Evaluation of Fractional CO2 Versus Long Pulsed Nd:YAG Lasers in Treatment of Hypertrophic Scars and Keloids: A Randomized Clinical Trial.

BACKGROUND: Keloids and hypertrophic scars are challenging to both patients and physicians. They can be aesthetically disfiguring, functionally debilitating, and emotionally distressing. Lasers have introduced new mechanisms to improve scars both on aesthetic and symptomatic levels. AIM OF WORK: Comparing the efficacy of fractional CO2 laser, long-pulsed Nd:YAG laser and their combination in the treatment of hypertrophic scars and keloids on clinical, histopathological, and biochemical basis. PATIENTS AND METHODS: Thirty patients with hypertrophic scars and keloids were enrolled in the study. Three scars in each patient were randomly assigned to treatment modalities (i) Fractional CO2 , (ii) Nd:YAG laser, (iii) Combined CO2 and Nd:YAG lasers. For each treatment area four sessions, 4-6 weeks apart were performed. Clinical evaluation was done before and 1 month following last session using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). Routine hematoxylin and eosin, Masson's trichrome, and Orcein stains were used to evaluate the appearance and pattern of dermal collagen and elastic fibers. Image analysis was used to quantitatively assess the density of collagen and elastic fibers. Biochemical evaluation of tissue level of transforming growth factor-ß I (TGF-ß I) and TGF-ß III was performed using enzyme-linked immunosorbent assay studies. RESULTS: Both VSS and POSAS showed significant improvement following treatment with the three used modalities. Collagen fibers showed significant improvement as regards appearance and pattern while it was insignificant as regards density. Elastic fibers density improvement was only significant in fractional CO2 (treatment area A). Hypertrophic scars showed more significant improvement with fractional CO2 laser, while in keloids there was no significant difference between the three modalities regarding improvement. Level of TGF-ß I showed significant reduction after treatment in all treatment modalities, while TGF-ß III levels showed insignificant elevation in all treatment modalities. Side effects were significantly higher in treatment area C (combined treatment). CONCLUSION: Long pulsed Nd:YAG laser is effective and safe treatment of hypertrophic scars and keloids. Fractional CO2 laser yields better improvement in hypertrophic scars, while in keloids both fractional CO2 and Nd:YAG lasers achieve comparable improvement. Combination in the same session did not add significant additional benefit and the side effects profile was higher. LIMITATIONS: small sample size and short follow-up period. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

Efficacy of fractional carbon dioxide laser versus microneedling in the treatment of striae distensae.

Background: Fractional photothermolysis is creation of microscopic thermal zones of controlled depth, width and density. Microneedling is a simple treatment modality to reduce striae distensae. Objective: Evaluate and compare the efficacy of fractional carbon dioxide laser and microneedling as a treatment of striae distensae. Methods: Individuals with striae distensae received three split-body treatments at four-week intervals. The right side of the body was treated with fractional CO2 laser, while the other side with microneedling. Assessment was done by comparing photographs before and after treatments by two blinded physicians using a quartile grading scale. Evaluation also included patient satisfaction score and histopathological examination. Results: In total 33 subjects were enrolled and 30 completed the study. By quartile grading score, we recorded 55% moderate-excellent improvement of striae in the dermaroller-treated side but with fractional CO2 laser-treated side, we recorded 76% of patients had moderate-excellent improvement. Patients were more satisfied with fractional CO2 laser than the microneedling. Post-inflammatory hyperpigmentation, as a complication of fractional CO2 laser, appeared in 11 patients. Conclusion: Fractional CO2 laser is more effective in treating striae with acceptable side effects but still microneedling can be afforded as an effective, safe and cheap method.

Effect of oral isotretinoin on the nucleo-cytoplasmic distribution of FoxO1 and FoxO3 proteins in sebaceous glands of patients with acne vulgaris.

