Successful treatment of classic pyoderma gangrenosum with intralesional infliximab injection: A case report.

Pyoderma gangrenosum (PG) is a rare dermatological disease characterized by the rapid development of painful skin ulcers. While systemic infliximab is considered a standard treatment for patients with PG, herein, we report our success with the use of intralesional infliximab in a 40-year-old woman with systemic lupus erythematosus (SLE) and PG.

Association of Human Leukocyte Antigen Alleles with Carbamazepine- or Lamotrigine-Induced Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in an Iranian Population: A Case-control Study.

Background: Genetic diversity in human leukocyte antigen (HLA) alleles across populations is a significant risk factor for drug-induced severe cutaneous adverse reactions (SCARs), e.g., carbamazepine (CBZ)- and lamotrigine (LTG)-induced Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). The present study aimed to investigate the frequency of different HLA alleles in Iranian patients with CBZ- and LTG-induced SJS/TEN. Methods: A case-control study was conducted from 2011 to 2018 at various hospitals affiliated with Shiraz University of Medical Sciences (Shiraz, Iran). A total of 31 patients receiving anticonvulsant drugs (CZB or LTG) were recruited and divided into two groups. The drug-induced group (n=14) included hospitalized patients due to CBZ- or LTG-induced SJS/TEN. The drug-tolerant group (n=17) included individuals receiving CBZ or LTG for at least three months with no adverse effects. In addition, 46 healthy individuals (control group) were recruited. The frequency of HLA-A, -B, and -DRB1 alleles in patients with CZB- or LTG-induced SJS/TEN was investigated. HLA typing was performed using the allele-specific polymerase chain reaction method. The Chi square test and Fisher's exact test were used to determine a potential association between SJS/TEN and HLA alleles. P<0.05 was considered statistically significant. Results: CBZ- or LTG-induced SJS/TEN was not significantly associated with HLA alleles. However, HLA-DRB1*01 showed a significantly higher frequency in patients with CBZ-induced SJS/TEN than the CBZ-tolerant patients (30% vs. 9%, P=0.07). Conclusion: Overall, no significant association was found between CBZ- or LTG-induced SJS/TEN and HLA alleles. Further large-scale studies are required to substantiate our findings.

Formaldehyde 5% in Flexible Collodion Compared to Cryotherapy for Treatment of Female Genital Warts: A Randomized Clinical Trial.

Objectives: Genital wart is a sexually transmitted disease caused by human papillomavirus (HPV) and is responsible for discomfort, and decreased quality of life and productivity in victims with a high recurrence rate after treatments. This study aimed to compare the efficacy and safety of formaldehyde 5% with cryotherapy for the treatment of female genital warts. Methods: Eighty women with at least two similar genital warts who visited the outpatient dermatology clinic of Shahid Faghihi hospital, Shiraz, Iran, were enrolled in this study. One lesion of each patient was self-treated with formaldehyde 5% in flexible collodion gel once daily for 28 days and the other matched lesion was treated by weekly repeated cryotherapy courses. The number of eradicated lesions and the mean days needed to treat, pain scores, complications and patient satisfaction were compared between the treatment methods. Results: Complete clearance of lesions was observed in 58.7% of formaldehyde-treated lesions compared to 88.7% for cryotherapy (P value = 0.000). With formaldehyde-treated lesions, 51% complained of pain, 36.3% had pruritus, 86.3% had skin dryness, 88.8% complained of burning sensation and 93.7% showed erythema. In the cryotherapy group, 92.5% complained of pain, 15% had burning sensation, 75% showed erythema, 5% had atrophy, 80% developed post-inflammatory hyper or hypopigmentation (PIH) and 92.5% suffered from ulceration. Seventy-five (93%) found it easy to apply and (47) 58% were satisfied with their treatment results. Conclusions: Self-administration of formaldehyde 5% resulted in a lower clearance rate but had better cosmetic outcomes with lower pain scores compared to cryotherapy.

Montelukast as an effective adjuvant in the treatment of moderate acne vulgaris.

