Two cases of neglected leishmaniasis with marked facial disfigurement: A diagnostic conundrum.

Key Clinical Message: There is a need to pay more attention to cutaneous leishmaniasis in endemic regions which may mimic other dermatoses and treatment should be initiated with a strong clinical suspicion even without any histopathologic or PCR confirmation to avoid disfigurement or development of secondary malignancy. Abstract: Leishmaniasis is a vector-borne disease with a variety of Clinical manifestations. Cutaneous leishmaniasis (CL) is the most common form of disease and can mimic other dermatoses. We describe two unusual cases of chronic leishmaniasis that remained undiagnosed for many years and led to superimposition of squamous cell carcinoma (SCC) on lesions of one patient. These reports showed that the leishmaniasis should be borne in mind by clinicians when encountering any infiltrated lesion in patients from endemic regions and treatment should be initiated with a strong clinical suspicion even without any histopathologic or PCR confirmation to avoid disfigurement or development of secondary malignancy.

A case report of esophageal cancer in a patient with pemphigus vulgaris: A coincidence or something beyond that?

BACKGROUND: Pemphigus is a group of rare but serious autoimmune blistering disorders, affecting skin and mucus membrane. Different reports have been published in respect to the coexistence of pemphigus with neoplasms, especially lympho-proliferative ones. CASE: Here, we have reported a patient previously diagnosed with pemphigus vulgaris (PV) who developed esophageal squamous cell carcinoma (SCC). CONCLUSION: Dyspepsia and dysphagia in patients with PV might not be merely due to pemphigus erosions or simply an adverse effect of systemic corticosteroid such as irritant or candidal esophagitis and should raise the suspicion of more serious conditions in case of resistant symptoms without appropriate response to treatment.

The impact of the COVID-19 pandemic on the diagnosis and treatment of skin cancers, a mini review.

BACKGROUND: The SARS-Cov-2 pandemic has caused dermatologists around the world to adapt their practice in the aim of protecting patients with special clinical conditions such as those having skin cancers or premalignant conditions and some diagnostic or therapeutic programs would be suspended due to being infected to SARS-CoV-2. We focused the existing data in this regard through searching on PubMed, Google Scholar, and Scopus and tried to summarize recommendations for treating this group of patients in COVID era to provide a practical guide for clinicians. RECENT FINDINGS: The number of diagnosed skin cancers dropped significantly since the beginning of the pandemic, specially in the peaks of various variants of the SARS-CoV-2 infection. The new guidelines allowed even a 3-month delay in excision and recommended surgery for non-melanoma growing skin cancers. CONCLUSION: Dermatologists should perform a careful, individualized risk-benefit assessment for their patients and consider some changes in routine protocols such as having a delayed diagnostic or therapeutic intervention.

Isotretinoin and timing of procedural interventions: Clinical implications and practical points.

BACKGROUND: For decades, the notion that elective surgeries and cutaneous procedures should be postponed for 6-12 months in patients on, or recently administered with isotretinoin, has been widely accepted. However, some recent studies showed the need for a change in this regard. METHOD: Here, we reviewed the existing data in this regard through searching on PubMed, Google Scholar, and Scopus. All of the relevant papers published in English, until October, 2022, which we could access to their full-texts, were included. RESULTS: We found some recommendations made by plastic surgeons, dermatologists, ENT surgeons, ophthalmologists, orthopedic surgeons, and dentists regarding the correct timing of procedural interventions in patients on, or recently administered with isotretinoin and tried to summarize them to provide a practical guide for clinicians. CONCLUSION: Physicians may discuss with patients regarding the known risk of abnormal wound healing in the setting of systemic isotretinoin treatment and suggest that, when possible, surgical procedures be postponed until the activity of the retinoids has time to subside. It is even more important regarding patients with darker skin phototypes to follow an even more strict guideline.

Kaposi's sarcoma in a patient with pemphigus vulgaris mimicking exacerbation of pemphigus.

BACKGROUND: Kaposi's sarcoma (KS) is a rare multifocal angiogenic tumor often seen in immunocompromised setting such as acquired immunodeficiency syndrome (AIDS) or organ transplantation recipients. Pemphigus vulgaris (PV) is a rare blistering disorder with mucocutaneous involvement for which immunosuppressive therapy has long been the core of treatment. Iatrogenic form of KS has been reported infrequently in pemphigus patients as a result of long-term immunosuppressive therapy. CASE: We describe a 39-year-old male patient with confirmed diagnosis of PV who developed KS after receiving immunosuppressive agents for his pemphigus. KS was initially localized to the oral cavity with features mimicking exacerbation of his pemphigus. CONCLUSION: This interesting case of KS suggests that dermatologists visiting patients with pemphigus with discomfort in the oral cavity should have a high degree of awareness and consider other differential diagnoses along with merely an exacerbation of PV.

