Chronic urticaria and the metabolic syndrome: a cross-sectional community-based study of 11 261 patients.

BACKGROUND: Emerging evidence suggests that chronic urticaria (CU) is associated with chronic, low-grade, inflammatory process. OBJECTIVE: To evaluate the association between CU and metabolic syndrome and its components in a large community-based medical database. METHODS: A cross-sectional study of CU patients and matched controls was performed. CU was defined as eight urticaria diagnoses (with each two diagnoses registered within a period of 6 weeks) from 2002 to 2012. Data regarding the prevalence of metabolic syndrome, its components and possible complications were collected. RESULTS: The study included 11 261 patients with CU and 67 216 controls. In a univariate analysis, CU was significantly associated with higher body mass index (BMI) and a higher prevalence of obesity, diabetes, hyperlipidaemia, hypertension, metabolic syndrome, chronic renal failure and gout. Multivariate analysis demonstrated a significant association between CU and metabolic syndrome (OR = 1.12, 95% CI 1.1-1.2, P < 0.001) and its components - obesity (OR = 1.2, 95% CI 1.1-1.3, P < 0.001), diabetes (OR = 1.08, 95% CI 1.01-1.15, P = 0.001), hyperlipidaemia (OR = 1.2, 95% CI 1.1-1.2, P < 0.001) and hypertension (OR = 1.1, 95% CI 1.1-1.2, P < 0.001). CONCLUSIONS: CU patients may have one or more undiagnosed components of metabolic syndrome despite their young age. Thus, appropriate targeted screening is advised.

Unexpected location of pilonidal sinuses.

Pilonidal sinuses usually occur in the sacrococcygeal area in young men, and occasionally can be found in other ectopic sites. We present a retrospective case review on unusual locations of pilonidal sinuses in the past 4 years. The lesion sites were as follows: one on the penis, two on the scalp, two on the abdomen, one on the neck, two in the groin and two in the axilla. Abdominal and penile lesions are uncommon, but the other locations reported are unusually rare. To our knowledge, the groin has not been reported previously as a site of a pilonidal sinus, although the histological appearance of hidradenitis suppurativa may well resemble it. When trying to clarify the pathogenesis of these occurrences, we found that recurrent hair removal was a common characteristic of the patients we contacted, and this may have been the initiating trauma.

Association between psoriasis and the metabolic syndrome. A cross-sectional study.

BACKGROUND: Previous reports have shown an association between inflammatory diseases such as systemic lupus erythematosus or rheumatoid arthritis and the metabolic syndrome. Recent data demonstrate that psoriasis is an inflammatory disease, suggesting that psoriasis may be one of the components of the metabolic syndrome. OBJECTIVE: To assess the association between psoriasis and the metabolic syndrome. METHODS: A cross-sectional study was performed utilizing the database of the Clalit Health Services. Case patients were defined as patients with a diagnosis of psoriasis vulgaris. Controls were randomly selected from the list of Clalit Health Services enrollees. The proportions of components of the metabolic syndrome (ischemic heart disease, hypertension, diabetes, obesity and dyslipidemia) were compared between case and control patients by univariate analyses. chi(2) tests were used to compare categorical parameters between the groups. Logistic and linear regression models served to measure the association between psoriasis and the metabolic syndrome. RESULTS: The study included 16,851 patients with psoriasis and 48,681 controls. In the case group, there were 8,449 men (50.1%) and 8,402 women (49.9%), with a mean age of 42.7 years (SD = 20.3, range = 2-111). Diabetes mellitus was present in 13.8% of the patients with psoriasis as compared to 7.3% of the controls (p < 0.001). Hypertension occurred in 27.5% of the patients with psoriasis and in 14.4% of the controls (p < 0.001). Obesity was present in 8.4% of the patients with psoriasis as opposed to 3.6% of the controls (p < 0.001). Ischemic heart disease was observed in 14.2% of the patients with psoriasis as compared to 7.1% of the controls (p < 0.001). Multivariate models adjusting for age, gender and smoking status of the patients demonstrated that psoriasis was associated with the metabolic syndrome (OR = 1.3, 95% CI = 1.1-1.4), ischemic heart disease (OR = 1.1, 95% CI = 1.0-1.2), diabetes mellitus (OR = 1.2, 95% CI = 1.0-1.3), hypertension (OR = 1.3, 95% CI = 1.2-1.5) and obesity (OR = 1.7, 95% CI = 1.5-1.9). LIMITATIONS: The study is designed as a case-control study, thus an association alone was proven and not causality. CONCLUSION: Our findings demonstrate a possible association between psoriasis and the metabolic syndrome. Appropriate treatment of the metabolic syndrome may be an important part of the management of patients with psoriasis.