Although antibiotics are among the most commonly used treatments of acne, there are refractory cases, or they can cause some complications. Recently, leukotriene B4 has been found to play a major role in inflammatory acne lesions. This double blind, randomized clinical trial was conducted on 108 patients with acne who needed systemic therapy and referred to dermatology clinics affiliated to Shiraz University of Medical Sciences. One group (53 patients) received 100 mg doxycycline daily plus placebo and the other group (55 patients) received 100 mg daily doxycycline plus 10 mg daily montelukast. Both groups also received topical benzoyl peroxide 5% every other night. The study period was 3 months and the patients were investigated by lesion count, investigator global assessment (IGA), global acne grading system (GAGS), and Cardiff acne disability index (CADI) scoring systems. Total lesion count, inflammatory lesion count, and non-inflammatory lesion count as well as IGA and GAGS decreased in both treatment groups. At the end of the study, however, the inflammatory lesion count and IGA score reduced more significantly in the montelukast group (p = 0.018 and 0.045, respectively). In addition, the two groups were significantly different with regard to the percentage of decrease in the total lesion count, inflammatory lesions, and IGA (p = 0.033, 0.003, and 0.044, respectively). Thus, montelukast can be used as an adjuvant therapy besides other treatments of acne, especially for inflammatory lesions.

Elevated Serum Interleukin-23 Levels in Patients with Oral and Cutaneous Lichen Planus.

Lichen planus is considered a chronic inflammatory disease which affects different sites, such as the skin, mucous membranes, hair, and nails. Based on the evidence, a complex cytokine network plays a crucial role in lichen planus pathogenesis. The study was aimed at assessing the serum IL-23 levels in the patients with cutaneous and oral lichen planus compared to healthy controls. Method. The study included 30 cutaneous lichen planus patients, 20 oral lichen planus patients, and 33 control subjects. Five milliliters of peripheral blood was obtained from each patient, and the serum was separated. IL-23 levels were determined using the ELISA kit, and the data were analyzed using the Mann-Whitney test. Results. IL-23 levels in the patient serum with oral lichen planus (P value ≤ 0.001) were significantly higher than in controls. Furthermore, there were significant differences in IL-23 serum levels in the patients with cutaneous lichen planus compared to the healthy controls (P value ≤ 0.001). Moreover, IL-23 serum levels were statistically different between patients with cutaneous lichen planus and patients with oral lichen planus (P value ≤ 0.001). Based on the mean concentration of interleukin-23, IL-23 levels were higher in the patients with oral lichen planus than in the patients with cutaneous lichen planus. Conclusions. Elevated serum IL-23 levels in the patients with oral lichen planus may indicate that IL-23 plays a crucial role in the pathogenesis of oral lichen planus. However, more research is needed with a larger sample size.

Serum Levels of IL-22 in Patients with Oral Lichen Planus and Cutaneous Lichen Planus.

STATEMENT OF THE PROBLEM: Lichen planus disease is a chronic inflammatory disorder of mucosal and cutaneous tissues with yet unclear etiology and pathogenesis. Cytokines play an important role in the initiation, maintenance of inflammatory and intercellular crosstalk. PURPOSE: We assessed serum levels of IL-22 in patients with oral and cutaneous lichen planus and made comparison with healthy individuals. MATERIALS AND METHOD: In this case-control study, peripheral blood samples of 40 patients with lichen planus disease, included two groups of oral lichen planus (n=20) and cutaneous lichen planus (n=20) were compared with 32 healthy individuals in this case-control study. Serum samples were prepared from patients with lichen planus and IL-22 concentration was measured in each serum sample by using a commercial ELISA Kit. The obtained data were then analyzed using the Kruskal-Wallis (one-way ANOVA) test. RESULTS: The IL-22 serum levels were significantly higher in patients with oral lichen planus compared to the healthy control group (p< 0.001). No statistically significant differences were observed in serum levels of IL-22 in cutaneous lichen planus patients compared to the controls (p= 0.183). CONCLUSION: Increased IL-22 serum levels in patients with oral lichen planus may play an important role in the pathogenesis of oral lichen planus. The administration of the recombinant or antagonist of IL-22 could be a new therapeutic opportunity in the treatment of oral lichen planus.

Predominant role of innate pro-inflammatory cytokines in vitiligo disease.