Anatomic evaluation of the normal variants of the arteries of face using color Doppler ultrasonography: Implications for facial aesthetic procedures.

BACKGROUND: Knowledge of normal facial vascular variations could prevent catastrophic complications of cosmetic procedures as well as providing a guide for surgical planning. Color Doppler ultrasound is a safe and noninvasive method for real time vascular evaluation. OBJECTIVE: The aim of this study was to evaluate the normal variations of the facial, angular, transverse facial, supratrochlear and supraorbital arteries in a sample of normal individuals. METHODS: Normal individuals referred for dermal filler injection to the tertiary dermatologic center, were selected. Patients who were smoker or had a history of facial filler injection, facial surgery, or trauma were excluded from the study. Facial artery at three levels as well as angular, supratrochlear, supraorbital, and transverse facial arteries were evaluated by an 18 MHz ultrasound linear probe regarding their distance from facial reference lines and landmarks, and also their depths in various regions of face. RESULTS: A total number of 43 individuals were evaluated in this study. Thirty-one (72.1%) were women. The number of absent facial artery was zero in level one, three (3.48%) in level two, and nine (10.46%) in level three. The angular artery was absent in 10 (11.62%) participants. The transverse facial artery was absent in 27 (31.39%) assessed individuals. Distance from reference lines at level 2 and 3 of facial artery and its depth at level 2 were significantly different between left and right side (p-values: <0.001, 0.01, and 0.03, respectively). No significant difference was seen between depth and distance of two sides for angular and transverse facial arteries. The comparison of the depths and distances from the reference lines of the assessed arteries between two sexes revealed only a significantly greater value of facial artery distance in level 1 in males (p-value: 0.001). BMI was also significantly correlated with the depth of facial artery in level 2 (Pearson correlation coefficient = 0.471, p-value = 0.002) and level 3 (Pearson correlation coefficient = 0.357, p-value = 0.03) and the distance of the facial artery in level 1 (Pearson correlation coefficient = 0.333, p-value = 0.029). CONCLUSIONS: Color Doppler ultrasound could be used to map the arteries of face to prevent vascular complications and safely guide cosmetic procedures.

Elevated serum level of B-cell activating factor (BAFF) after rituximab therapy in pemphigus vulgaris patients suggests a possible therapeutic efficacy of B-cell depletion therapies combined with anti-BAFF agents.

BACKGROUND: Rituximab is widely used for treatment of pemphigus patients. B-cell activating factor (BAFF) and a proliferation-inducing ligand (APRIL) play key roles in B cell survival, maturation, and differentiation. Here, the effect of rituximab on BAFF and APRIL in patients with pemphigus vulgaris (PV) was studied. METHODS: Fifty PV cases and 56 healthy individuals were recruited. Patients received rituximab for a period of 6 months. The levels of BAFF and APRIL were measured in the serum samples. The frequency of CD19+ B cells was measured by flow cytometry. RESULTS: The level of BAFF was significantly higher in the patients at the baseline level than controls (P = 0.0005). The level of BAFF was significantly higher at the 3rd month follow-up compared to the baseline (P = 0.033). There was a significant increase in the BAFF level at the 6th month follow-up compared to baseline (P = 0.0134). There was no significant difference in the CD19+ B cells/total lymphocytes ratio in the PV patients between the 3rd and 6th month follow-ups. CONCLUSIONS: Elevated BAFF in the sera could be associated with PV immunopathogenesis. Inhibition of BAFF after rituximab therapy might interfere with repopulation of B cells and confer a therapeutic approach in PV.

Indirect immunofluorescence on rat bladder epithelium in patients with pemphigus vulgaris with an extended follow-up.

Background: Indirect immunofluorescence (IIF) on rat bladder epithelium (RBE) has been widely used to detect anti-plakin antibodies present in paraneoplastic pemphigus (PNP). However, anti-plakin antibodies have also been found in a group of patients with pemphigus vulgaris (PV). Objectives: To assess the reactivity rate of PV sera in IIF using RBE as substrate and the diagnostic usefulness of the aforementioned test. Methods: Patients diagnosed with PV presenting to Razi Hospital, Tehran, Iran, were recruited. The patients' demographics, disease severity, and response to the initial treatment were recorded. Sera were collected and tested by IIF on RBE and by desmoglein 3/1 (Dsg 3/1) enzyme-linked immunosorbent assay. Patients were followed up closely for a mean of 53.9 months for any evidence of malignancy. Results: Forty-six patients were enroled (mean age of 42.9 years old, 31 females). Nine sera (19.6%) showed reactivity in IIF on RBE. Mean serum anti-Dsg levels did not differ significantly among the two groups with positive and negative IIF results. Negative anti-Dsg3 was related to a higher positive rate in IIF on RBE. There was no significant correlation between the reactivity of IIF on RBE and patients' demographic, clinical, or serological characteristics. Conclusions: IIF on RBE is a sensitive test for detecting antibodies against plakins. However, it has a relatively high false-positive rate in PV, probably due to the epitope spreading phenomenon. This test should be suggested when there is a clinical or immunohistopathological suspicion of PNP and should be interpreted with caution.