Oral isotretinoin is the most effective anti-acne drug with the strongest sebum-suppressive effect caused by sebocyte apoptosis. It has been hypothesized that upregulation of nuclear FoxO transcription factors and p53 mediate isotretinoin-induced sebocyte apoptosis in vivo. It is the aim of our study to analyse the distribution of the pro-apoptotic transcription factors FoxO1 and FoxO3 in the nuclear and cytoplasmic compartments of human sebocytes in vivo before and during isotretinoin treatment of acne patients. Immunohistochemical analysis of skin biopsies with antibodies distinguishing phosphorylated and non-phosphorylated human FoxO1 and FoxO3 proteins was performed before isotretinoin treatment, six weeks after initiation of isotretinoin therapy, and in acne-free control patients not treated with isotretinoin. Our in vivo study demonstrates a significant increase in the nucleo-cytoplasmic ratio of non-phosphorylated FoxO1 and FoxO3 during isotretinoin treatment of acne patients. Translational and presented experimental evidence indicates that upregulation of nuclear FoxO1 and FoxO3 proteins is involved in isotretinoin-induced pro-apoptotic signalling in sebocytes confirming the scientific hypothesis of isotretinoin-mediated upregulation of FoxO expression.

The role of systemic steroids and phototherapy in the treatment of stable vitiligo: a randomized controlled trial.

Pathogenesis of vitiligo is believed to be multifactorial disease with a wide variety of therapeutic modalities. The aim of this work is to assess the efficacy of oral mini-pulse steroids (OMP) plus Nb-U.V.B in comparison to OMP alone and Nb-U.V.B alone in treating stable vitiligo. A prospective randomized controlled study including 45 patients categorized into three groups receiving therapy for 3 months; Group A received Nb-U.V.B plus OMP, Group B received OMP alone while Group C received Nb-U.V.B alone. Clinical assessment and PCR evaluation of bFGF, ICAM1, and ELISA for AMA were done. Patients receiving Nb-U.V.B plus OMP and using Nb-U.V.B alone gave statistically significant clinical response than those treated with OMP alone. Statistically significant rise of BFGF was noticed after treatment with Nb-U.V.B plus OMP and with Nb-U.V.B alone. Patients treated with OMP alone and with Nb-U.V.B alone showed statistically significant drop of ICAM-1 after therapy. NB-U.V.B plus OMP and Nb-U.V.B alone were found to be clinically superior over OMP alone in treating stable vitiligo patients, hence suggesting that adding OMP to Nb-U.V.B can maintain clinical and laboratory success for a longer period of time and with less relapse.

Percutaneous collagen induction versus full-concentration trichloroacetic acid in the treatment of atrophic acne scars.

BACKGROUND: Percutaneous collagen induction (PCI) promotes removal of damaged collagen and induces more collagen immediately under the epidermis. The chemical reconstruction of skin scars (CROSS) method is a focal application of full-concentration trichloroacetic acid (TCA) to atrophic acne scars. The CROSS method has the advantage of reconstructing acne scars by increasing dermal thickening and collagen production. OBJECTIVE: To compare the safety and efficacy of PCI and the 100% TCA CROSS method for the treatment of atrophic acne scars. MATERIALS AND METHODS: Thirty participants were randomly equally divided into two groups; group 1 underwent four sessions (4 weeks apart) of PCI, and group 2 underwent four sessions (4 weeks apart) of 100% TCA CROSS. RESULTS: Acne scarring improved in 100% of patients. Scar severity scores improved by a mean of 68.3% (p<.001) in group 1 and a mean of 75.3% (p<.001) in group 2. The difference in the degree of improvement was not statistically significant between the groups (p=.47). CONCLUSIONS: PCI and 100% TCA CROSS were effective in the treatment of atrophic acne scars.

Bcl-2 expression in mycosis fungoides before and after PUVA therapy.

PUVA is the first therapeutic choice in early stages of mycosis fungoides (MF). In this study the effect of PUVA on bcl-2 expression in MF was assessed in 15 patients (three stage Ia and 12 stage Ib) and 10 controls. Two biopsies were taken from each patient before and after 24 sessions of PUVA therapy. Histopathological assessment and immunohistochemical staining for bcl-2 was performed and showed positive bcl-2 staining of lymphocytes in 53% of MF cases (8/15) before PUVA, with no statistically significant difference in the bcl-2 level before and after PUVA therapy (P value 0.3). A statistically significant difference was found in the bcl-2 level between control samples and MF patients' biopsies before (P value 0.02) and after PUVA therapy (P value 0.011). In conclusion, a lack of decline in the bcl-2 level and the absence of clinical or histopathological correlation with the bcl-2 level before and after PUVA therapy in MF patients suggest that PUVA-induced apoptosis in MF cases may occur through pathways other than bcl-2 inhibition.