Vitiligo is a skin disorder with melanocyte destruction and an autoimmune basis. Given the importance of cytokines in autoimmunity, we aimed to find the cytokine profile of innate and adaptive immunity in vitiligo patients, and correlate them with clinical parameters. The serum levels of innate immunity [interleukin(IL)-1α, IL-1ß, IL-6, IL-8, IL-12, IL-15 and tumor necrosis factor (TNF)-α] and T helper(Th)1 [IL-2, interferon (IFN)-γ, TNF-ß], Th2 (IL-4, IL-5, IL-10, IL-13) and Th17 (IL-17, IL-23) cytokines in 44 vitiligo patients were measured by multiplex cytokine assay and compared with 44 healthy subjects. All innate immunity (p < 0.04), Th1 (p < 0.01), Th2 (p < 0.05) and Th17 (p < 0.001) cytokines were higher in patients than controls. Total summation levels of innate immunity and adaptive immunity cytokines showed a remarkable up-regulation in the patients (p < 0.0001). The ratio of innate immunity to Th1 (p = 0.03), Th2 (p = 0.01) and Th17 (p = 0.03) cytokines was significantly higher in patients vs. controls. We found significant higher ratio of Th1 to Th2 cytokines and TNF-ß elevated levels in patients with a family history of autoimmunity (p < 0.05). IL-4 and IL-13 (p < 0.04) levels were lower in patients with amelanotic hair. Increased IL-10 level was observed in patients with stable disease (p = 0.02).In conclusion, the profile of cytokines in patients showed a dominant role of innate immunity pro-inflammatory cytokines in vitiligo, which suggests the potential of targeting these cytokines for vitiligo treatment. While a higher ratio of Th1/Th2 cytokines was observed in the patients, association of decreased Th2 cytokines with disease complications suggests a protective role for Th2 pathway.

Cutaneous lymphoid hyperplasia induced by Hirudo medicinalis (leeches).

For centuries, Hirudo medicinalis (medicinal leech) has been used as a remedy to treat many discomforts, such as muscle and joint pain. Nowadays, using leech in reconstructive surgery, microsurgery, wound and flap healing, venous insufficiency, varicosities and many other disorders has increased. In this study, we report a 45 year old female patient with six pruritic papules on her legs since10 months ago that appeared about 4 weeks after one session of leech application. Skin biopsy was performed on one of the papules, and in histopathology, superficial ulceration with a dense superficial and deep inflammatory infiltrate within the dermis composed of lymphocytes and eosinophils detected that considering history of leech application at this site, these constellation of data was compatible with the diagnosis of cutaneous lymphoid hyperplasia induced by leeches and the patient was cured by a topical steroid and cryotherapy.

Identification and Antifungal Activity Profile of Candida Species Isolated from Patients with Pemphigus Vulgaris with Oral Lesions.

Pemphigus vulgaris is an autoimmune disease that mostly affects the mucosa and oral cavity. Candida species can invade the mucosal lesions of these patients and cause diseases. The aim of this study was to identify the fungal agents isolated from mucosal lesions and evaluate antifungal activity profile against the isolates. A total of 25 patients with pemphigus vulgaris with active oral lesions and 25 healthy people serving as a control group were included in this study. Identification of the fungal isolates was performed based on conventional methods and DNA sequence analysis of the internal transcribed spacer (ITS) rDNA gene region. The sequence results were deposited in the NCBI database using the Basic Local Alignment Search Tool. Antifungal activity of fluconazole, itraconazole, ketoconazole, posaconazole, econazole, and amphotericin B against the isolates were evaluated based on the CLSI M-44 A protocol. Oral candidiasis was detected in 20% of the patients. Candida species isolated from oral lesions of patients with pemphigus were identified as Candida albicans 22/25, Candida glabrata 2/25, and Candida dubliniensis 1/25. All of the isolates were sensitive to amphotericin and econazole, 96% to fluconazole and posaconazole, and 92% to ketoconazole and itraconazole. One patient showed a profile resistant to fluconazole, posaconazole, and ketoconazole, simultaneously. Ninety six percent of control group isolates were sensitive to six antifungals. Candida albicans was the most prevalent species isolated from oral lesions of patients with pemphigus vulgaris and the control group. Amphotericin B and econazole were the most effective antifungals against the isolates.

Amyloidosis cutis dyschromica: report of 3 cases.

Amyloidosis cutis dyschromica (ACD) is a rare pigmentary disorder with about 50 cases having been reported in the English literature. Only one case of ACD has been reported from Iran. We present three patients who presented with generalized hyper- and hypopigmented patches, sparing face, hands, and feet in all three cases. The presence of amorphous eosinophilic deposits in the papillary dermis confirmed the diagnosis of ACD; the deposits were stained by crystal violet in the histopathological examination of the lesions. In all three cases, similar lesions were present in some of the family members. ACD should be considered in the differential diagnosis of diffuse hyperpigmentation studded with hypopigmentation, especially when beginning in childhood.

Topical application of Cassia fistula L. fruit gel in management of cutaneous lesions of pemphigus vulgaris: A double-blind, placebo-controlled clinical trial.

