Recurrent papulonodular herpes zoster, with syringitis, folliculitis, and vasculitis as clues to the diagnosis.

Herpes zoster (HZ) may have atypical clinical presentations, particularly in immunosuppressed patients. Nodular HZ is an extremely rare condition. We report the first case of recurrent papulonodular HZ in an adult patient with inflammatory bowel disease (IBD) receiving biologic treatment. More interestingly, there was no epidermal involvement on histopathological examination, but the involvement of the adnexa and blood vessels was a clue to the diagnosis in view of the clinical context. We wish to raise awareness of this rare manifestation of HZ for early diagnosis and proper treatment.

Efficacy of narrow band UVB with or without OMP in stabilization of vitiligo activity in skin photo-types (III-V): A double-blind, randomized, placebo-controlled, prospective, multicenter study.

BACKGROUND: NB-UVB has long been the vitiligo management pillar with capability of achieving the main treatment outcomes; repigmentation and stabilization. Its stabilizing effect in dark skin has been debatable. However, randomized controlled trials regarding NB-UVB ability to control disease activity are lacking. PURPOSE: To assess stabilizing effect of NB-UVB in comparison to systemic corticosteroids, the mainstay in vitiligo stabilization, in skin photo-types (III-V). METHODS: This is a multicenter, placebo-controlled, randomized, prospective study. Eighty patients with active nonsegmental vitiligo (NSV) (Vitiligo disease activity (VIDA) ≥2) were randomized to either NB-UVB and placebo (NB-placebo) or NB-UVB and dexamethasone oral mini-pulse (OMP) therapy (NB-OMP) for 6 months. Sixty four patients completed the study, 34 in the NB-OMP group and 30 in the NB-placebo group. Patients were evaluated fortnightly according to presence or absence of symptoms/signs of activity. RESULTS: In spite of earlier control of disease activity observed in the NB-OMP group, it was comparable in both groups by the end of the study period. Disease activity prior to therapy, but not extent, was found to influence control of activity in both groups. Thus, NB-UVB is a safe sole therapeutic tool in vitiligo management. Not only does it efficiently achieve repigmentation, but also it is a comparable stabilizing tool for systemic corticosteroids in spite of slightly delayed control. CONCLUSION: NB-UVB is the only well-established vitiligo therapy that can be used solely whenever corticosteroids are contraindicated or immune-suppression is unjustified. Nonetheless, its combination with corticosteroids expedites response and improves compliance.

Fractional Erbium-Doped Yttrium Aluminum Garnet Laser in the Treatment of Primary Cutaneous Amyloidosis.

BACKGROUND: Although various treatments are currently available for primary cutaneous amyloidosis (PCA), there is no entirely satisfactory treatment. Recently, fractional ablative lasers are claimed to have therapeutic effects for PCA. OBJECTIVE: To evaluate the efficacy and safety of fractional Er:YAG laser for the treatment of PCA. METHODS AND MATERIALS: Ten patients with macular and lichen amyloidosis received 4 treatment sessions with 4-week intervals. The outcome was assessed clinically (degree of pigmentation, rippling, lichenification, and itching) through photographs and histologically (amount of amyloid, melanin, epidermal thickness, and depth of rete ridges) through biopsy specimens stained with hematoxylin-eosin, Congo red, and Fontana-Masson stain. Patients were followed up for 3 months after the final treatment. RESULTS: At 3-month follow-up, fractional Er:YAG laser exhibited a significant clinical and histological improvement. Patient satisfaction concurred with physicians' evaluations. Recurrence was detected in 1 patient. CONCLUSION: In light of the authors' findings, fractional Er:YAG laser offered a great clinical and histological efficacy with excellent safety profile. Careful laser selection based on making a compromise between efficacies and safeties may improve outcome.

Estimation of Homocysteine Level and Methylenetetrahydrofolate Reductase (MTHFR) Gene and Cystathionine B Synthase (CBS) Gene Polymorphisms in Vitiligo Patients.