Increased tenascin C and DKK1 in vitiligo: possible role of fibroblasts in acral and non-acral disease.

Recently, multiple culprits-in addition to melanocytes-have been implicated in the pathogenesis of vitiligo. Among those factors are fibroblasts. However, their exact role has not been clearly elucidated. The aim of the study was to evaluate the possible role played by fibroblasts in vitiligo via studying the expression Tenascin C and DKK1 in acral versus non-acral vitiligo lesions. This case-control study included 19 non-segmental vitiligo patients and ten controls. All patients were subjected to thorough clinical evaluation. Both Tenascin C and DKK1 were measured in lesional and peri-lesional skin of acral and non-acral lesions using ELISA technique. The measured levels of Tenascin C and DKK1 were significantly higher in the vitiligo group when compared to controls in all assessed sites (P < 0.05). Tenascin C was found to be significantly higher in lesional areas compared to peri-lesional ones only in the acral sites. DKK1 was significantly higher in lesional areas in all assessed sites (P < 0.05). The current work suggests a malfunction of fibroblasts in vitiligo, through demonstrating significant up-regulation of two melanogenesis inhibitory products (Tenascin C and DKK1) in patients compared to controls. Larger scale studies are warranted to detect the possible implications of such findings on vitiligo treatment.

CXCL-10 and Interleukin-6 are reliable serum markers for vitiligo activity: A multicenter cross-sectional study.

This cross-sectional multicenter study aimed to evaluate serum CXCL-10, as an activity marker for vitiligo, and compare it with other putative serum and tissue markers. Serum CXCL-10 was compared to interferon gamma (IFN-γ), interleukin 6 (IL-6), and IL-17 using ELISA in 55 non-segmental vitiligo patients (30 active and 25 stable) and 30 healthy controls. Marginal skin biopsy was taken for immunohistochemical evaluation of CD8+T cells and CXCL-10+ve cells. Serum levels of CXCL-10, IL-17, and IL-6 were elevated in all vitiligo patients compared to controls (p < .05). All investigated serum markers were higher in active versus stable vitiligo. Tissue expression of CXCL-10+ve cells and CD8+ve T cells was stronger in vitiligo patients compared to controls, and tissue CXCL-10+ve cell expression was stronger in active versus stable cases. Positive correlations were noted between the different serum and tissue markers. CXCL-10 was the most specific, whereas IL-6 was the most sensitive serum marker to distinguish active from stable disease.

Hair loss at injection sites of mesotherapy for alopecia.

BACKGROUND: The side effects of mesotherapy for treatment of various forms of alopecia are often underreported, while scientific data for its efficacy are severely lacking. OBJECTIVE: To demonstrate the late onset side effects of mesotherapy for alopecia. METHODS: Three patients with androgenetic alopecia showed hair loss after previously uneventful mesotherapy sessions up to 1 year. RESULTS: Clinical, dermoscopic, and histopathological findings suggested an inflammatory scaring process at sites of mesotherapy injections. CONCLUSION: Mesotherapy for androgenetic alopecia may paradoxically induce hair loss and scarring. Proper regulation and monitoring of the use of mesotherapy products for treating hair loss in women, needs to be addressed.

Autologous platelet-rich plasma versus readymade growth factors in skin rejuvenation: A split face study.