OBJECTIVE: Cassia fistula L. fruit extract has been traditionally used in the treatment of pemphigus vulgaris (PV) lesions in Iran. The aim of this study was to determine the efficacy of C. fistula fruit gel on healing time of PV lesions in a clinical setting. MATERIALS AND METHODS: This was a randomized, double-blind placebo-controlled clinical trial that was performed in dermatology ward at Saadi hospital, affiliated to Shiraz University of Medical Sciences, Shiraz, Iran. Right- or left- sided lesions of PV patients on standard systemic treatment were randomized for treatment with either C. fistula fruit gel or placebo prescribed twice daily. The largest diameter of each lesion was measured at the baseline (day 0) and on days 10 and 20. Epithelialization Index (EI), as outcome measure was calculated and compared between the two groups. RESULTS: The present study comprised 20 patients, with overall 82 cutaneous lesions including 41 lesions in the C. fistula fruit gel group and 41 lesions in the placebo group. The EI in the C. fistula fruit gel group was significantly higher than that of the placebo group both on day 10 (65±28vs 30±34; p=0.001) and at the end of the study (91±22 vs 69±49; p=0.003). CONCLUSION: Topical application of C. fistula fruit gel can be considered as an effective adjuvant therapy in treatment of PV.

Crusted scabies masquerading as psoriasis plaques in a patient suffering from burn scars.

A 30-year-old woman, presented with erythematous scaling plaques on her trunk with severe pruritus and a burning sensation that began 3 months prior to her visit. She had a history of a thermal burn in that area, three years prior. Topical corticosteroid application for 3 months had no positive effects. Skin biopsy was done and scabies mites were found.

Efficacy of Topical Coriandrum sativum Extract on Treatment of Infants with Diaper Dermatitis: A Single Blinded Non-Randomised Controlled Trial.

Diaper dermatitis is a common disorder. Coriandrum sativum is a herbal remedy with anti-inflammatory, analgesic, anti-microbial and anti-oxidant activities effects. In this non randomised clinical trial which was performed on 58 infants with diaper dermatitis referred to Faghihi Hospital, Shiraz University of Medical Sciences, the efficacy and safety of topical Coriandrum extract cream is compared with hydrocortisone ointment. Coriandrum sativum extract cream was administered for 37 (intervention group) and hydrocortisone 1% ointment for 21 (control group) patients. Patients were examined on days 3 and 10. Chi-square test was applied for statistical analysis. The results demonstrated a statistically significant difference in the cure rate (20 (54.1%) for the intervention group versus 19 (90.5%) for the control group) (P-value = 0.005) and side effects (10 (27%) for the intervention group versus 0 (0%) for control group) (P-value = 0.009) both in favor of hydrocortisone. This trial failed to confirm the efficacy of Coriandrum sativum in the treatment of diaper dermatitis; however, it seems that if soothing compounds are used in combination with Coriandrum sativum to reduce the mild irritation, Coriandrum extract can be an alternative treatment for diaper dermatitis.

Autoimmune progesterone dermatitis presenting as fixed drug eruption: a case report.

Autoimmune progesterone dermatitis (APD) is a rare disorder characterized by periodic skin lesions that erupt during the luteal phase of the menstrual cycle. Clinical manifestations of APD is caused by an unusual allergy to progesterone and has a wide range of clinical manifestations from eczema and urticaria to angioedema and erythema multiforme. A 46-year-old woman described recurrent, round erythematous plaques on the lower lip, both forearms and buttocks. These skin eruptions waxed and waned for 10 months, reoccurring 3-4 days before menstruation. Based on her medical history and physical examination, APD was suspected and the progesterone challenge test showed positive results. After treatment with oral prednisolone (30 mg/day) before menstruation, the severity of eruptions decreased dramatically but recurrence did not cease completely.

The Prevalence of Complementary and Alternative Medicine Use Among Dermatology Outpatients in Shiraz, Iran.

The objective of this study was to assess complementary and alternative medicine use and its related factors among Iranian dermatology outpatients. In this cross-sectional study, a self-structured questionnaire was administered to 600 dermatology outpatients. Mann-Whitney U test, chi-square test, and binary logistic regression test were used. A total of 188 (31.3%) patients had used one of complementary and alternative medicine methods. The most frequent method used was herbal medicine (89.9%). The mean years of duration of the skin condition were significantly higher in complementary and alternative medicine users compared with nonusers ( P = .037). Patients with acne and alopecia significantly used more complementary and alternative medicine (odds ratio: 2.48 and 3.19, respectively). There was a significant relationship between education and using complementary and alternative medicine ( P < .001). Complementary and alternative medicine use is prevalent among our patients and we should think of ways of educating general population about complementary and alternative medicine methods and their potential risks and benefits and encourage our health care workers to communicate these materials with their patients.