BACKGROUND: Vitiligo is an acquired, multifactorial disorder of the skin and mucous membranes. An elevated homocysteine level has been described in vitiligo. Methylenetetrahydrofolate reductase (MTHFR) and cystathionine B synthase (CBS) are major determinants of the homocysteine metabolism. OBJECTIVES: Determine serum homocysteine levels in vitiligo patients as well as the association between MTHFR (C677T, A1298C) and CBSgene polymorphisms and susceptibility to vitiligo in a sample of those populations. METHODS: Homocysteine levels were estimated by radioimmunoassay while MTHFR (C677T, A1298C) and CBSgene polymorphisms were detected by the polymerase chain reaction-restriction fragment length polymorphism technique in 100 vitiligo patients and 80 healthy controls. RESULTS: The homocysteine level was significantly higher in vitiligo patients than controls (p = 0.000). Significant differences in the genotype and allele distributions of single nucleotide polymorphisms of the MTHFR (C677T, A1298C) with the mutant genotypes are more common in the controls than patients (p = 0.001, 0.029, respectively). CBS gene mutant genotypes and alleles are more common in vitiligo patients than controls (p = 0.002). CONCLUSION: CBSand MTHFRgene polymorphisms may play a major role in the genetic susceptibility to vitiligo.

Fractional Erbium-Doped Yttrium Aluminum Garnet Laser Versus Microneedling in Treatment of Atrophic Acne Scars: A Randomized Split-Face Clinical Study.

BACKGROUND: Ablative fractional erbium-doped yttrium aluminum garnet (Er:YAG) laser and microneedling have been popularized in recent years and their effectiveness and side effects individually reported. No previous study, however, has directly compared the efficacy and safety between the 2 different treatments. OBJECTIVE: To compare the efficacy and safety of the ablative fractional Er:YAG laser and microneedling for the treatment of atrophic acne scars. MATERIALS AND METHODS: Thirty patients with atrophic acne scars were randomly treated in a split-face manner with a fractional Er:YAG laser on one side and microneedling on the other side. All patients received 5 treatments with a 1-month interval. Objective and subjective assessments were obtained at baseline and at 3 months after the final treatment. RESULTS: At the 3-month follow-up, both treatment modalities induced noticeable clinical and histological improvement, with significantly better results in fractional Er:YAG laser versus microneedling (70% vs 30%), respectively (p < .001). Fractional Er:YAG laser sides had significantly lower pain scores. Total downtime was significantly shorter in microneedling sides. CONCLUSION: Both treatment modalities are effective and safe in the treatment of atrophic acne scars, with significantly higher scar response to the fractional Er:YAG laser treatment.

Treatment of dystrophic epidermolysis bullosa with bone marrow non-hematopoeitic stem cells: a randomized controlled trial.

Patients with dystrophic epidermolysis bullosa (DEB) have mutations in type VII collagen gene. Type VII collagen is synthesized by keratinocytes and fibroblasts. Based on the ability of bone marrow non-hematopoeitic stem cells (NHBMSC) to develop into fibroblasts, we decided to investigate the use of NHBMSC in the treatment of recessive DEB (RDEB). This study included fourteen patients with RDEB; the first seven of them were given cyclosporine after the infusion of NHBMSC. As cyclosporine has been used for the treatment of RDEB we decided not to use cyclosporine for the second group of seven patients. Skin biopsies from the lesions were studied by electron microscopy before and after treatment. The number of new blisters decreased significantly after treatment in both groups (p = 0.003 and 0.004 respectively) and the rate of healing of new blisters became significantly faster after treatment in both groups (p < 0.001) with no significant difference between the two groups. Electron microscopic examination revealed increased number of anchoring fibrils after treatment in both groups. No major side effects were reported during the 1-year follow-up period. Our findings highlight the efficacy as well as the safety of NHBMSC in the treatment of RDEB.

Vitiligo - The story from within: A transmission electron microscopic study before and after narrow-band ultraviolet B.

