does not alter patients' habits.

Mycosis Fungoides: A 10-year Turkish Experience.

Mycosis fungoides is the most common primary cutaneous T cell lymphoma, characterized by erythematous patches and plaque lesions with slow progression to cutaneous tumors or extracutaneous involvements in some patients. We aimed to evaluate the clinical characteristics, treatment responses, disease courses, and mortality rates of our MF cases. The data of 100 patients with MF were retrospectively examined from medical records in our clinic between January 2005 and January 2015. Demographic and clinical characteristics of the patients, disease stage, treatment protocols, response to treatment, recurrence, progression, and mortality rates were recorded. The male to female ratio in patients was 1.2. Mean age at onset of disease was 46, and duration of disease ranged from one to 42 years. At time of diagnosis 31 patients were at stage 1A, 31 at stage 1B, 30 at stage 2A, 2 at stage 2B, 1 at stage 3, and 5 at stage 4. Stable disease was observed in 35% of patients, progression in 10%, relapse in 27%, and complete response in 28%. Large cell transformation was found in 3 patients and additional malignity in 11. Thirty-seven patients (37%) were still surviving disease-free. 10 patients had died, three of them due to disease-related conditions. The most common first-line therapy in our study was phototherapy. It was applied to 87% of patients from stage 1A. Our results are generally consistent with current literature, but disease progression and disease-specific mortality rates were significantly lower than the literature, probably due to early phototherapy.

Coexistence of Mayer-Rokitansky-Kuster-Hauser syndrome and neurofibromatosis type I.

Neurofibromatosis type 1 (NF-1) is the most frequently seen form of neurofibromatosis. The characteristic features of this disorder are café au lait macules, neurofibromas, axillary and inguinal freckling, Lisch nodules, bone lesions such as sphenoid dysplasia, and optic glioma. Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a rarely seen disease characterized by complete vaginal agenesis and uterine aplasia/hypoplasia. We report a case of an 18-year-old female patient who presented with complaints of brown marks, freckling, and primary amenorrhea. NF-1 and MRKH syndrome were diagnosed by physical examination and radiologic imaging. To our knowledge, this is the first report of coexistence of these rare genetic diseases in the literature.

Clinical and Demographic Characteristics of Pemphigus Vulgaris Patients.

Pemphigus is an autoimmune disease characterized by intraepithelial bullae and erosions in the skin and mucosa. We aimed to evaluate the clinical and demographic characteristics of pemphigus vulgaris (PV) patients who presented to our Department. Patients who presented to our Department between May 2013 and May 2014, were examined dermatologically and diagnosed with PV based on clinical, histological and direct immunofluorescent findings. Name, family name, and gender of the patients, their complaint at presentation, onset time and location of the lesions, the number of lesions, systemic treatments received by patients and patients' medication histories were recorded. Forty-nine PV patients were included in our study. Among these, 22 (44.9%) were female and 27 (55.1%) male. The mean age of the patients was 53.28±14.70 (range 23 to 79) years. The mean duration of the disease was 44.45±45.68 (range 1 to 180) months. The most common complaints at presentation were lesion in the mouth (47/49) and lesion/blister in the skin (39/49). The onset locations of the lesions were the oropharynx (63.3%), the skin and oropharynx combined (16.3%), the skin (18.4%) and the anus (2%). The chronological order for the sites of involvement were as follows: first the oropharynx then the skin (42.9%), first the skin then the oropharynx (18.4%), and the oropharynx and the skin combined (16.3%). Ten patients (20.4%) had mucosal involvement and one (2%) had skin involvement alone, whereas both mucosal and skin involvements were observed in 38 patients (77.6%). Forty-seven patients (95.9%) had not used any medications that could have led to pemphigus. One patient had a history of beta-blocker use and another had a history of ACE inhibitor prior to the emergence of the pemphigus lesions. The clinical and demographic results of the PV patients in our region were consistent with those from other studies.

HLA-E*0101/0103X is Associated with Susceptibility to Pemphigus Vulgaris: A Case-control Study.

Pemphigus vulgaris (PV) is a life-threatening, autoimmune blistering disease of the skin and mucous membranes. The relationship between PV and human leukocyte antigen (HLA) has been studied in several reports. Previous reports have demonstrated that HLA-E polymorphisms may have a role in the susceptibility to various autoimmune diseases. Our aim was to evaluate the role of HLA-E gene polymorphisms in the pathogenesis of PV in a Turkish population. A total of 49 patients with PV and 50 healthy subjects were enrolled into the study. We sequenced and analyzed the HLA-E gene from genomic DNA obtained from peripheral blood samples of the study groups. HLA-E haplotyping was performed by Sanger sequencing of PCR products of the HLA-E gene and HLA-E alleles determined by using SeqScape® software according to the World Health Organization (WHO) Nomenclature Committee for Factors of the HLA System. The frequency of the HLA-E*0101/*0103X genotype in male patients with PV was found to be significantly higher than in men in the control group (P=0.023). In addition, the frequency of the HLA-E*0103X/*0103X genotype was significantly lower in patients with PV than the control group (P=0.040). We also detected that the frequency of the HLA-E*0101/*0103X genotype in patients with mucocutaneous type PV and the frequency of the HLA-E*0101/*0101 genotype in patients with mucosal type PV was significantly higher than those in other types of PV (P=0.001 and P=0.006). The results of this study indicate that carrying the HLA-E*0101/0103X genotype may increase the risk of PV in male patients.

A case of juvenile hyaline fibromatosis.

