COVID-19: The experience from Iran.

The first cases of coronavirus disease 2019 (COVID-19) in Iran were detected on February 19, 2020. Soon the entire country was hit with the virus. Although dermatologists were not immediately the frontline health care workers, all aspects of their practice were drastically affected. Adapting to this unprecedented crisis required urgent appropriate responses. With preventive measures and conserving health care resources being the most essential priorities, dermatologists, as an integral part of the health system, needed to adapt their practices according to the latest guidelines. The spectrum of the challenges encompassed education, teledermatology, lasers, and other dermatologic procedures, as well as management of patients who were immunosuppressed or developed drug reactions and, most importantly, the newly revealed cutaneous signs of COVID-19. These challenges have paved the way for new horizons in dermatology.

Oral provocation of patients allergic to sesquiterpene lactones with German chamomile tea to demonstrate possible systemic allergic dermatitis.

BACKGROUND: Most patients with contact allergy to Asteraceae plants are patch test positive to sesquiterpene lactone mix (SLM). There are several reports among these patients of a flare-up of hand eczema after ingestion of food and beverages originating from Asteraceae plants. AIM: To investigate whether German chamomile tea can elicit systemic allergic dermatitis. PATIENTS AND METHODS: Individuals with or without contact allergy to SLM were patch tested with an extract of German chamomile tea. Six weeks later, they were provoked with capsules containing either freeze-dried German chamomile tea or placebo capsules containing lactose, in a double-blind, randomized study. A numerical rating scale (NRS) was used to ascertain the volunteers' opinion of their hand eczema status. The study individuals were examined to detect a possible flare-up of healed patch test reactions to chamomile. RESULTS: None of the subjects had a flare-up of healed patch test reactions. According to the NRS, SLM-positive individuals experienced a significant worsening of hand eczema, independently of whether they received chamomile or lactose capsules. CONCLUSION: No evidence suggestive of systemic allergic dermatitis was found.

Efficacy and safety of a rosehip seed oil extract in the prevention and treatment of skin lesions in the hands of patients with type 1 diabetes mellitus caused by finger prick blood glucose monitoring; a randomized, open-label, controlled clinical trial. / Eficacia y seguridad del aceite de rosa mosqueta en las lesiones de los dedos provocadas por las punciones capilares para el control glucémico en niños con diabetes tipo 1; un ensayo clínico aleatorizado, abierto, controlado.

INTRODUCTION: This study was intended to assess the efficacy and safety of a rosehip seed oil (RHO) extract in the prevention and treatment of skin lesions in the hands of patients with type 1 diabetes mellitus (T1DM) caused by finger prick blood glucose monitoring. PATIENTS AND METHOD: A prospective, randomized, controlled, open-label, rater-blinded trial in patients aged 6-17 years with T1DM and intensive blood glucose control (≥7 finger pricks daily) for 12 days. Three main variables (erythema, skin thickening, and loss of skin integrity) were assessed using a scale ranging from 0 (absent) to 3 (severe involvement). The study was approved by the ethics committee of the hospital. RESULTS: Sixty-eight children, and thus 136 hands, were included; 80 hands received rosehip seed oil and 56 hands acted as controls. Baseline characteristics of both groups were similar, with 76.3% and 78.6% of the hands respectively showing skin lesions at study start. Median final global assessment was 0.10 (0.03; 0.30) in the group that received rosehip seed oil and 0.06 (0.00; 0.23) in the control group. A statistically significant improvement in global assessment was found in the control group (P=0.049). No significant differences were found when the medians of the other main variables were compared. No adverse effects were recorded. CONCLUSION: A high prevalence of skin lesions secondary to finger prick glucose monitoring, most of them mild lesions, was found at study start. Treatment with rosehip seed oil was safe and was not effective for improving skin lesions.

Natural Thermal Spa Water Versus Hyperthermic Tap Water for Treatment of Recalcitrant Hand Warts in Organ Transplant Recipients: A Patient-Blinded, Comparative Preliminary Study.