Melanocyte loss is the main feature of vitiligo, but evidence refers to pathological multiplayers. Transmission electron microscopy was utilized to further explore vitiligo before and after narrow-band ultraviolet B (NB-UVB) therapy. Skin biopsies were retrieved from lesional and perilesional skin and compared to normal control skin. Sections were examined for melanocytes and keratinocytes and the number of melanosomes and thickness of basal lamina were measured. In lesional skin, keratinocytes revealed two types of degeneration with a significant increase in the mean thickness of basal lamina and decrease in the number of melanosomes. After treatment, lesional and perilesional skin showed variable ultrastructural features.

Comparison of the effectiveness of two fluences using long-pulsed Nd:YAG laser in the treatment of striae distensae. Histological and morphometric evaluation.

Striae distensae are common undesirable skin lesions of significant aesthetic concern. To compare the efficacy of two fluences (75 and 100 J/cm2) of long-pulsed Nd:YAG laser in the treatment of striae. Forty-five patients (Fitzpatrick skin types III-V) aged between 11 and 36 years with striae (23 patients with rubra type and 22 with alba type) were enrolled in the study. Each stria was divided into three equal sections, whereby the outer sections were treated with long-pulsed 1064 nm Nd:YAG laser, at a fluence of 75 or 100 J/cm2, and fixed laser settings of 5 mm spot size and 15 ms pulse duration. The middle section was an untreated control. All subjects received four treatments at 3 weeks interval. Three 2-mm punch biopsies were taken from six subjects, all of the same stria, one before treatment and the other two from the outer sections, 3 months after the last session. Paraffin-embedded skin sections were subjected to histological and quantitative morphometric studies for collagen and elastic fibres. Results were assessed clinically through photographic evaluation and were considered satisfactory for both doctors and patients. A significant improvement in appearance of striae alba using 100 J/cm2 was found while striae rubra improved more with 75 J/cm2. Histologically, collagen and elastin fibres increased in posttreatment samples. A satisfactory improvement in striae distensae lesions was seen through clinical and histological evaluation. Thus, long-pulsed Nd:YAG laser is a safe and effective module of laser treatment for these common skin lesions.

T helper 17 and Tregs: a novel proposed mechanism for NB-UVB in vitiligo.

Narrowband ultraviolet (NB-UV)B is accepted as corner stone therapy for vitiligo. Its influence on the expression of IL-17, IL- 22 and FoxP3 as markers for the Th17 and Tregs lineages has not been studied before in the context of non-segmental vitiligo (NSV). The study included 20 active NSV patients who received 36 NB-UVB sessions and 20 controls. Clinical evaluation Vitiligo Area Scoring Index (VASI) and determination of tissue expression of IL-17, IL-22 and FoxP3 by qRT-PCR (lesional, perilesional) were carried out before and after therapy. Baseline levels of IL-17 and IL-22 were significantly higher in patients, whereas FoxP3 was significantly lower. After therapy, IL-17 and IL-22 significantly dropped, whereas FoxP3 significantly increased (lesional, perilesional). Baseline and post-treatment VASI showed significant positive correlations with IL-17 and IL-22 and significant negative correlation with FoxP3 expression. Restoration of the balance between Th17 and Tregs might represent a novel pathway for the improvement that NB-UVB exerts in vitiligo patients.

Autologous platelet rich plasma: topical versus intradermal after fractional ablative carbon dioxide laser treatment of atrophic acne scars.

