Fractional CO2 Laser-Assisted Delivery Versus Intralesional Injection of Methotrexate in Psoriatic Nails.

BACKGROUND: Nail psoriasis has a major negative impact on physical and psychological aspects of the patient's life. Treatment is often unsatisfactory because of difficult penetration of the drug into the nail. OBJECTIVE: To evaluate and compare the efficacy of laser-assisted delivery of methotrexate versus its intralesional injection in fingernail psoriasis. MATERIALS AND METHODS: Twenty-eight patients with fingernail psoriasis were divided into 2 groups of 14 patients each. Group A was treated with intralesional injection of methotrexate while Group B received fractional CO2 laser followed by topical application of methotrexate. The treatment was given at a 2-week interval for 6 sessions. The improvement of nail psoriasis was assessed by clinical and dermoscopic evaluation. RESULTS: At the end of treatment, both laser-assisted delivery and intralesional injection of methotrexate were associated with statistically significant improvement of psoriatic signs. No statistically significant difference was found between the 2 groups regarding total nail psoriasis severity Index (p = .18), matrix score (p = .38), bed score (p = .23), and dermoscopic score (p = .78). However, the pain and subungual hematoma were significantly less in the laser group (p < .001 and p = .03, respectively). CONCLUSION: Fractional CO2 laser-assisted delivery of methotrexate can be an effective and well-tolerated alternative to intralesional injection in nail psoriasis.

Intralesional Acyclovir: A Potential Therapeutic Option for Cutaneous Warts.

BACKGROUND: The treatment of warts is challenging and the development of an antiviral drug that can eradicate the human papilloma virus (HPV) is difficult. The viral origin of warts suggests that acyclovir, an antiviral drug with a proven efficacy in DNA viruses, may be a potential therapeutic option. AIM: To evaluate the efficacy and safety of intralesional acyclovir in the treatment of cutaneous warts. METHODS: Thirty-one patients with cutaneous warts were allocated into 2 groups. Group A (19 patients) had intralesional acyclovir (70 mg/ml) injected into the warts, while group B (12 patients) received intralesional saline as control. The treatment was repeated at 2 week intervals until complete clearance or for a maximum of 5 sessions. RESULTS: Complete clearance of warts was observed in 52.6%, partial response in 36.8%, and no response in 10.5% of the patients in the acyclovir group. Partial response was reported in 16.7%, and no response in 83.3% of the patients in the control group. A high statistically significant difference was found between the treatment and control groups (P < .01). Adverse effects included pain during injection in 89.5%, blistering in 52.6% and erythema in5.3% of the patients. No recurrence was detected during the follow-up period. CONCLUSION: Intralesional acyclovir can be an effective and well-tolerated treatment modality for cutaneous warts.

Comparison of fractional laser-assisted drug delivery and intralesional injection of triamcinolone acetonide in nail psoriasis.

BACKGROUND AND OBJECTIVES: The treatment of nail psoriasis is often unsatisfactory due to poor penetration of topical therapeutics through the nail plate. The development of innovative methods that provide adequate delivery of the drug into the nail is warranted. In this study, we aim to compare the efficacy of intralesional corticosteroid injection versus its topical application after fractional CO2 laser in the treatment of fingernail psoriasis. PATIENTS AND METHODS: The study included 36 patients with fingernail psoriasis divided into two groups. The nails in group A were treated with intralesional injection of triamcinolone acetonide while the nails in group B received fractional CO2 laser therapy followed by topical application of the drug for six sessions. The evaluation was performed using NAPSI and dermatoscopic scores. RESULTS: Both modalities yielded a significant improvement of the nail matrix and bed psoriatic signs. No statistically significant difference was found between the two groups by both clinical and dermatoscopic assessment. The laser treatment was associated with significantly lower pain scores (P = 0.03) and higher patient satisfaction (P = 0.007). CONCLUSIONS: Fractional CO2 laser-assisted delivery of topical corticosteroids can be a potentially effective and well-tolerated therapeutic modality in the treatment of nail psoriasis with comparable efficacy to intralesional injection.

Vergleich der fraktionierten laserunterstützten Medikamentengabe und der intraläsionalen Injektion von Triamcinolonacetonid bei Nagelpsoriasis.