Nonattendance in a dermatology clinic--a large sample analysis.

BACKGROUND: Previous studies have described factors determining non-attendance at dermatology appointments in small sample sizes. OBJECTIVE: To perform an analysis of factors associated with non-attendance in a dermatology clinic in a larger sample. METHODS: Factors determining non-attendance were examined in 52 604 consecutive first-time visits to a dermatology clinic over a period of 44 months. RESULTS: Non-attendance proportion was 27.6%. Among children, non-attendance was associated with waiting for an appointment < 7 days [odds ratio (OR), 1.44], Bedouin sector (OR, 1.30), rural Jewish sector (OR, 0.45) and the treating physician. Among adults, non-attendance was associated with female gender (OR, 1.08), age < 55 years (OR, 1.65), waiting time for an appointment < 7 days (OR, 1.44), timing of the appointment between 1 and 4 pm (OR, 1.13), Bedouin sector (OR, 1.63), rural Jewish sector (OR, 0.46) and the treating physician. CONCLUSION: Non-attendance is common among Bedouins, adult female patients and young adults and is more likely as waiting times become longer. Strategies to reduce non-attendance are needed.

Psoriasis and diabetes: a population-based cross-sectional study.

BACKGROUND: Previous reports have shown an association between psoriasis and the metabolic syndrome, but there are only a few studies on the association between psoriasis and diabetes. OBJECTIVES: To study the association between psoriasis and diabetes. METHODS: A cross-sectional study was performed utilizing the database of Clalit Health Services (CHS). Patients who were diagnosed with psoriasis were compared with CHS enrolees without psoriasis regarding the prevalence of diabetes. Patients with diabetes were identified using the CHS chronic diseases registry. Chi-squared tests were used to compare categorical parameters. Logistic regression models were used for multivariate analyses. RESULTS: The study included 16 851 patients with psoriasis and 74 987 subjects without psoriasis (control patients). The proportion of diabetes was significantly higher in patients above 35 years (P < 0.05). The age-adjusted proportion of diabetes was significantly higher in psoriasis patients as compared to the control group [odds ratio (OR), 1.38, P < 0.05] and was similar in men and women (OR, 1.32, 1.45, respectively). A multivariate logistic regression model showed that psoriasis was significantly associated with diabetes, independently of age and gender (OR, 1.58, P < 0.001). CONCLUSIONS: Our study supports previous reports of an association between psoriasis and diabetes. Dermatologists taking care of patients with psoriasis should be aware of this association and advise the patients to reduce additional risk factors such as smoking, hypertension or dyslipidemia.

Local cutaneous reaction induced by subcutaneous interleukin-2 and interferon alpha-2a immunotherapy following ABMT.

Immunotherapy using subcutaneous injections of recombinant interleukin-2 (IL-2) and recombinant interferon alpha-2a (IFN-alpha) for advanced hematologic and solid tumors is rapidly developing. We report five patients with Hodgkin's and non-Hodgkin's lymphoma who developed a local cutaneous reaction consisting of inflammatory painful nodules with a central multiloculated vesicle at the site of sc injections of IL-2 and IFN-alpha immunotherapy following ABMT. This is the first report of a local cutaneous adverse reaction induced by IL-2 and IFN-alpha immunotherapy following ABMT.

Chronic radiodermatitis following cardiac catheterization.

BACKGROUND: Fluoroscopy and cineradiography used during coronary angiography expose patients to some of the highest doses of ionizing radiation in diagnostic radiology. The possibility of radiation-induced damage has been discussed by several authors in the past. However, to the best of our knowledge, chronic radiation dermatitis caused by exposure to x-rays during cardiac catheterization has not been described. OBSERVATIONS: We describe 4 patients in whom chronic radiodermatitis developed following multiple cardiac catheterizations and coronary angioplasties. The cumulative radiation doses to which these patients were exposed were retrospectively calculated to be a mean of 24.6 Gy per patient, with a range of 11.4 to 34.9 Gy. CONCLUSIONS: Chronic radiodermatitis is a threat in patients undergoing multiple cardiac catheterizations and angioplasties. In susceptible patients, radiation doses as small as 11.4 Gy, which can sometimes be emitted during 1 or 2 procedures, are potentially harmful. Awareness and protective measures against this long-term side effect of cardiac catheterization should be encouraged.

Treatment of vulvar lichen sclerosus in the elderly: an update.