BACKGROUND: A proposal has recently been made regarding the potential adjuvant use of platelet-rich plasma (PRP) with fractional carbon dioxide laser (FCL) for the correction of acne scars. OBJECTIVE: To compare the efficacy and safety of two administration modes of autologous PRP (intradermal injection (ID) and topical application) after FCL with that of FCL alone in the treatment of atrophic acne scars. PATIENTS AND METHODS: Thirty patients were randomly divided into two groups. Both underwent split-face therapy. Group 1 was administered FCL followed by ID PRP on one side and FCL followed by ID saline on the other. In group 2, one cheek was treated with FCL followed by ID PRP, and the other received FCL followed by topical PRP. Each patient received 3 monthly sessions. The final assessment took place at 6 months. RESULTS: Combined PRP- and FCL-treated areas had a significantly better response (p = .03), fewer side effects, and shorter downtime (p = .02) than FCL-treated areas, but there were no significant differences in ID- and topical PRP-treated areas in degree of response and downtime (p = .10); topically treated areas had significantly lower pain scores. CONCLUSION: The current study introduces the combination of topical PRP and FCL as an effective, safe modality in the treatment of atrophic acne scars with shorter downtime than FCL alone and better tolerability than FCL combined with ID PRP.

Randomized split-face controlled study to evaluate 1550-nm fractionated erbium glass laser for treatment of acne vulgaris--an image analysis evaluation.

BACKGROUND: Novel and promising results in acne treatment with infrared lasers have been reported. The 1,550-nm erbium glass laser is one of the infrared lasers that may be useful in the treatment of acne. OBJECTIVE: The aim of this study was to evaluate the efficacy of an erbium glass laser in treatment of active acne and to study the effect of this type of laser on sebaceous glands. PATIENTS AND METHODS: Twenty-four patients with active acne lesions were treated using 1,550-nm (30-40 mJ) fractional erbium glass laser. Every patient received 4 sessions with a 2-week interval. Follow-up was done every 3 months for 1 year. The image analyzer computer system was used to measure the sebaceous gland size. RESULTS: A significant reduction (p < .0001) in the mean count of lesions was observed after treatment and in the follow-up period. A significant reduction in the size of sebaceous glands was also evident after laser treatment. CONCLUSION: Treatment of active acne with the 1,550-nm erbium glass laser is effective. Papules, pustules, and nodules all respond well to therapy. The sebaceous gland size decreased significantly, which accounts for the long remission period.

Topical sodium valproate-loaded nanospanlastics versus conventional topical steroid therapy in alopecia areata: a randomized controlled study.

BACKGROUND: A myriad of therapeutic modalities for alopecia areata are available; however, none is of high level of evidence, creating an immense need for the evaluation of other treatment modalities, of which topical sodium valproate is of potential role via proposed decrease in beta-catenin breakdown, despite its well-known side effect of hair fall as an oral therapy. OBJECTIVE: Evaluating the efficacy and the safety of sodium valproate (SV)-loaded nanospanlastics, in comparison to topical corticosteroids, this is the currently available gold standard topical treatment for patchy AA. METHODOLOGY: A total of 66 patients with patchy AA were randomly assigned to receive either topical mometasone furoate lotion or topical SV applied twice daily to all patches except a control patch, which was left untreated. Clinical, trichoscopic and biochemical assessments of beta-catenin tissue levels and Axin-2 gene expression were carried out at baseline and after 3 months. RESULTS: Both therapeutic modalities were comparable. Potential efficacy was highlighted by significant improvement in the representative patch, the largest treated patch, to the control patch, the smallest untreated patch in both steroid and valproate groups (p = 0.027, 0.003 respectively). Both beta-catenin levels and Axin-2 gene expression were reduced after treatment, pointing to the inhibitory effect of dominating uncontrolled inflammatory milieu. Baseline beta-catenin was found to significantly negatively correlate with improvement in the representative patch in patients with baseline level above 0.42 ng/ml (p = - 0.042). CONCLUSION: Both topical SV and steroids are of comparable modest efficacy. Thus, further evaluation of SV is due in combination with intralesional steroids and other anti-inflammatory treatment modalities, together with developing individualized approaches based on baseline beta-catenin level. GOV IDENTIFIER: NCT05017454, https://clinicaltrials.gov/ct2/show/NCT05017454 .

Tabit Ibn Qurrah's contributions to toxicology.