HINTERGRUND UND ZIELE: Die Behandlung der Nagelpsoriasis ist wegen mangelnder Penetration topischer Therapeutika durch die Nagelplatte häufig unbefriedigend. Daher sind innovative Methoden zur adäquaten Verabreichung des Arzneimittels in den Nagel erforderlich. In dieser Studie vergleichen wir die Wirksamkeit der intraläsionalen Corticosteroid-Injektion mit topischer Applikation nach fraktionierter CO2 -Laser-Behandlung bei Fingernagelpsoriasis. PATIENTEN UND METHODEN: In der Studie wurden 36 Patienten mit Fingernagelpsoriasis in zwei Gruppen eingeteilt. Bei Gruppe A wurden die Nägel mit intraläsionalen Injektionen von Triamcinolon behandelt, in Gruppe B durch fraktionierte CO2 -Lasertherapie, gefolgt von topischer Applikation des Arzneimittels in sechs Sitzungen. Die Beurteilung erfolgte anhand des NAPSI und eines dermatoskopischen Scores. ERGEBNISSE: Beide Modalitäten führten zu signifikanter Besserung der Psoriasis an Nagelmatrix und Nagelbett. Statistisch signifikante Unterschiede zwischen den Gruppen bestanden weder klinisch noch dermatoskopisch. Die Laserbehandlung war mit signifikant geringeren Schmerz-Scores (P = 0,03) und höherer Patientenzufriedenheit (P = 0,007) verbunden. SCHLUSSFOLGERUNGEN: Die fraktionierte CO2 -Laser-unterstützte Applikation topischer Steroide könnte eine effektive und gut verträgliche Therapie der Nagelpsoriasis sein, die eine der intraläsionalen Injektion vergleichbare Wirksamkeit hat.

H syndrome: A review of treatment options and a hypothesis of phenotypic variability.

H syndrome is a rare autosomal recessive disorder with clinical features comprising: hyperpigmentation, hypertrichosis, hearing loss, heart anomalies, low height, hypogonadism and hepatosplenomegaly. H syndrome results from loss-of-function mutations in SLC29A3 which leads to abnormal proliferation and function of histiocytes. Herein, we discuss the considerable phenotypic heterogeneity detected in a consanguineous Egyptian family comprising of four affected siblings, two of which are monozygotic twin and the possible therapeutics. The phenotypic variability may be attributed to the role of histiocytes in the tissue response to injury. Such variable expressivity of H syndrome renders the diagnosis challenging and delays the management. The different treatment approaches used for this rare entity are reviewed.

Trichloroacetic Acid in Different Concentrations: A Promising Treatment Modality for Vitiligo.

BACKGROUND: Despite the recent advances in the treatment of vitiligo, results are still largely unsatisfactory and many patients show either weak or no response to treatment. Few clinical trials have investigated the use of trichloroacetic acid (TCA) to induce repigmentation in stable vitiligo. OBJECTIVE: To evaluate the efficacy and safety of TCA, in different concentrations, for the treatment of stable localized vitiligo. METHODS: The study included 100 patients with acral/nonacral stable vitiligo. Trichloroacetic acid was applied, as a monotherapy, to the vitiliginous patches at different concentrations according to the treated site every 2 weeks until complete repigmentation or for a maximum of 6 treatment sessions. Follow-up was done every month for 6 months to detect any recurrence. RESULTS: Eyelid vitiligo showed the highest response to TCA treatment (excellent response in 80% of cases), followed by the face, trunk, and extremities. Lower response rates were noticed in the hands and feet vitiligo. Adverse effects were transient and insignificant in few patients. CONCLUSION: Trichloroacetic acid seems to be a potential, cost-effective, well-tolerated therapeutic option for the treatment of vitiligo in the adults and pediatric populations.

Intralesional Measles, Mumps, and Rubella Vaccine Versus Intralesional Candida Antigen in the Treatment of Common and Plantar Warts.

BACKGROUND: Intralesional immunotherapy has been effectively used in the treatment of warts; however, comparative studies between different antigens are limited. OBJECTIVE: To evaluate the efficacy and safety of intralesional measles, mumps, and rubella (MMR) vaccine compared with intralesional Candida antigen for the treatment of multiple common and plantar warts. METHODS: Sixty-eight adult patients with multiple common and plantar warts were randomly assigned into two groups, each containing 34 patients. The first group received intralesional MMR vaccine, while the second group received intralesional Candida antigen. Each treatment was injected into the largest wart at 2-week intervals until complete clearance or for a maximum of 5 sessions. RESULTS: The overall therapeutic response was higher in the Candida antigen group (73.5%) compared with the MMR group (67.7%); however, the difference was not statistically significant. Complete clearance of common warts was higher in the Candida antigen group, while that of plantar warts was higher in the MMR group. Adverse effects were transient and well tolerated in both groups. No recurrence was detected during the 6-month follow-up period. CONCLUSION: Intralesional MMR and intralesional Candida antigen showed comparable efficacy and safety in the treatment of common and plantar warts.

