Multicenter study evaluating the impact of COVID-19 outbreak on dermatology outpatients in Turkey.

COVID-19 pandemic has a significant impact on public health, whether directly or indirectly. The first case was seen in Turkey on March 11, and the World Health Organization (WHO) declared a pandemic on March 12, 2020. The study aimed to document the effect of pandemic on dermatology outpatient clinics in Turkey. Fifteen tertiary hospitals from 13 provinces were included in the study, which was conducted between January 12 and May 12, 2020. The International Codes of Diseases (ICD-10) categories and patients' characteristics were evaluated before and after the pandemic. A total of 164 878 patients, 133 131 before and 31 747 after the pandemic, were evaluated. The daily hospital applications were found reduced by 77%. The three of the most frequent diagnoses; dermatitis, acne, and psoriasis remained unchanged after the pandemic. While the frequency of herpes zoster, scabies, urticaria, pityriasis rosea and sexually transmitted diseases increased significantly; allergic and irritant contact dermatitis decreased after the pandemic. The applications regarding cutaneous neoplasms were considerably reduced during the pandemic, and this effect was more pronounced in cities with higher COVID incidence. The pandemic caused a noteworthy reduction in the number of patients accessing dermatological care. The pandemic caused significant changes in the frequency of a wide range of dermatological diseases. The application of cutaneous neoplasms is considerably reduced after the pandemic, and this effect was more pronounced in cities where pandemics are frequent. Therefore, the pandemic has resulted on numerous impacts on many critical issues in dermatology and dermatological care.

Evaluation of the Factors Influencing Mortality in Patients with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Multicenter Study of 166 Patients.

INTRODUCTION: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening acute mucocutaneous disorders usually triggered by drugs. In this study, we aimed to evaluate the factors affecting mortality in patients with SJS-TEN. METHODS: Our study is a retrospective cohort study, analyzing data collected from a total of 12 tertiary care centers between April 2012 and April 2022. RESULTS: The study included 59 males and 107 females, a total of 166 patients, with an average age of 50.91 ± 21.25 years. Disease classification was TEN in 50% of cases, SJS in 33.1%, and SJS-TEN overlap in 16.9%. The average SCORTEN within the first 24 h was 2.44 ± 1.42. Supportive care was provided to 99.4% of patients. The most commonly used systemic immunomodulatory treatments were systemic steroids (84.3%), IVIG (intravenous immunoglobulin) (49.3%), and cyclosporine (38.6%). Plasmapheresis was administered to five patients. While 66.3% of patients were discharged, 24.1% resulted in exitus. Our comparative analysis of survivors and deceased patients found no effect of systemic steroids, IVIG, and cyclosporine treatments on mortality. Univariate analysis revealed that the SCORTEN scores on days 1 and 3 as well as the rates of detachment at the onset and during follow-up were significantly higher in deceased patients compared to survivors. The rates of fever, positive blood cultures, and systemic antibiotic use were higher in deceased patients compared to survivors. The presence of comorbidities, diabetes, and malignancy were significantly more common in deceased patients. Multivariate regression analysis indicated that over SCORTEN 2, the mortality risk exponentially rose with each SCORTEN increment, culminating in an 84-fold increase in mortality at SCORTEN 5-6 (odds ratio [95% confidence interval]: 13.902-507.537, p < 0.001) compared to SCORTEN 0-1. Additionally, the utilization of plasmapheresis was associated with a 22-fold increase in mortality (odds ratio [95% confidence interval]: 1.96-247.2, p = 0.012). CONCLUSION: Our study found that a high SCORTEN score within the first 24 h and the use of plasmapheresis were related to increased mortality, while systemic steroids, IVIG, and cyclosporine treatments had no impact on mortality. We believe that data gathered from one of the most comprehensive studies which we conducted on SJS-TEN will enrich the literature, although additional research is warranted.

Analysis of clinical characteristics and factors affecting treatment responses in patients with pyoderma gangrenosum: a multicenter study of 239 patients☆.