Mankind has been familiar with poisons since ancient times. On the other hand, there is a wealth of knowledge in the medical books including medieval works of Middle Eastern polymaths such as Avicenna, "al-Razi," and "Tabit Ibn Qurrah." This study presented and analyzed the knowledge of medical toxicology in one of the mainstay works of "Tabit Ibn Qurrah" entitled "al-Dahirah Fy Ꜥilm al-Tibb" also known as The Treasury of Medicine after the translation of the book from Arabic to English carefully and faithfully. Also, related toxicological literature was applied wherever required using English, Arabic, and Persian databases including Scopus, PubMed, Web of Science, WorldCat, Magiran, IranDoc, Scientific Information Database, Noor Mags, Noorlib, and Al Manhal. Our research revealed that chapter 25 of the mentioned book specifically focused on toxicology. This chapter was divided into sections on different aspects of toxicology from the categorization of poisons to compound mixtures causing poisonings to introducing blade poisons to signs and symptoms of poisonings, preventive approaches, and therapeutic agents. Specific antidotes and general therapies were introduced that included medicinal plants, cupping therapy, and bandages, just to name a few. Also, there were some monographs on the common poisonous agents and their treatments. The toxicological data of the book was comparable with modern toxicology. Our study highlighted the contributions of "Tabit Ibn Qurrah" to medical toxicology by authoring The Treasury of Medicine. Further research is recommended to elucidate the full aspects of the history of toxicology including the contributions of the past scholars.

BB-UVA vs. NB-UVB in the treatment of vitiligo: a randomized controlled clinical study (single blinded).

BACKGROUND: Vitiligo is an acquired pigmentary disorder that affects between 1% and 2% of the general population. Phototherapy remains the cornerstone of treatment, with NB-UVB being the most frequently used. BB-UVA can be a plausible alternative for darker population; skin photo type III and IV. PATIENTS AND METHODS: The study was a prospective, randomized, controlled, and single-blinded clinical trial, conducted on 40 patients with bilateral symmetrical vitiligo. The patients were randomly divided into two equal groups; group (A) received a fixed dose of 15 J/cm(2) BB-UVA, while group (B) received NB-UVB. The study was conducted for a period of 16 weeks (48 sessions). RESULTS: The final percentage of clinical improvement was significantly higher (P = 0.047) within the BB-UVA group (63.82% ± 27.42), than within the NB-UVB group (44.32% ± 29.78). CONCLUSION: BB-UVA can be considered as an alternative treatment line for vitiligo.

Hypopigmented parapsoriasis en plaque, a new, overlooked member of the parapsoriasis family: a report of 34 patients and a 7-year experience.

BACKGROUND: In the past 7 years we have extensively studied an uncommon hypopigmented disorder that, apart from hypopigmentation, showed many common features with parapsoriasis en plaque (PSEP), both clinically and histopathologically. OBJECTIVE: We sought to verify whether this disorder should be considered a hypopigmented variant of PSEP and thus be referred to as hypopigmented PSEP. METHODS: A total of 34 patients presenting with this peculiar hypopigmented disorder were included (2003-2010). Patients were subjected to a predesigned algorithm excluding all possible differential diagnoses of hypopigmented lesions. RESULTS: Our findings indicated that this disorder can be diagnosed as hypopigmented PSEP. These findings included: (1) exclusion of all other disorders causing similar hypopigmented lesions; (2) shape and size of the lesions being very similar to those of classic small PSEP (small-plaque parapsoriasis [SPP]); (3) similar distribution of the lesions (trunk, proximal upper and lower limbs) to the classic PSEP; (4) digitiform extensions of most the lesions (70.5% of our patients) as in SPP; (5) absence of itching as in PSEP (SPP type); (6) good response to narrowband ultraviolet B in 76.4% of the patients (n = 26); and (7) during follow-up 5 patients (14.7%) converted into hypopigmentd mycosis fungoides. LIMITATIONS: A limitation in our study is that we did not perform clonal T-cell receptor gene rearrangement because of limited resources. CONCLUSION: Based on our findings we believe that this hypopigmented disorder is a well-defined new variant of the PSEP family that shows, apart from the hypopigmentation, all the features of PSEP, particularly the SPP variant, and accordingly could be referred to as hypopigmented PSEP.