Intralesional Antigen Immunotherapy in the Treatment of Periungual Warts.

BACKGROUND: Intralesional immunotherapy using different types of antigens is considered an effective and safe treatment option for different types of warts. However, there are few studies that illustrate the use of these antigens in the treatment of periungual warts as a distinct type of warts. OBJECTIVE: To evaluate the efficacy and safety of three antigens: measles, mumps, rubella (MMR) vaccine, Candida antigen, and purified protein derivative (PPD) in the treatment of periungual warts. METHODS: The study included 150 patients who were randomly assigned to 3 groups with 50 patients in each. Each agent was injected intralesionally at a dose of 0.1 mL into the largest wart at 2-week intervals until complete clearance or for a maximum of 5 sessions. RESULTS: Complete clearance of warts was observed in 70%, 80%, and 74% in PPD, Candida antigen, and MMR vaccine groups, respectively. There was no statistically significant difference regarding the therapeutic response between the 3 studied groups. Adverse effects were transient and insignificant in the 3 groups. No recurrence of the lesions was reported in any of the studied groups. CONCLUSIONS: Intralesional antigen immunotherapy seems to be an effective therapeutic option for the treatment of periungual warts.

Atypical presentations of erythema nodosum leprosum: Diagnostic and therapeutic aspects.

Classic erythema nodosum leprosum (ENL) is characterized clinically by abrupt eruption of tender erythematous nodules, papules and plaques. Variable atypical patterns have been described, for example pustular, bullous, ulcerative, necrotic and Sweet's syndrome-like ENL. We aim to review previously reported cases of atypical ENL addressing the diagnostic and therapeutic aspects of these uncommon presentations. A search of medical literature for all cases of atypical ENL was conducted in the PubMed database till 2020. Data of patients with atypical ENL were collected and analyzed to describe the epidemiological, clinico-histological and therapeutic features. The major five clinically described presentations of atypical ENL include vesiculo-bullous lesions (46 % of patients), ulcero-necrotic lesions (41 %), erythema multiforme-like lesions (28 %), Sweet's syndrome-like lesions (11 %) and pustules (9 %). The skin lesions were accompanied by fever and constitutional symptoms in all patients. Oral steroids and thalidomide were the main lines of therapy in most of the reported patients. Dermatologists and pathologists should keep in mind the clinical variability of ENL to avoid misdiagnosis and delayed management. Early recognition can help control disease progression and save the patients from further complications.

The use of trichloroacetic acid as a depigmenting therapy in universal vitiligo.

BACKGROUND AND OBJECTIVES: Several modalities have been used to clear residual facial pigmentation in patients with extensive vitiligo; however, the ideal depigmenting agent does not yet exist. The use of trichloroacetic acid (TCA) for depigmentation in universal vitiligo has been recently reported. We aim to evaluate the efficacy and safety of TCA 100 % as a depigmenting therapy for recalcitrant facial pigmentation in Egyptian patients with universal vitiligo. PATIENTS AND METHODS: The study included 50 patients with universal vitiligo who had residual spotted pigmentation on the face causing psychological distress. TCA was focally applied to cover the pigmented patches at 100 % concentration. The treatment was repeated every two weeks until complete depigmentation or for a maximum of five treatment sessions. RESULTS: Excellent response to TCA treatment (> 90 % depigmentation) was reported in 80 % of the studied cases, partial response (50-90 % depigmentation) in 12 % and poor response (< 50 % depigmentation) in 8 % of the cases. Minor adverse effects were reported e.g. burning sensation, erosions and local infection. CONCLUSIONS: TCA seems to be a cost-effective and well tolerated therapeutic option for the treatment of recalcitrant residual pigmentation in patients with extensive vitiligo. This modality is associated with reduced downtime and minimal adverse effects.

Intralesional antigen immunotherapy for the treatment of plane warts: A comparative study.

Intralesional immunotherapy by different antigens has shown promising efficacy and safety in the treatment of warts. However, the use of these antigens for the treatment of plane warts has been investigated in two studies only. To evaluate the efficacy and safety of three antigens; Measles Mumps, Rubella vaccine (MMR), Candida antigen, and purified protein derivative (PPD) in the treatment of multiple plane warts. The study included 120 patients who were randomly assigned to three groups, 40 patients in each group. Each agent was injected intralesionally at a dose of 0.1 mL into the largest wart at 2-week intervals until complete clearance or for a maximum of five sessions. Complete clearance of warts was observed in 55% of the PPD group, in 70% of the Candida antigen group, and in 62.5% of the MMR group. No statistically significant difference in the therapeutic response was found between the three groups. Intralesional antigen immunotherapy seems to be a promising well-tolerated and effective therapeutic option for the treatment of multiple plane warts, with relatively higher efficacy of Candida antigen.