BACKGROUND: The escalating urge for a youthful-looking skin instigates continuous innovations with minimally invasive procedures. Readymade growth factors and autologous platelet-rich plasma (PRP) represent such therapeutic interventions. OBJECTIVE: Compare the efficacy and safety of PRP to readymade growth factors in skin rejuvenation. PATIENTS AND METHODS: Twenty adult females with Fitzpatrick skin types III-IV and Glogau photoaging types II and III were enrolled in this study. They underwent a split face therapy where each side was randomly assigned to treatment by either readymade growth factors (area A) or autologous PRP (area B). All patients received six sessions at 2-weeks interval. Evaluation was carried out using Global Aesthetic Improvement Scale (GAIS) and optical coherence tomography (OCT). Patients were followed up for 6 months. RESULTS: Both procedures yielded significant improvement regarding both GAIS (skin turgor and overall vitality) and OCT (epidermal and dermal thickness) assessment. Significant negative correlation was detected between patients' age, sun exposure, and GAIS. Burning sensation was significantly higher in area A. Patient satisfaction was significantly higher in area B. Improvement was more sustained in area B on follow-up. CONCLUSION: Platelet-rich plasma is effective and safe for skin rejuvenation, comparable to readymade growth factors with noticeable higher longevity.

Assessment of Tissue Level of Histone Deactylase-2 (HDAC-2) in Patients With Mycosis Fungoides.

BACKGROUND: Histone deactylases (HDAC) have a role in the pathogenesis of mycosis fungoides (MF) through their actions on different apoptosis pathways. OBJECTIVE: To assess the possible role played by HDAC-2 in MF by estimating the tissue expression of HDAC2 mRNA in different stages of MF. METHODS: This study included 28 MF patients and 30 controls. The HDAC-2 levels were detected by real-time polymerase chain reaction (PCR). Correlations of HDAC-2 levels with clinical presentation and different stages of MF were analyzed. RESULTS: Mean HDAC-2 level was significantly higher in patients (P < .001) than in controls. HDAC-2 highest mean value was significantly detected in patients with stage IIb, and the lowest mean value was detected in patients with stage Ia (P < .001). CONCLUSION: Up-regulation of tissue HDAC-2 in MF patients might develop a new approach in the understanding of the pathogenesis of MF. Histone deactylases are important targets for molecular cancer therapeutics.

Subclinical Onychomycosis in Patients With Type II Diabetes.

Fungal organisms could be present in the nail without any clinical manifestations. As onychomycosis in diabetics has more serious complications, early detection of such infection could be helpful to prevent them. We aim in this study to assess the possibility of detecting subclinical onychomycosis in type II diabetic patients and addressing possible associated neuropathy. A cross sectional, observational study included patients with type II diabetes with normal big toe nail. All were subjected to nail clipping of the big toe nail, followed by staining with Hematoxylin and Eosin and Periodic-Acid-Schiff (PAS) stains and examined microscopically. A total of 106 patients were included, fungal infection was identified in eight specimens, all were uncontrolled diabetes, and six had neuropathy. Using the nail clipping and microscopic examination with PAS stain to detect such subclinical infection could be an applicable screening test for diabetic patients, for early detection and management of onychomycosis.

Study of T helper 1 and T helper 2 responses in pemphigus vulgaris patients receiving interferon alpha 2a injections in addition to a standard protocol therapy: a randomized controlled trial.

T helper (Th)1 insufficiency was recently found to be related to the pathogenesis of pemphigus vulgaris (PV). Decreased Th1 response was particularly noticed in the early stages of PV. Therefore, administration of interferon alpha in the early stages of aggressive PV may lead to rapid control of the acute stage of the disease. Our aim was to evaluate the role of interferon alpha in the treatment of PV. 30 patients with acute severe PV (>60 % affection) and 30 age and sex-matched healthy subjects were included in this RCT. Patients were randomly divided into two groups (A and B). Group B patients received interferon retard (one subcutaneous injection/week for 4 weeks) in addition to our protocol for the treatment of PV (systemic pulse corticosteroids/cyclophosphamide in combination with sulphasalazine and pentoxifylline) that was administered to all the included patients. IFN-γ and IL-4 were estimated by ELISA before treatment, after 4 weeks and at the end of the study duration (12 weeks). Clinical assessment was done by PAAS on a biweekly basis. All PV patients showed significantly (P < 0.001) elevated levels of IL-4 and significantly (P < 0.001) depressed mean concentration of IFN-γ as compared with healthy controls. Twelve weeks after therapy both groups showed significant improvement in their mean PAAS being more evident and more rapid in group B. IFN-γ was elevated significantly and IL-4 was dropped significantly in group B patients in comparison to group A (P < 0.001). As a conclusion, interferon therapy in severe PV could achieve a more prompt and better clinical response.