Lichen sclerosus et atrophicus is a disorder of the skin that can occur anywhere on the body and in all age groups but mainly affects middle-aged and elderly women in the vulvoperineal area. It consists of ivory or pink papules or macules that eventually coalesce into thin, gray, parchment-like areas. Clinically, the main symptoms are severe and intractable itching and vaginal soreness with dyspareunia. Although it has been described to be associated with an increased risk for epithelial malignancy this, in fact, very rarely occurs. The exact nature of LSA is still unknown. The accumulation of evidence does little to clarify its pathogenesis and etiology. The different reports indicate at least three general possibilities; autoimmune, metabolic, and more recently infectious etiology. The coexistence of such diverse findings in one disease entity may indicate one of the two; either we are facing a group of very similar conditions, which will be separated in the future into several closely related clinical entities, each with its own etiology, or that all findings represent a complex multi-step single pathogenetic mechanism. The latter possibility seems more probable because it has previously been suggested that B. burgdorferi, a recent prime suspect in the pathogenesis of LSA, may induce both metabolic and autoimmune abnormalities in the course of infection. New therapeutic options and attitudes emerge that dramatically improved the conservative treatment of this disease (Table 5).(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of multiple miliary osteoma cutis of the face with local application of tretinoin (all-trans-retinoic acid): a case report and review of the literature.

BACKGROUND: Multiple miliary osteoma cutis of the face represents primary extra-skeletal bone formation that arises within the skin of the face. METHODS: A 60-year-old woman with multiple miliary osteoma cutis of the face was treated by application of 0.05% tretinoin (all-trans-retinoic acid) cream nightly. RESULTS: After 3 months of therapy there were fewer papules and a decrease in size of remaining lesions. In a literature search, it was found that local application of tretinoin was successful and achieved a decrease in the number of papules over the face in all patients with multiple miliary osteoma cutis of the face; however, the length of time to achieve response varied from a few weeks to 6 months. CONCLUSION: It is suggested that local application of tretinoin cream should be considered in the therapy of multiple miliary osteoma cutis of the face, particularly when the lesions are small and superficial.

An independent comparison of terbinafine and itraconazole in the treatment of toenail onychomycosis.

BACKGROUND: Previously, sponsored publications have shown that either terbinafine or itraconazole (pulse regimen) are effective for patients with toenail onychomycosis. However, independent comparative studies are lacking. OBJECTIVES: To objectively compare treatment with terbinafine and itraconazole in patients with toenail onychomycosis. METHODS: The effectiveness of terbinafine (250 mg/day 3 months) versus itraconazole pulse regimen (400 mg/day for the first week of each month, for three cycles) was retrospectively evaluated in patients with toenail onychomycosis using mycological tests and subjective outcome measures. Statistical analyses were performed using one-way analyses of variance (ANOVA) for continuous variables and Fisher exact tests for categorical variables. RESULTS: Included in the study were 117 patients (74 patients treated by terbinafine and 43 patients treated with itraconazole). Patients were examined at an average period of 20 months after the end of therapy. Mycological cure was observed in 70.6% and 62.8% of the patients who were treated by terbinafine or itraconazole, respectively (not statistically significant). Mean visual analogue scale assessment of treatment outcome was 79.9 mm (SD 24.7 mm) and 65.2 mm (SD 34.6 mm) for patients treated by terbinafine or itraconazole, respectively (p=0.008). When the results were stratified according to age and gender, it was observed that the advantage of terbinafine versus itraconazole retained statistical significance only for patients who were 55 years old and above, or females. CONCLUSIONS: Mycological cure proportions were not statistically significant between patients treated by terbinafine or itraconazole for toenail onychomycosis. However, better subjective outcome measures indicated an advantage for terbinafine over itraconazole, noticeable in females and patients 55 years old and above.

Extramammary Paget's disease recurring on the skin of the lower abdomen and entire right leg two and half years after simple vulvectomy for minimally invasive Paget's disease of the vulva.

We encountered an unusual case of extramammary Paget's disease (EMPD) recurring on the skin of the lower abdomen and entire right leg two and a half years after simple vulvectomy for minimally invasive Paget's disease of the vulva. Histologic examination of the skin metastases demonstrated that the proliferation of Paget cells was confined to the dermis, most of them were located in lymphatic vascular spaces. This case confirms that minimally invasive Paget's disease of the vulva may sometimes be an aggressive disease. We consider that lymphatic metastases already existed in this patient at the time of initial surgery; thus, the recurrence of EMPD on extragenital skin sites may have been prevented if initial treatment would have included radical vulvectomy and bilateral groin lymph node dissection instead of simple vulvectomy without groin lymph node dissection.

Full skin thickness burns caused by contact with the pavement in a heat-stroke victim.

A 70-year-old woman, with a previous history of heat-stroke, suffered another heat-stroke on a hot summer day (air temperature 43 degrees C (109 degrees F)). She presented the rare complication of a heat-stroke plus deep burns sustained while lying unconscious on the pavement. In addition to age, obesity, previous illness, incidental fever, drugs, dehydration and physical effort, a previous history of heat-stroke is probably an important risk factor for a second heat-stroke. Burns from contact with the pavement are uncommon but possible, especially if the patient is obese, immobile and poorly insulated.