Juvenile hyaline fibromatosis (JHF) is a rare, autosomally-recessive disease characterized by papulonodular skin lesions, soft tissue masses, joint contractures, gingival hypertrophy and osteolytic bone lesions. Its onset is in infancy or early childhood. The most commonly affected sites are the nose, chin, ears, scalp, back and knees. The accumulation of an amorphous, hyaline material is typical in the skin and the other organs. Herein, we report a 14-month-old boy who presented with confluent pink papules on the paranasal folds and the chin, and nodular lesions on the periauricular and perianal regions. He had gingival hypertrophy and contractures of the shoulders, knees and elbows. He also had third-degree consanguineous parents. Histopathological studies confirmed the diagnosis of JHF with the presence of increased numbers of fibroblasts embedded in a hyalinized connective tissue stroma.

Lipoid proteinosis: A case with ophthalmological and psychiatric findings.

Lipoid proteinosis (LP) is an uncommon, recessively inherited disorder. The disease usually has its onset in the newborn period and is manifested by hoarseness. The skin and mucous membrane involvement arises between the first and second year of age. A 14-year-old male presented with the complaint of blistering on various sites of his skin, from the age of 12 months, resulting in scarring. Ophthalmological and psychiatric findings also appeared during the clinical course. The histological findings of skin biopsy included extensive deposits of amorphous eosinophilic material in the papillary dermis. No known therapy exists for LP.

Vitamin D status and the effects of oral vitamin D treatment in children with vitiligo: A prospective study.

BACKGROUND & AIMS: Vitiligo is a pigmentary disorder and autoimmune pathogenesis seems most likely. Decreased vitamin D levels have been related to several autoimmune diseases. Little is known about the association of vitiligo and vitamin D. We aimed to evaluate serum 25-hydroxyvitamin D [25(OH)D] levels in children with vitiligo and to determine the efficacy of oral vitamin D therapy on the repigmentation of vitamin D deficient patients. METHODS: Thirty patients aged 6-17 years with vitiligo and 30 sex- and age-matched apparently healthy controls were included in this prospective study. Size of the vitiligo representative area was estimated using the point counting method and blood samples were obtained at the beginning and month six. By the end of the study, all patients treated with topical tacrolimus for six months and the patients who were vitamin D deficient (n = 14) had been on combination treatment of oral vitamin D and topical tacrolimus. A dose of 1500 IU/day vitamin D was given if the serum 25(OH)D levels <20 ng/ml and 3000 IU/day was given if the levels <10 ng/ml for six months. Serum 25(OH)D levels were measured by high-performance liquid chromatography. RESULTS: Serum 25(OH)D levels of patients and controls were not significantly different (p > 0.05). Lesion size decreased from 66.1 ± 58.3 cm2 to 48.0 ± 52.6 cm2 after six months of treatment in patients who received combination treatment (p < 0.001) and increased in patients who received only topical therapy from 34.8 ± 48.1 cm2 to 53.5 ± 64.9 cm2 (p < 0.01). CONCLUSIONS: Although we did not determine decreased serum 25(OH)D levels in children with vitiligo, we showed that combination treatment with oral vitamin D and topical tacrolimus is more effective in reaching repigmentation than topical tacrolimus alone. Oral vitamin D supplementation might be useful for children with vitiligo who are also deficient in vitamin D.

Pyoderma gangrenosum in association with juvenile rheumatoid arthritis.

A 17-year-old girl presented with multiple, painful, erythematous blisters and ulcerated lesions on the shins and buttocks. She also had arthralgia. She had suffered from juvenile rheumatoid arthritis (JRA) and received anti-inflammatory agents and oral glucocorticoids for eight years. A biopsy of a lesion showed epidermal ulceration with marked neutrophilic infiltrates in the dermis. The patient was diagnosed with pyoderma gangrenosum (PG). PG is an uncommon cutaneous ulceration within the spectrum of the neutrophilic dermatoses that is reported in association with a number of systemic disorders, including inflammatory bowel disease, hematologic disease, internal malignancies, arthritis, immune abnormalities, and solid tumors. To our knowledge, this is the first reported case of PG associated with JRA.

Prevalence of Metabolic Syndrome in Patients with Mucosal Lichen Planus: A Case-Control Study.

BACKGROUND: Previous reports have demonstrated an association between chronic inflammation with metabolic syndrome (MS) and cardiovascular risk factors. AIM: As lichen planus (LP) is a chronic inflammatory disease, the purpose of this study was to assess the prevalence of MS, dyslipidemia, insulin resistance and obesity in LP patients. METHODS: A total of 79 patients with LP and 79 controls were examined in this case-control study. Both groups were evaluated for the presence of MS, dyslipidemia, obesity and insulin resistance, and other cardiovascular risk factors. Erythrocyte sedimentation rate, fibrinogen and C-reactive protein were measured as inflammation markers. RESULTS: The prevalence of MS was significantly higher in the patients with LP than in controls (26.6 vs. 12.7%; P = 0.045). It was also significantly higher in LP patients with mucosal involvement than without (34.5 vs. 8.3%; P = 0.032). Among the MS criteria, mean fasting blood glucose and diastolic blood pressure were also significantly higher in LP patients than in controls (P = 0.012 and P = 0.021, respectively). No significant differences between LP patients and controls were observed with respect to prevalence of dyslipidemia and insulin resistance (P = 0.866 and P = 1.000, respectively). However, duration of disease was significantly longer in patients with insulin resistance than in those without (P = 0.034). CONCLUSIONS: The patients with LP, particularly those with mucosal involvement, have a higher prevalence of MS, which is associated with a risk for cardiovascular diseases and diabetes mellitus.