Platelet-rich plasma versus CROSS technique with 100% trichloroacetic acid versus combined skin needling and platelet rich plasma in the treatment of atrophic acne scars: a comparative study.

BACKGROUND: Platelet-rich plasma (PRP) is an autologous preparation of platelets in concentrated plasma that may be beneficial in the treatment of atrophic acne scars by promoting collagen deposition. Skin needling is a technique that uses a sterile dermaroller to puncture the skin and release growth factors. The combination of skin needling and PRP could enhance the efficacy of both modalities. Chemical reconstruction of skin scars technique consists of focal application of high concentration of trichloroacetic acid (TCA) on the acne scars to stimulate collagen production. OBJECTIVE: To evaluate the efficacy and safety of intradermal injection of PRP, 100% focal TCA, and combined skin needling plus topical PRP in the treatment of atrophic acne scars. PATIENTS AND METHODS: Forty-five patients with atrophic acne scars were randomly assigned to 3 equal groups; Group A received intradermal injection of PRP, Group B received chemical reconstruction of skin scars technique with TCA 100%, and Group C was treated by combined skin needling and PRP. Each patient underwent 3 sessions at 2-week interval. RESULTS: All the patients completed the study. The 3 groups showed statistically highly significant improvement in the degree of acne scars after treatment (p < .001). No major adverse effects were observed in the studied groups. CONCLUSION: This is the first study to use intradermal injection of PRP alone for the treatment of atrophic acne scars. The 3 modalities showed a promising efficacy and safety in the treatment of atrophic acne scars.

Intralesional methotrexate versus 5-flurouracil in the treatment of keratoacanthoma.

BACKGROUND: Keratoacanthoma (KA) is a benign neoplasm that affects mainly photodamaged skin. It is locally destructive and may rarely spread. Surgery is not always suitable and usually disfiguring. Thus, non-operative modalities represent good alternatives. OBJECTIVE: To assess and compare the efficacy of intralesional methotrexate (MTX) and 5-flurouracil (5-FU) in the treatment of KA. PATIENTS AND METHODS: Randomized controlled trial included 20 patients with biopsy proven KA divided into 2 equal groups; group (A) received intralesional MTX, 25 mg/ml and group (B) received intralesional 5-FU, 50 mg/ml every 2 weeks till complete clearance or for a maximum 5 sessions. RESULTS: In the MTX group, complete clearance was observed in 7 patients (70%) compared to 8 patients (80%) in the 5- FU group with no statistically significant difference. However, the median number of injections needed to achieve complete response in the MTX group was 3 sessions versus only 2 sessions in the 5-FU group. LIMITATIONS: the small sample size due to the relatively low incidence of KAs in our population. CONCLUSION: Intralesional therapy is a good alternative to surgery in selected cases of KA. Both drugs showed comparable efficacy, but 5-FU may give faster results, hence increasing patient satisfaction and compliance.

Intralesional immunotherapy for the treatment of anogenital warts in pediatric population.

BACKGROUND: The prevalence of anogenital warts is increasing in adults as well as in pediatric population. The treatment of anogenital warts is challenging, particularly in children as most conventional modalities are painful and associated with high recurrence rates. OBJECTIVES: To evaluate the efficacy and safety of intralesional immunotherapy for the treatment of anogenital warts in pediatric patients. METHODS: Forty child presenting with multiple anogenital warts were randomly assigned into 3 groups. The first group (15 patients) received intralesional MMR vaccine, the second group (15 patients) received intralesional Candida antigen and the third group (10 patients) received intralesional saline as a control. Each modality was injected into the largest wart at 2-week intervals until complete clearance or for a maximum of 5 sessions. RESULTS: Highly significant difference was found between the therapeutic response of anogenital warts to both MMR vaccine and Candida antigen compared to intralesional saline (p = .005). No significant difference was observed between MMR vaccine and Candida antigen groups (p = .885). Side effects were mild and no recurrence was detected in the 6 month follow-up period. CONCLUSIONS: Intralesional immunotherapy is a promising effective and well-tolerated treatment modality for multiple anogenital warts in children.