OBJECTIVES: Cutaneous warts represent a major problem in organ transplant recipients because of their extensive involvement and persistent course. Current therapeutic modalities often fail to achieve a successful response in patients with warts. We experienced a case involving an organ transplant recipient with recalcitrant mosaic warts who presented with complete clearance of lesions in 3 days after thermal spa bathing. Here, we evaluated the efficacy of natural thermal water versus hyperthermic tap water for treatment of recalcitrant hand warts in organ transplant recipients. MATERIALS AND METHODS: In this preliminary study, the right hands of 5 organ transplant recipients with hand warts were immersed in thermal water, while the left hands were soaked in tap water at 44°C to 47°C. Treatment involved three 45-minute sessions per week for 1 month. The total number and size of the warts and the hyperkeratosis severity grade were noted. RESULTS: After 12 sessions, none of the patients exhibited any marked improvement in the size or number of warts, although 3 patients had a slight decrease in their hyperkeratosis severity grade. CONCLUSIONS: Our preliminary data indicate that neither thermal spa water nor hyperthermic tap water is effective for treatment of recalcitrant hand warts in organ transplant recipients. However, new trials using thermal water supplied from different geographical locations should be performed before this observation can be generalized.

Allergic contact dermatitis caused by topical herbal remedies: importance of patch testing with the patients' own products.

BACKGROUND: Natural ingredients have variable compositions, so their allergenic potencies may differ. OBJECTIVES: To retrospectively analyse subjects reacting to herbal remedies over the past 27 years, with the aim of (i) evaluating demographic characteristics and lesion locations, (ii) describing the frequencies of positive patch test reactions, (iii) identifing sensitization sources, and (iv) studying concomitant sensitivity. PATIENTS AND METHODS: In total, 15980 patients were patch tested between 1990 and 2016 with the European baseline series and/or other series, product(s) used, and, whenever possible, the respective ingredients. RESULTS: Altogether, 8942 (56%) of 15 980 patients presented with at least one positive reaction. Reactions to topical herbal medicines, most often applied to treat an eczematous condition, leg ulcers, or other wounds, were seen in 125 (0.8%), that is, 1.4% of the contact-allergic subjects. Hands, legs and feet were the most frequently affected body sites. Twenty-one botanical allergens were identified, the commonest being Myroxylon pereirae (balsam of Peru), Compositae plants, and tincture of benzoin. Many patients presented with multiple positive test reactions, and some did not react to the commercial allergens but only to the products used. CONCLUSIONS: Topical herbal remedies should not be applied on damaged skin, as multiple sensitization may develop. Moreover, patch testing with the culprit products is important for the diagnosis.

Contact dermatitis caused by tulips: identification of contact sensitizers in tulip workers of Kashmir Valley in North India.

BACKGROUND: Tulip, belonging to the genus Tulipa and family Liliaceae, is a spring-blooming perennial that grows from bulbs. Owing to manual handling, contact dermatitis can occur in professionals at any stage of the growth cycle of the tulip plant. OBJECTIVES: To determine the clinical pattern of contact dermatitis resulting from tulip plant cultivation, and to assess contact allergy in workers coming into contact with this plant. METHODS: One hundred and sixty-four tulip workers were screened, and 48 patients with suspected contact dermatitis were patch tested with 39 allergens, including haptens from the Indian baseline series, a plant series, and extracts from different parts of the tulip plant. RESULTS: Thirty-nine positive patch test reactions were observed in 21 patients. Seventeen patients showed positive reactions to either α-methylene-γ-butyrolactone or to tulip plant extract. Clinical relevance was observed for 13 of 17 positive patch test reactions. CONCLUSIONS: Contact dermatitis is an important health hazard in workers dealing with tulip bulbs. Further studies to identify and isolate other possible tulip allergens, and to quantify the amounts of allergens in different parts of the tulip plant, are recommended.

Acquired Acrodermatitis Enteropathica Syndrome in a Kidney Transplant Receipt: A Case Report.

Acrodermatitis enteropathica syndrome (AE) is a clinical entity that results in severe zinc deficiency. It can be genetic or acquired. Acquired AE has been reported in patients with chronic liver disease, malabsorption syndrome, sickle cell anemia, and chronic renal failure. We present a kidney transplant recipient with skin rash and watery diarrhea. The patient had low serum zinc levels, which quickly resolved after zinc supplementation. Skin biopsy showed cytoplasmic pallor and vacuolization and ballooning degeneration of keratinocytes within the superficial epidermis, which may have led to confluent necrosis of keratinocytes. Large amounts of keratinosome-derived lamellae were found in the intercellular spaces in the keratinized area, probably related to disturbance of keratinosome metabolism due to zinc deficiency.