Recalcitrant cases of pyoderma gangrenosum, responding dramatically to systemic tacrolimus.

Pyoderma gangrenosum (PG) is an uncommon ulcerative cutaneous disease, without any well-known specific and effective treatment. Here we report two patients with severe recalcitrant perineal pyoderma gangrenosum, successfully treated with low dose systemic tacrolimus. Tacrolimus can be a safe effective drug in the management of recalcitrant PG.

Cassia fistula: A remedy from Traditional Persian Medicine for treatment of cutaneous lesions of pemphigus vulgaris.

OBJECTIVE: Pemphigus is a rare autoimmune disease that may be fatal without proper medical intervention. It is a blistering disease that involves both the skin and mucus membranes, in which the most important causes of death comprise superimposed opportunistic infections and complications of long-term high-dose corticosteroid therapy or prolonged consumption of immune suppressant drugs. Skin lesions are the most important sources of infection, and any local treatment decreasing the healing time of lesions and reducing the total dosage of drugs is favorable. MATERIALS AND METHODS: Here, we review the probable mechanism of action of a traditional formulary of Cassia fistula (C. fistula) fruit extract in almond oil as a new topical medication for reducing the duration of treatment of pemphigus vulgaris erosions. RESULTS: C. fistula fruit oil has lupeol, anthraquinone compounds as rhein and flavonoids. Previous in vitro and animal studies on C. fistula fruit have demonstrated wound healing, antioxidative, anti-leukotrienes, anti-inflammatory, antibacterial and antifungal effects of this plant. CONCLUSION: It is hypothesized that C. fistula L. can be a botanical therapeutic choice for treatment of pemphigus erosions.

A review on botanicals with wound healing activity for pemphigus vulgaris: perspective of traditional Persian medicine and conventional medicine.

OBJECTIVE: As a rare autoimmune disease, pemphigus vulgaris has a poor prognosis especially in lack of proper medical support. This blistering disease involves both the skin and mucus membranes. The challenge is improving the healing process of skin lesions of which, superimposed infections are among the main causes of the disease mortality. Accordingly, we aimed to assess the treatment options suggested by traditional Persian medicine (TPM) and compare them with current findings. MATERIALS AND METHODS: We studied the main clinical and pharmaceutical textbooks of TPM (Kitab al-hawifi al-tibb, the Canon of Medicine, Eksir-e-Aazam, Tuhfat al-mu'minin, Makhzan al-adviyah (focusing on the skin chapter and respective herbal remedies for the inflamed skin and ulcers. Additionally, scientific databases such as PubMed, Science direct, Scopus, and Google Scholar were searched for the current pharmacological evidence. In the studied books, the term "hot ulcers" was found close to what is known as "Pemphigus vulgaris". RESULTS: Reported medicinal herbs possess anti-inflammatory, antioxidant, wound healing, and antibacterial activities reported by recent studies. Therefore, they could be introduced as novel natural remedies for pemphigoid wounds. CONCLUSION: Taken as a whole, the review of traditional remedies for hot ulcers in Persian medical and pharmaceutical literature may open a new window toward developing new topical treatments for this disease.

The Prevalence of Complementary and Alternative Medicine Use among Dermatologic Outpatients in Shiraz, Iran.

BACKGROUND: The use of complementary and alternative medicine (CAM) has been increasing among patients worldwide. The objective of this study was to assess CAM use and its related factors among Iranian dermatologic outpatients in Shiraz, Iran. METHODS: This cross-sectional study was conducted in Shiraz, Iran. Six hundred dermatologic outpatients were randomly selected. We used a self-structured questionnaire with 14 items to assess CAM use and its related factors among our participants. We used descriptive statistics reported as mean±SD and frequency by Mann-Whitney U test, chi square and binary logistic regression tests for statistical analysis. RESULTS: Among the 600 participants, 188 (31.3%) had used one of the CAM methods for resolving their dermatologic problems. The most frequent method used was herbal medicine (89.9%). The mean age and years of duration of the skin condition were significantly higher in patients using CAM compared to non-users (P=0.001 and 0.037, respectively). Patients with acne, alopecia, and hair loss significantly used CAM more than other diseases (OR: 2.48, CI 95%: 1.28-4.78) and (OR: 3.19, CI 95%: 1.62-6.27), respectively. There was a significant relationship between education and using CAM (P<0.001). CONCLUSION: Community member's behavior in CAM use without adequate knowledge may have a noticeable influence on each other. Since it is a prevalent matter, we should think of ways of educating the general population about CAM methods and its potential risks and benefits. We also should encourage our healthcare workers to communicate such materials with their patients.