An analysis of mortality in patients with burns covering 40 per cent BSA or more: a retrospective review covering 24 years (1964-88).

The charts of patients with burns covering more than 40 per cent of the body surface area (BSA) who were admitted to the Burn Unit of the Soroka Medical Center, Beersheva, Israel, between the years 1964 and 1988 were reviewed for mortality rate and causes of deaths. The factors affecting survival are reviewed and analysed.

Knuckle pads--a forgotten skin condition: report of a case and review of the literature.

A 12-year-old boy presented with knuckle pads, palmar keratoderma, and hand eczema. Since Morginson's description of knuckle pads associated with other dermatoses almost forty years ago, little attention has been given to this disorder. We describe a case and review some of the clinical aspects of this disorder.

Specific cutaneous infiltrates in chronic myelogenous leukemia.

Specific leukemic infiltration of the skin is possible in all types of leukemia, and occurs most commonly in monocytic leukemias. We report the case of a 76-year-old woman with chronic myelogenous leukemia who showed specific cutaneous lesions one month before she died. In the absence of other signs of accelerated disease or blast crisis, cutaneous lesions should be considered an ominous sign in chronic myelogenous leukemia.

Eosinophilic pustular folliculitis (Ofuji disease) in a child.

Eosinophilic pustular folliculitis (EPF) has been described mostly in adults from Japan. From the few reports of children with EPF it is clear that the disease displays the characteristic features, with some clinical differences compared to EPF in adults. We describe the case of an 8-year-old boy with multiple vesicles, pustules, and erythema multiforme-like lesions on the trunk and lower extremities. Results of histopathologic examination revealed subcorneal and intraepidermal pustules, and an inflammatory infiltrate consisting of lymphocytes and eosinophils mainly with a perifollicular distribution. The patient also had impaired chemotaxis, IgG3 subclass deficiency, and elevated IgE levels.

Association of Ureaplasma urealyticum colonization in male urethra and Condyloma acuminatum.

BACKGROUND: The frequent coexistence of two or more sexually transmitted diseases in one patient has been reported in non-dermatological literature, mostly in languages other than English. Identification of Ureaplasma urealyticum, Chlamydia trachomatis and Mycoplasma hominis in men with other STDs is important, since these bacteria have been implicated in a variety of diseases such as non-gonococcal urethritis, premature rupture of fetal membranes, and infertility in female sexual partners of these patients. OBJECTIVE: To assess the frequency of concomitant STD, particularly urethral colonization of U. urealyticum, C. trachomatis and M. hominis, in men consulting for suspected STD-related symptoms. METHODS: All patients attending our dermatology clinic for STD-related symptoms during a 12 month period in 1996-97 underwent systematic clinical and laboratory screening for syphilis, gonorrhea, NGU, prostatitis, genital herpes simplex infection, Condyloma acuminatum, urethral carriage of U. urealyticum, C. trachomatis and M. hominis, as well as serological screening for HIV, and hepatitis B and C infections. RESULTS: A total of 169 men with STD-related symptoms were enrolled in the study. The following clinical diagnoses were established: NGU in 109 men, C. acuminatum in 40, genital herpes simplex in 10, prostatitis in 7, latent syphilis in 6, primary syphilis in 1, and Behcet's disease in 1. No clinical evidence of STD was found in 13 patients. Of the 169 patients, 39 (23%) had two or more concomitant STDs, of whom 27 (69%) had C. acuminatum associated with one or more of the urethral pathogens. A positive U. urealyticum culture was found in 67.5% (27/40) of the men with C. acuminatum as compared to 42% (40/96) among the patients with NGU who did not have C. acuminatum (P = 0.004, chi 2 test). Conversely, the prevalence of C. acuminatum among patients positive for U. urealyticum was significantly higher than the prevalence among those who were negative--27/75 (36%) vs. 13/94 (14%), P < 0.0009, chi 2 test. About half of the U. urealyticum-positive patients with C. acuminatum had no clinical signs or symptoms of urethritis. CONCLUSION: Our findings suggest that patients with C. acuminatum should be assessed for U. urealyticum carriage and, when identified, their sexual contacts should be actively sought and treated.

Case study: full thickness chemical burn of the abdomen and chest.

An 81 year old patient, suffering from Alzheimer's disease sustained a full thickness HCI Acid burn of her abdomen and chest wall due to leakage of gastric content from her gastrostomy feeding tube. The controversial management of such a patient is discussed and early surgical treatment is recommended.