Palmoplantar psoriasis.

Palmoplantar psoriasis refers to a localized psoriasis variant. The disease can be associated with many clinical forms, including predominantly pustular lesions to thick scaly, hyperkeratotic plaques, or an overlapping of both of them. Palmoplantar psoriasis accounts for 3-4% of all psoriasis cases in most studies. Although it is localized only on the palms and the soles, the fissures, the hardening of the tissue, and hyperkeratosis affect daily routine activities. Taking the body surface area as a measure of severity can sometimes be misleading. In clinical practice, the level of functional impairment should be taken into account rather than relying on traditional instruments to evaluate the severity. Palmoplantar psoriasis is usually managed with topical therapy as a first step. Systemic therapy is needed when the topicals fail or when the disease becomes more severe. Sometimes, biologic agents are required for adequate maintenance of clinical response.

Acrodermatitis caused by nutritional deficiency and metabolic disorders.

Both the metabolism and dietary intake of vitamins and minerals are essential to homeostatic function in the body. Dietary excess or deficiency, as well as genetic and acquired disorders in metabolism, can present dermatologically and systemically. More specifically, disorders in metabolism of zinc, biotin, essential fatty acids, and vitamin B, can appear with acrally distributed dermatoses. Recognition of the dermatologic manifestations associated with nutritional disorders is important for early diagnosis and management.

Efficacy and Safety of Topical Pidobenzone 4% as Adjuvant Treatment for Solar Lentigines: Result of a Randomized, Controlled, Clinical Trial.

BACKGROUND/OBJECTIVE: This study aims at the evaluation of the efficacy and safety of a combination therapy based on pidobenzone 4% and fractional CO2 laser or cryotherapy in the treatment of solar lentigines and the prevention of eventual posttreatment hyperchromia. METHODS: Efficacy was clinically evaluated by grading the pigmentation level with the Skin Tone Color Scale (STCS), and by grading patients' impression through a Visual Analog Scale (VAS). RESULTS: Our study shows that the associated treatment was safe and that it improves the therapeutic results on solar lentigines and prevents postiatrogenic hyperpigmentation compared with physical therapy alone. CONCLUSION: The combination of cryotherapy and pidobenzone 4% has been found to be the most useful treatment.

Triple combination as adjuvant to cryotherapy in the treatment of solar lentigines: investigator-blinded, randomized clinical trial.

BACKGROUND: Post-inflammatory hyperpigmentation is a frequent concern when treating solar lentigines. OBJECTIVES: To assess the safety and efficacy of a triple combination cream with fluocinolone acetonide 0.01%, hydroquinone 4% and tretinoin 0.05% as adjuvant to cryotherapy in the treatment of solar lentigines in hands dorsum, and in the prevention of post-inflammatory hyperpigmentation after cryotherapy. METHODS: This prospective, randomized, controlled, investigator-blinded, single-centre study enrolled 50 patients. Twenty-five patients received a 2-week daily triple combination cream plus sunscreen pre-treatment and 25 received sunscreen alone. After that, cryotherapy was performed in all patients followed by a 3-week recovery period. After this period, patients received the same initial treatment and were followed up for 8 weeks. Melanin and erythema levels of a target and a control lentigo were objectively measured using a narrowband reflectance spectrophotometer. Lentigines count, colour homogeneity and global improvement were also assessed. RESULTS: The number of solar lentigines reduced in the first 2 weeks only in patients who used the triple combination 25 ± 7 vs. 22 ± 8 (P < 0.0001), and reduced at the end of the study for both groups (P < 0.0001). The melanin levels also reduced in the first 2 weeks only in patients who used the triple combination 297 ± 69 vs. 273 ± 66 (P < 0.0001) and reduced at the end of the study for both groups (P < 0.0001). Erythema and residual blisters from cryotherapy were the reported adverse reactions. CONCLUSION: Triple combination cream can be used to enhance the resolution of solar lentigines, and to significantly reduce melanin levels and lentigines count, improving treatment results. It was well-tolerated and did not increase the occurrence of neither erythema nor other side-effects after the cryotherapy.