Broad band UVA: a possible reliable alternative to PUVA in the treatment of early-stage mycosis fungoides.

UVA1 phototherapy was found to induce marked improvement in skin lesions of patients with stages IA and IB mycosis fungoides (MF). Broad band UVA (BB-UVA) is composed of 80.1% UVA1, with similar mechanisms of action. Our aim was to evaluate the efficacy of BB-UVA in the treatment of early-stage MF. Thirty patients with early stage MF were included. They were divided into two equal groups receiving either BB-UVA at 20 J/cm2/ session or PUVA three times/week for 40 sessions. Clinical and histopathological evaluations were performed before and after therapy in addition to immunohistochemical measurement of CD4+ cells and Bcl-2. Patients were followed up for an average duration of 36 months. Comparable clinical and histopathological improvement was noted in MF patients in both groups. Clinical improvement graded 'Excellent' was achieved in 33% of patients in the BB-UVA versus 13.3% in the psoralen and UVA (PUVA) group. Long-term follow-up indicated superiority of BB-UVA over PUVA. BB-UVA group showed a more rapid clearance rate, shorter time to achieve complete clearance, a longer disease-free interval and lower relapse rate. The use of BB-UVA in the treatment of early-stage MF is comparable or even superior to PUVA regarding efficacy and remission periods.

Platelet-rich plasma versus carboxytherapy in the treatment of periorbital dark circles: A split-face study.

BACKGROUND: Periorbital hyperpigmentation is a recurrent problem in dermatologic clinics that affect the patients' quality of life and their psychological status. Platelet-rich plasma (PRP) may serve as a source of different growth factors which may reduce the pigmentation in this problem. Carboxytherapy is carbon dioxide infusion into human tissue for therapeutic purposes. OBJECTIVE: To evaluate and compare the clinical efficacy of PRP and carboxytherapy in the treatment of periorbital dark circles (PODC). Histopathological evaluation was also done. PATIENTS AND METHODS: Split-face study of 23 patients with PODC treated with PRP at the right side and carboxytherapy at the left side. Patients received four sessions; one session/week. Final follow-up evaluation was done 3 months after the last session by clinical and histopathological assessment. RESULTS: PRP showed significant better response (p = 0.002), shorter downtime, and tolerable side effects than caboxytherapy. Reduction in area percent of melanin after PRP injections showed 46.6% improvement, while after carboxytherapy, it showed only 14.3% improvement. CONCLUSION: The present study showed that PRP is more effective and tolerable than caboxytherapy in the treatment of PODC.

Value of silicone gel in prevention of cobblestoning following punch minigrafting in vitiligo.

BACKGROUND: Cobblestoning is the most common complication of minipunch grafting. OBJECTIVE: To assess the value of silicone gel application following minipunch grafting and the histopathological and immunohistochemical changes in cases with cobblestoning. METHODS: Minipunch grafting was performed in two similar vitiligo lesions in 27 cases with stable vitiligo. After healing, silicone gel was applied twice daily on one lesion while zinc oxide ointment was applied to the other lesion serving as a control. Four biopsies were taken from each case; normal, vitiliginous skin before treatment and the two treated lesions 3 months after therapy, for histopathology and immunohistochemical staining for MMP9 & tenascin-C. RESULTS: Repigmentation occurred in 19 cases (70.7%). The number of lesions showing excellent and good response was significantly higher on the silicone gel side (p < .001). In 20 cases, cobblestoning either occurred or was absent on both sides. Histopathologically, cobblestoning was similar to hypertrophic scarring. Both markers were elevated after therapy on both sides with no significant difference in percentage change between lesions showing positive and negative cobblestoning. CONCLUSION: Silicone gel application after minigrating improved the final response with no significant effect on the occurrence of cobblestoning. Cobblestoning resembled hypertrophic scarring histopathologically.