Crude Coal Tar and Ultraviolet (UV) A radiation (Modified Goeckerman Technique) in Treatment of Psoriasis.

Psoriasis is a chronic inflammatory dermatosis that has a substantial impact on the quality of life. Goeckerman's technique (GT) has been implemented for the treatment of psoriasis with high clearance rates and long periods of remission. The objective of this article was to evaluate the efficacy and safety of modified GT (crude coal tar 2.5% plus UVA) as an alternative therapeutic modality for psoriatic patients with skin types III-V. Twenty two patients with moderate, severe, and erythrodermic psoriasis were included in this study. All patients received modified GT (crude coal tar 2.5% plus UVA) six days per week for a period of 3 months. Assessment of the rate of reduction of psoriasis area severity index (PASI) was performed, as well as photographic documentation of each patient at baseline and after completion of therapy. There was a significant reduction in PASI scores after therapy in all patients (P=0.001). The rate of PASI reduction after therapy was >50% in 63.6% of patients; 27.3% of patients achieved >75% reduction and 9.1% of patients achieved 26-50% reduction. No serious side effects were reported in any of the patients. Modified GT is a safe and effective therapeutic option for patients with moderate and severe psoriasis.

Analysis of oxidative stress status, catalase and catechol-O-methyltransferase polymorphisms in Egyptian vitiligo patients.

Vitiligo is the most common depigmentation disorder of the skin. Oxidative stress is implicated as one of the probable events involved in vitiligo pathogenesis possibly contributing to melanocyte destruction. Evidence indicates that certain genes including those involved in oxidative stress and melanin synthesis are crucial for development of vitiligo. This study evaluates the oxidative stress status, the role of catalase (CAT) and catechol-O-Methyltransferase (COMT) gene polymorphisms in the etiology of generalized vitiligo in Egyptians. Total antioxidant capacity (TAC) and malondialdehyde (MDA) levels as well as CAT exon 9 T/C and COMT 158 G/A polymorphisms were determined in 89 patients and 90 age and sex-matched controls. Our results showed significantly lower TAC along with higher MDA levels in vitiligo patients compared with controls. Meanwhile, genotype and allele distributions of CAT and COMT polymorphisms in cases were not significantly different from those of controls. Moreover, we found no association between both polymorphisms and vitiligo susceptibility. In conclusion, the enhanced oxidative stress with the lack of association between CAT and COMT polymorphisms and susceptibility to vitiligo in our patients suggest that mutations in other genes related to the oxidative pathway might contribute to the etiology of generalized vitiligo in Egyptian population.

Expression of TNF-α, APRIL and BCMA in Behcet's disease.

BACKGROUND: Tumor necrosis factor-alpha (TNF-α) is an important proinflammatory cytokine which plays an important role in the immunopathogenesis of Behcet's disease (BD). B cell activating factor (BAFF) and its homolog A proliferation inducing ligand (APRIL) are members of the tumor necrosis factor family. BAFF binds to 3 receptors, B cell activating factor receptor (BAFF-R), transmembrane activator and calcium modulator ligand interactor (TACI), and B cell maturation antigen (BCMA) that are expressed by B cells. OBJECTIVE: Estimation of the serum levels of TNF-α, APRIL, BAFF, and BCMA in patients with BD in an effort to evaluate their degree of involvement in the pathogenesis and development of BD. PATIENTS AND METHODS: This study included 30 male patients fulfilling the international study group criteria for the diagnosis of BD. Twenty age-matched healthy male volunteers served as control. Serum samples were used for quantification of TNF-α, APRIL, BCMA, BAFF, and hsCRP using ELISA techniques. RESULTS: The mean serum levels of TNF-α, APRIL, BCMA, and BAFF were more elevated in cases than in controls in a statistically significant manner (P < 0.001). Positive correlation was observed between hs-CRP and BDCAF (Behcet's disease current activity forum) index (r 0.68, P < 0.001). None of the TNF family members tested was affected by a positive pathergy test. CONCLUSIONS: Patients have significantly higher levels of TNF family members' (TNF-α, BAFF, APRIL, and BCMA) compared to controls which might contribute to the pathogenesis of BD.