Botulinum toxin injection as a single or combined treatment with non-cross-linked high molecular weight and low molecular weight hyaluronic acid gel for neck rejuvenation: A randomized clinical trial.

The unpleasant appearance of the neck through the aging process could burden the psychosocial quality of life, therefore various treatment modalities have been used to rejuvenate the neck. The present study aimed to evaluate the efficacy of botulinum toxin injection as a single or combined treatment with Profhilo gel for neck rejuvenation. Patients with a request for neck rejuvenation meeting the inclusion criteria were randomly divided into two groups. Initial clinical scoring based on Wrinkle Severity Rating Scale (WSRS) and skin biomechanical parameters using a multiadaptor system (MPA) were performed before starting the treatment. Dysport Botox was injected for all of the participants, moreover, in one of the groups (intervention), Profhilo gel was injected after 2 weeks and a follow-up visit was performed for both groups 3 months later. Patients were evaluated according to the GAIS (global aesthetic improvement scale) by two blind dermatologists and skin biophysical parameters were measured by MPA such as TEWL, hydration, thickness, density, visco-elasticity, net elasticity, pliability/firmness. In this study, 19 participants in the control (Dysport) and intervention (Dysport + PROFhilo gel) groups were evaluated. Before starting the treatment, the two groups were similar in terms of WSRS scores and biophysical skin parameters. Three months after the treatment, it was observed that Hydration (p < 0.001) and Thickness of the skin (p = 0.028) in the intervention group were significantly higher than in the control group. Similarly, the GAIS scores of the intervention group showed significantly better results comparing to the control group (p < 0.001). Profhilo gel following Dysport Botox can be considered as a safe and more effective treatment of neck aging comparing to Dysport Botox injection alone in patients who are not a candidate for surgery due to any reason.

SARS-CoV-2 vaccination and practical points in psoriasis patients: A narrative review.

SARS-CoV2 vaccines were approved without long-term monitoring due to emergent situations. This has raised some issues about timing and protocol of receiving vaccines in specific situations including patients with chronic inflammatory disorders such as psoriasis. Here, we present different aspects of SARS-CoV-2 infection and vaccination in psoriasis patients and aim to provide solutions to overcome the potential challenges. In brief, the benefits of vaccination outweigh the potential risk; vaccine-triggered de novo or flares of psoriasis is uncommon. As such, all psoriasis patients, especially those receiving systemic treatments including anti tumor necrosis factor agents, are strongly recommended to get SARS-CoV-2 vaccines. It is recommended that new immunosuppressive/immunomodulatory therapies be initiated at least 1 week after the second SARS-CoV-2 vaccine dose, if possible. In addition, in severe and active forms of psoriasis, it is better to delay vaccination until stabilization of the disease.

Rituximab exhibits a better safety profile when used as a first line of treatment for pemphigus vulgaris: A retrospective study.

BACKGROUND: Pemphigus is an autoimmune disease that is challenging to treat and has few available therapeutic options. Recently, several studies have demonstrated that rituximab may be an efficacious first-line treatment in newest guidelines. AIM: To compare the side effect profiles of rituximab administered after a course of immunosuppressant agents versus as a first-line therapy and evaluate the impact of patient characteristics and disease severity indices on occurrence of adverse effects. METHODS: A retrospective cross-sectional study was conducted on 999 patients with pemphigus vulgaris who received rituximab either as a first-line treatment or after conventional adjuvant therapies. The occurrence of partial or complete remission as well as the incidence of drug-related adverse effects were evaluated and compared between the two groups. RESULTS: Smoking, pulmonary comorbidity, and mucocutaneous phenotype were associated with an increased risk of developing infectious complications by 12.49, 5.79, and 2.37 fold, respectively. These associations were more prominent among those who received rituximab after immunosuppressant agents. CONCLUSIONS: Early use of rituximab benefits pemphigus patients, especially those with a mucocutaneous phenotype, pulmonary comorbidity, or history of smoking, and reduces their risk of infectious adverse events.

Does Double-Pass Pulsed-Dye Laser With Long and Short Pulse Duration Increase Treatment Efficacy of Port-Wine Stain? A Randomized Clinical Trial.