BACKGROUND: Pyoderma Gangrenosum (PG) is a chronic disease characterized by recalcitrant skin ulcers. OBJECTIVE: We aimed to evaluate the demographic, clinical characteristics, treatments and factors affecting the treatment responses of patients with PG. METHODS: We performed a multicenter study of 12 tertiary care centers. We analyzed the data of the patients who were followed up with a diagnosis of PG between the years 2012‒2022 retrospectively. RESULTS: We included a total of 239 patients of whom 143 were female and 96 were male, with an average age of 54.2 ±â€¯17.4 years. The most common treatment was systemic steroids (n = 181, 75.7%). Among these patients, 50.8% (n = 92) used systemic steroids as the sole systemic agent, while 49.2% (n = 89) used at least one adjuvant immunosuppressive agent. The independent factors determined in regression analysis to influence response to systemic steroids positively were disease onset age ≥ 30-years, negative pathergy, absence of leukocytosis, negative wound culture, presence of a single lesion, and absence of upper extremity involvement. Biological agents were used in 18.4% (n = 44) of the patients in the present study. We also analyzed pathergy positive PG and early onset (onset age < 30) PG separately due to their distinct clinical features which were revealed during statistical analysis. STUDY LIMITATIONS: Retrospective nature of the present study. CONCLUSIONS: Analyses of the factors influencing treatment responses are addressed in this study. Also, we concluded that investigation for accompanying autoinflammatory diseases of pathergy positive PG and early onset PG is necessary and the patients in these two groups are more resistant to treatment, necessitating more complicated treatments.

The impact of COVID-19 pandemic on psoriasis patients, and their immunosuppressive treatment: a cross-sectional multicenter study from Turkey.

BACKGROUND: Immunosuppressive therapy has been a great concern during the pandemic. This study aimed to evaluate the pandemic's impact on psoriasis patients treated with immunosuppressive drugs. MATERIAL AND METHODS: The multicenter study was conducted in 14 tertiary dermatology centers. Demographic data, treatment status, disease course, and cases of COVID-19 were evaluated in patients with psoriasis using the immunosuppressive treatment. RESULTS: Of 1827 patients included, the drug adherence rate was 68.2%. Those receiving anti-interleukin (anti-IL) drugs were more likely to continue treatment than patients receiving conventional drugs (OR = 1.50, 95% CI, 1.181-1.895, p = .001). Disease worsening rate was 24.2% and drug dose reduction increased this rate 3.26 and drug withdrawal 8.71 times. Receiving anti-TNF or anti-IL drugs was associated with less disease worsening compared to conventional drugs (p = .038, p = .032; respectively). Drug withdrawal causes were 'unable to come' (39.6%), 'COVID concern' (25.3%), and 'physician's and patient's co-decision' (17.4%). Four patients had COVID-19 infection with mild symptoms. The incidence was 0.0022% while it was 0.0025% in the general population. CONCLUSION: Our study shows that psoriasis patients using systemic immunosuppressive do not have a higher, but even lower COVID-19 risk than the general population, and treatment compliance with biological drugs is higher.

Expression of p53 in lesions and unaffected skin of patients with plaque-type and guttate psoriasis: a quantitative comparative study.

Psoriasis is a common inflammatory and hyperproliferative skin disease characterized by hyperproliferation of keratinocytes. The pathogenesis of psoriasis has yet to be determined. The control of cell growth is a delicately balanced process, regulated by external signals or the internal genetic program of an individual cell. In psoriasis, these processes are disturbed and some candidate genes like p53 are suspected of being involved in the pathogenesis of the disease. The p53 protein is essential for the regulation of cell proliferation. The study was performed on 32 patients with psoriasis (24 plaque type, eight guttate type). Biopsy specimens for immunohistochemical determination of p53 protein expression were collected from both the lesional and the nonlesional skin sites that were not exposed to sun in all of the patients (n = 32). Taking the ultraviolet (UV) exposure of the skin into consideration, a third skin sample was taken from each patient (n = 7) who had lesions on the sun-exposed areas. Immunohistochemical assessment of p53 expression in skin was determined as p53 protein expression per 1000 cells (keratinocytes). The statistical analysis revealed that the expressions of p53 per 1000 cells were higher in non-sun-exposed lesional skin than the non-sun-exposed nonlesional skin, also in plaque-type psoriasis than guttate-type psoriasis (P = 0.000, P = 0.046, P = 0.037, respectively). There was a positive correlation between the p53 expression in non-sun-exposed lesional skin versus expression in sun-exposed lesional skin (cubic centimeters = 0.811, P = 0.027). Our results show a stronger association of elevated p53 expression with chronic rather than acute inflammatory psoriasis. This may indicate a mechanistic difference between plaque-type and guttate psoriasis. Alternatively, this could reflect a chronological course as the disease transitions from an acute to a chronic phase.