Topical antioxidants protect the skin from chemical-induced irritation in the repetitive washing test: a placebo-controlled, double-blind study.

BACKGROUND: There is increasing evidence that reactive oxygen species play an important role in the development of both irritant and allergic contact dermatitis. OBJECTIVES: To assess the potential of topical antioxidants to prevent the development of experimentally induced irritant contact dermatitis. METHODS: We evaluated the effect of a cream containing a combination of antioxidants on sodium lauryl sulfate-induced irritant contact dermatitis in the repetitive washing test. As readout parameters for skin barrier function and cutaneous inflammation stratum corneum hydration, cutaneous blood flow and transepidermal water loss were assessed in 25 volunteers with bioengineering methods. RESULTS: In comparison with the cream base and a frequently used barrier cream, the antioxidant cream had high radical scavenging activity and effectively protected the skin from chemical-induced irritation. CONCLUSIONS: The superiority of the cream with antioxidants to the cream base suggests that reactive oxygen species, at least in part, play a role in the development of irritant contact dermatitis.

Occupational contact allergy to cocamidopropyl betaine and its impurities.

BACKGROUND: Contact allergy to cocamidopropyl betaine has been attributed to its impurities dimethylaminopropylamine and cocamidopropyl dimethylamine. OBJECTIVES: To describe patients with positive patch test reactions to cocamidopropyl betaine-related compounds in an occupational dermatology clinic. METHODS: We reviewed the 2002-2009 patch test records at the Finnish Institute of Occupational Health for allergic reactions to cocamidopropyl betaine, dimethylaminopropylamine, cocamidopropyl dimethylamine, and oleamidopropyl dimethylamine. Results. Irritant reactions to at least one of the test substances were seen in 39% of the 1092 patients tested. Fifteen (1.3%) patients showed allergic reactions: 13 to cocamidopropyl dimethylamine, 11 to dimethylaminopropylamine, 8 to oleamidopropyl dimethylamine, and 2 to cocamidopropyl betaine. Concomitant reactions to cocamidopropyl dimethylamine, dimethylaminopropylamine and oleamidopropyl dimethylamine were common. Ten of the 15 patients were diagnosed with occupational allergic contact dermatitis caused by cocamidopropyl betaine-related compounds. The sources of occupational exposure included hair care products, hair colours, perm wave solutions, and liquid soaps. Multiple contact allergies and exposure to several irritant factors were common, and all patients had hand eczema. CONCLUSIONS: Patch test reactions to cocamidopropyl betaine-related compounds are difficult to interpret, owing to extremely common irritant reactions. Cocamidopropyl betaine itself is probably not an allergen. Occupational allergic contact dermatitis caused by cocamidopropyl betaine-related compounds is relatively rare and, unlike non-occupational cocamidopropyl betaine-related allergy, typically manifests as hand dermatitis.

[Health services research: the example of hand eczema]. / Versorgungsforschung am Beispiel des Handekzems.

Hand eczema is one of the most frequent skin diseases with a lifetime prevalence of up to 15% and a median incidence rate of 6 cases per 1000 person-years. Female gender, contact allergy, atopic eczema and wet work have been identified as the most important associated risk factors. Hand eczema has a high public health and socio-economic significance, since the vast majority of occupational skin disease is hand eczema. Hand eczema is often chronic, chronically relapsing or persisting. It entails substantial impairment of health-related quality of life for the affected individual. The cost-of-illness of hand eczema is estimated to be in the range of moderate to severe psoriasis and even higher than that of atopic eczema. Although various therapeutic options to treat hand eczema exist, an assessment of these options in randomized, controlled clinical trials to build up an evidence base is mostly lacking. The investigation of the treatment of chronic hand eczema under everyday conditions in dermatological clinics and private practices has only just begun. The first register of patients with chronic hand eczema (acronym: carpe) is expected to yield substantial insights in the effectiveness and safety of different therapeutic measures. A related task is the assessment of the quality of care in the light of the guidelines for the management of chronic hand eczema.