BACKGROUND: Although pulsed-dye laser (PDL) 595 nm is known as the gold standard for treatment of port-wine stains (PWS), complete clearance of lesions occurs in a minority of cases. OBJECTIVE: To compare the efficacy and safety of double-pass pulsed-dye laser (DPL), long pulse duration (20 m/s) followed by short pulse duration (1.5 m/s) within 20 minutes interval, with single-pass pulsed-dye laser (SPL) for (1.5 m/s) in the treatment of PWS. METHODS: Twenty-four patients with PWS underwent 3 sessions of PDL. Each lesion was randomly divided into 2 portions to receive DPL or SPL. Colorimetric and dermoscopic evaluations were used to determine the response objectively. In addition, improvement was scored subjectively using the visual analog scale (VAS). RESULTS: According to colorimetric analysis, the mean blanching rates for DPL and SPL treated sites were 48% (SD = 0.215) and 37% (SD = 0.213), respectively (p = .001). With VAS, 3.79 (SD = 0.93) and 3.33 (SD = 0.91) improvement scores were reported in the DPL and SPL treated areas, respectively (p = .008). Dermoscopic images showed that larger deep vessels were the most common remnant vessels in both treatment areas. CONCLUSION: Compared with SPL, DPL with 20 minutes interval seems to be a more effective and safe method for the treatment of PWS.

Efficacy and safety of biosimilar rituximab in patients with pemphigus vulgaris: a prospective observational study.

Background: The optimal treatment for pemphigus vulgaris (PV) has not been clearly determined yet. Rituximab (RTX) was recently approved for the management of adults with moderate to severe PV. Objectives: This prospective observational study was designed to evaluate the efficacy and safety of biosimilar RTX in PV patients.Methods: The efficacy and safety were evaluated by assessing the pemphigus disease area index (PDAI) score, clinical response and any adverse events (AEs) during at least 12-month follow-up. We evaluated anti-desmoglein (Dsg) 1,3 level at baseline, 3 months and 12 months after RTX infusion.Results: A total of 110 patients treated with biosimilar RTX were enrolled between May 2016 and July 2017. The mean age was 43.58 ± 11.77 years and the mean follow-up time was 16.22 ± 3.45 months. A notable decrease in PDAI score, anti-Dsg 1,3 level and prednisolone dosage was observed. Median delay to achieve complete remission (CR), median duration of CR, and median time to relapse were 3, 9, and 12 months, respectively. Newly diagnosed patients (NDPs) experienced higher rate of CR, longer duration of remission and lower risk of relapse, compared to previously treated patients (PTPs). A total of 47 AEs were observed in 33 (30%) patients, which were mostly mild infusion-related reactions.Conclusion: Administration of biosimilar RTX in PV patients was associated with desirable outcomes in terms of efficacy and safety in both NDPs and PTPs.First-line use of RTX in NDPs was more effective and allowed a rapid tapering of corticosteroid doses compared to PTPs.

Granuloma annulare after Botulonium toxin A injection: A rare association.

BACKGROUND: Botulinum toxin is generally considered safe and has been used in constantly expanded cosmetic and therapeutic indications. However, long-term side effects such as granulomatous reactions have been associated with this drug. AIMS: We aim to evaluate a rare reaction to Botulonium toxin A injection. PATIENTS/METHODS: A 44-year-old woman, developed annular plaques eleven months after botulinum toxin A injection for the correction treatment of wrinklesglabellar rhytides. RESULTS: Histopathological examination revealed granuloma annulare formation. Clinical and biological investigations were negative, ruling out the hypothesis of systemic sarcoidosis. Triamcinolone acetonide injection was followed by a regression of the plaques. CONCLUSION: There are previous reports in the literature of sarcoidal and foreign body granuloma at the sites of injection of botulinum toxin A injection. To our knowledge this is the first report of granuloma annulare occurrence after botulinum toxin A injection.

Self-limited acne agminate-like granulomatous reaction to facial laser rejuvenation in a patient with comedonal acne vulgaris.

Minimally invasive fractional rejuvenation was developed to overcome the drawbacks of the traditional ablative laser. The Fotona 4D laser is one of these lasers used for face lifting. This laser uses two wavelengths such as Nd-YAG 1064 and Er-YAG 2940 nm in four different modes of non-ablative and ablative fractional laser to induce bulk heating in different tissue layers of facial skin. Although the overall rate of fractional laser complications is much lower than that of traditional techniques, recent studies have shown that fractional lasers can cause complications such as acne, milia, prolonged erythema, infections, and pigmentary alterations.In this report, we present a very unique case of a 41-year-old female patient with mild comedonal acne who developed severe acne agminate-like granulomatous reaction following fractional rejuvenation laser therapy that resolved spontaneously within 2 months after laser therapy. To the best of our knowledge, this is the first case of acne agminate as a side effect of rejuvenation laser therapy.As ruptured hair follicles are proposed as a pathogenic factor in both acne agminate and developing acne following fractional laser therapies, it is recommended to cautiously use resurfacing fractional lasers or to thoroughly treat acne before laser therapy due to the risk of developing a granulomatous reaction.