Lack of association with TNF-alpha-308 promoter polymorphism in patients with vitiligo.

Vitiligo is an acquired depigmentary disorder of the skin, characterized by incomplete penetrance, multiple susceptibility loci and genetic heterogeneity. An immunologic hypothesis is currently advanced as a possible pathogenesis of vitiligo. The cytokines have an important role in pathogenesis of autoimmunity in which tumor necrosis factor-alpha (TNF-alpha), a paracrine inhibitor of melanocytes, is especially important. Several single-nucleotide polymorphisms (SNP) have been identified in the human TNF gene promoter. The polymorphism at position -308 (TNF-308), which involves substituting G for A and designing the AA genotype, leads to a higher rate of TNF gene transcription than the wild-type GG genotype in in vitro expression studies. It has also been linked to increased susceptibility to several chronic metabolic, degenerative, inflammatory and autoimmune diseases. Therefore, we investigated the TNF-alpha-308 SNP in patients with vitiligo. We examined 61 patients with vitiligo. Healthy age-, ethnically- and sex-matched individuals (n = 123) served as controls. Polymerase chain reaction amplification was used for analysis of the polymorphism at position -308 in promoter of TNF-alpha gene. We found that the distribution of TNF-alpha genotypes in vitiligo patients did not differ from that in control subjects (P > 0.05). Moreover, there was no association between TNF-alpha genotypes and types of vitiligo. In conclusion, we suggest that TNF-alpha-308 SNP is not a genetic risk factor for vitiligo susceptibility.

A high prevalence of parvovirus B19 DNA in patients with psoriasis.

Psoriasis is a common inflammatory skin disease. Infectious models are considered to be of pathophysiological importance in psoriasis. The immunological profile of stable psoriasis plaques suggests that viral antigens may be important. Human parvovirus B19 (PVB19) is a single-stranded DNA virus that causes various clinical symptoms. Several case reports have suggested associations between PVB19 infection and various chronic autoimmune and dermatologic diseases. There has so far been no information regarding the role of PVB19 in psoriasis, except psoriatic arthritis. In this report, to investigate the role of PVB19 in psoriasis, we analyzed PVB19 DNA of peripheral blood from psoriatic patients (n = 47) in comparison with blood donors (n = 20). We also determined the presence of anti-PVB19 IgG and IgM antibodies by using enzyme-linked immunosorbent assay (ELISA). We found that the presence of PVB19 DNA in patients with psoriasis (38%) was significantly higher than in controls (0%, P < 0.01). Anti-PVB19 IgG antibodies were detected in 79% of the cases while only 6% had anti-PVB19 IgM antibodies. PVB19 DNA presence was associated with seropositivity for anti-PVB19 IgG (P < 0.05) but not with IgM antibodies, indicating subclinical activation of latent infection. No correlation was found between the presence of PVB19 DNA and a patient's age, sex, type of psoriasis, or psoriasis area and severity index. The data demonstrated a statistically significant association between psoriasis and PVB19. Therefore, we suggest that PVB19 infection may be of pathophysiological importance in psoriasis.

Superficial basal cell carcinoma of the scalp mimicking seborrhoeic dermatitis.

Superficial basal cell carcinomas (BCC) comprise 9% to 11% of BCC, and are commonly found on the trunk or limbs. We report a case of a superficial BCC on the scalp that was misdiagnosed and treated as seborrhoeic dermatitis. Any erythematous plaque-type lesion of long duration must have superficial BCC considered in the differential diagnosis.

TUR-PSO: A cross-sectional, study investigating quality of life and treatment status of psoriasis patients in Turkey.

Psoriasis is a common inflammatory disease that has a severe impact on quality of life. There is lack of data regarding epidemiological and clinical features of psoriasis patients in Turkey, a country with a population of 76 million. The aim of this study was to define the demographic and clinical characteristics, quality of life and treatment patterns of psoriasis patients in Turkey. A cross-sectional observational study was conducted at 40 centers, chosen from geographically diverse locations in Turkey. Patients diagnosed with psoriasis were assessed by investigators who were specialists of dermatology using standardized study questionnaire forms. Dermatology Life Quality Index (DLQI) and EuroQol-5 dimension (EQ-5D) forms were also filled out by each patient. 3971 psoriasis patients were included in this study. 24.2% of plaque psoriasis patients had moderate to severe psoriasis (Psoriasis Area and Severity Index, ≥10). Mean DLQI was 7.03 ± 6.02; quality of life was moderately, severely or very severely affected in 49.2% of patients. The most severely affected component of EQ-5D was anxiety/depression. Among all patients, 22.9% were not receiving any treatment, 39.8% were receiving only topical treatment, 11.5% were on phototherapy, 26.1%, were taking conventional systemic agents and 4.1% were on a biologic treatment. 31.3% of psoriasis patients with moderate to severe disease were treated with only topical agents and only 30.5% of moderate to severe psoriasis patients were receiving systemic therapy. Moderate to severe psoriasis has a considerable impact on quality of life. Treatment in Turkey of patients with moderate to severe psoriasis is insufficient.

The changes in expression of ICAM-3, Ki-67, PCNA, and CD31 in psoriatic lesions before and after methotrexate treatment.

Although the effectiveness of methotrexate (MTX) in the treatment of psoriasis is very well established, the mechanism of action is poorly understood. It was suggested that the therapeutic effect of MTX in psoriasis might be mediated by inhibition of adhesion molecule expression. The aim of our study was to investigate the different effects of MTX treatment on cell proliferation, inflammatory infiltrate, adhesion molecules, and angiogenesis in psoriasis, and to clarify the mechanism by which MTX exerts its therapeutic effects. Clinical response, the morpho-phenotypic changes, epidermal thickness, and mitosis count were analyzed and the expression of CD31 and ICAM-3, proliferative markers such as Ki-67, PCNA, were evaluated by immunohistochemical techniques in lesional psoriatic epidermis, before and after the treatment with MTX in ten patients. In posttreatment biopsies a decrease in the degree of epidermal hyperplasia and a significant reduction in the severity of the inflammatory infiltrate (P<0.05) were observed. In addition, CD31 and ICAM-3 expression was significantly decreased on dermal cellular infiltrate, (respectively; P<0.05, P<0.01). Ki67 and PCNA expression were suppressed concurrently in about 90% of cases (P<0.01). We suggest that MTX may have an inhibitory effect on an initial integral component of the pathways that lead to psoriasis. Immunopharmacologic intervention in adhesion event has the potential to improve psoriasis. Inhibition of revascularization may be another mechanism of action of MTX.

Oxidant / antioxidant status in patients with psoriasis.

Psoriasis is a common, chronic inflammatory skin disease with unknown etiology. Recently it has been suggested that increased ROS production and deficient function of antioxidant systems activities may be involved in the pathogenesis of the disease. Although there are several studies investigating oxidant/antioxidant systems in psoriatic patients, the data obtained from these studies is not concordant. In this study, superoxide dismutase (SOD) enzyme activity, and malondialdehyde (MDA) and antioxidant potential (AOP) levels in thirty-five patients with psoriasis were investigated and compared with those of twenty-four control subjects. Clinical severity of the disease was determined according to the Psoriasis Area and Severity Index (PASI) scores in the patients. Plasma SOD activity and MDA levels were significantly higher (p=0.012 and p=0.005 respectively), whereas AOP levels were lower, in patients than controls (p=0.001). There was no correlation between PASI scores and plasma SOD, MDA, and AOP levels. Our findings may provide some evidence for a potential role of increased ROS production and decreased antioxidant activity in psoriasis.

Bullous erythema ab igne.

Erythema ab igne is a localized, cutaneous condition, consisting of reticulate hyperpigmentation, dusky erythema, epidermal atrophy, and telangiectasia, all the result of repeated exposures to heat. We describe a patient with a bullous form of erythema ab igne: bullae and crusts within a localized area of reticular, brown, macular pigmentation on the lateral side of the left leg, an area that had repeated close exposure to an electrical heater over the previous 3 months. We believe that bullous erythema ab igne, something rarely reported in the literature, should be considered a well-defined variant of erythema ab igne; it may be more common than the literature suggests.

Association between tumor necrosis factor-alpha gene promoter polymorphism at position -308 and acne in Turkish patients.

Acne is a multifactorial, chronic inflammatory disease of pilosebaceous unit in which cytokines have been implicated in the pathogenesis. Although it is thought to be an inherited disease, there are limited data supporting the relevant genetic elements. Tumor necrosis factor-alpha (TNF-alpha) is one of the proinflammatory cytokines involved in the acne pathogenesis. Several single-nucleotide polymorphisms (SNPs) have been identified in the human TNF-alpha gene promoter. The polymorphism at position -308, which involves substituting guanine (G) for adenine (A) (TNFA-308 G/A) has been linked to increased susceptibility to several chronic inflammatory diseases. The aim of this study was to determine the TNFA-308 G/A polymorphism in acne and to examine whether there is a relationship between this polymorphism and disease susceptibility. Exactly, 113 patients with acne and 114 healthy control subjects were included in the study. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay was used for analysis of the TNFA-308 G/A polymorphism. We found that the frequency of the TNFA-308 GA genotype was statistically significantly increased in patients compared with healthy controls (P < 0.001). There was no association between TNFA genotypes and severity of acne (P > 0.05). There was also no significant difference between male and female patients. Our results suggest that TNFA-308 G/A polymorphism may contribute to a predisposition to acne in Turkish population.

Cerebriform intradermal nevus.

Cerebriform intradermal nevus is a rare form of cutis verticis gyrata. Clinically it manifests as a scalp deformity resembling the surface of the brain, with cerebriform morphologic characteristics. Degeneration into malignant melanoma has been reported. Herein, a cerebriform intradermal nevus of the scalp in a 7-year-old girl is reported. The clinical and histopathologic presentations of cerebriform intradermal nevus are described and the therapeutic possibilities discussed.

GSTM1 and GSTT1 null genotypes as possible heritable factors of rosacea.

PURPOSE: Rosacea might be related to an increased activity of reactive oxygen species (ROS) and deficient function of the antioxidant system. Glutathione S-transferases (GSTs) play a primer role in cellular defense against electrophilic chemical species and radical oxygen species. We hypothesized that increased ROS activity or decreased antioxidant potential, possibly induced by GST gene polymorphism, might have a pathogenic role in rosacea. METHODS: The study group consisted of 45 patients with rosacea and 100 control subjects. DNA samples were isolated from blood samples using high pure polymerase chain reaction (PCR) Template preparation Kit. The GSTM1, GSTT1, and P1 polymorphisms were detected using a real-time PCR and fluorescence resonance energy transfer with a Light-Cycler Instrument. Associations between specific genotypes and the development of rosacea were examined using logistic regression analyses to calculate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: GSTM1 and GSTT1 null genotypes were found to be statistically different from control (P=0.005, P=0.009, respectively), and associated with an increased risk of rosacea (OR [95% CI]: 2.84 [1.37-5.89]; OR [95% CI]: 2.68 [1.27-5.67], respectively). There was a statistically significant relationship between both null combination of the GSTM1 and GSTT1 genotype polymorphisms and rosacea (P=0.003, OR [95% CI]: 4.18 [1.57-11.13]). There were no statistically significant differences between patient and control groups for the GSTP1 Ile/Ile, Ile/Val, and Val/Val genotypes (P>0.05). CONCLUSION: We demonstrated a significant association between the GSTT1 and/or GSTM1 null genotypes and rosacea. However, the potential role of GSTs as markers of susceptibility to rosacea needs further studies in larger patient groups.

Celecoxib-induced photoallergic drug eruption.

Photoallergic dermatitis is caused by a photosensitizing substance plus sunlight exposure in a sensitized person. If the photosensitizer is delivered internally, it is called a photoallergic drug reaction. Celecoxib is a new generation non-steroidal anti-inflammatory drug and sulfonamide derivative. We report a photoallergic drug eruption associated with the introduction of celecoxib. To our knowledge, this is the first report of photoallergic drug reaction associated with celecoxib.