Introduction of a novel quantitative scoring system for acanthosis nigricans and its validation in a pilot study.

Inconsistent data exist regarding the diagnostic value of acanthosis nigricans (AN) or skin tags as clinical markers for obesity or diabetes. In an outpatient department-based prospective study, we designed a scoring for AN severity (SCANS) to evaluate AN and skin tags, their correlation with obesity or diabetes. Quantification of AN in six anatomic sites, in consideration of the affected skin surface areas, texture changes, number of skin tags, leads to a total severity score between 0 and 46. Among 336 adult patients (aged ≥18 years) with AN, a higher BMI was associated with AN (r = 0.299, P < .001), but not with diabetes (P = .43), as compared with 243 age- and sex-matched controls without AN. Among nondiabetics, AN scores were significantly correlated with waist circumference (r = 0.131, P = .024) and total cholesterol levels (r = 0.155, P = .04). Skin tags alone in the absence of AN were not associated with obesity (P = .333) or diabetes (P = .164). The total AN scores were positively correlated with the presence of skin tags (r = 0.132, P < .001), and the involvement of anterior neck (r = 0.668, P < .001) and axilla (r = 0.793, P < .001). Knuckles and groins were unaffected in our series. Our results indicate that combination of AN with skin tags can be used as clinical marker for obesity, but not for diabetes. Large-scale studies on patients of different ethnic background are required to further validate our proposed scoring.

Nineteen-year retrospective evaluation of pemphigus in a single dermatology centre in Istanbul, Turkey.

INTRODUCTION: Pemphigus is an autoimmune intra-epidermal bullous disease of the skin and mucosae. AIM: To retrospectively evaluate the course, prognosis and clinical features of pemphigus. MATERIAL AND METHODS: The files of 196 pemphigus patients admitted to our clinic between December 1995 and December 2014 were collected and analysed. RESULTS: The male to female ratio among patients was 1 : 1.88. Pemphigus vulgaris (PV) was the most common clinical variant observed in 175 (89.3%) of the patients, followed by pemphigus foliaceus (PF) in 14 (7.1%) of the patients. The mean patient age at disease onset was 50 years. PV presented itself as skin lesions in 55 (31.4%) of the patients and as oral mucosa lesions in 120 (68.6%) of the patients. Complete remission and treatment withdrawal were obtained in 112 (57.1%) of the patients, for a mean period of 2.91 ±2.66 years (range: 4 months to 13 years). The mortality rate was 6%, and relapse occurred in 16 (14.3%) of the patients for a mean relapse period of 2.15 ±1.88 years (range: 6 months to 7 years). Mucocutaneous pemphigus (MCP) was the major clinical pattern observed in 96 (49%) of the patients. CONCLUSIONS: Within our study population, pemphigus predominately affected females, and the most common clinical variant was PV, a subtype that frequently occurs in middle-aged individuals. MCP was the most common clinical pattern. Although MCP and higher doses of corticosteroids were needed to control pemphigus, they did not seem to influence the prognosis.

The rapid effect of pulsed dye laser on demodex density of facial skin.

BACKGROUND: Recently, treatment with acaricides, which is aimed at reducing excessive proliferation of demodex mites, has gained popularity due to its providing a significant improvement in the symptoms of diseases, such as rosacea, seborrhoeic dermatitis, and perioral dermatitis. The effect of IPL on demodex mites was reported in skin biopsy specimens in three patients; however, to the best of our knowledge, no study exists to date, which evaluates the effect of pulsed dye laser (PDL) on demodex density (Dd) in larger patient group. We aim here in to observe the Dd before and after PDL therapy with two different skin biopsy techniques. MATERIAL AND METHODS: Thirty-one patients diagnosed with rosacea were included in the study who received PDL treatment. Dds which were measured by using both the SSSB (standardized skin surface biopsy) and CTM (cellophane tape method) techniques before and after 3 weeks of PDL therapy were evaluated. RESULTS AND DISCUSSION: The Dd of patients before PDL treatment was 13.0 (interquartile range (IQR): 5.0-28.0) and after 3 weeks of PDL treatment it was 6.0 (IQR: 3.0-12.0) with SSSB. After PDL treatment, the Dd was significantly lower than pretreatment the Dd (p = 0.002). The present study shows that PDL significantly reduced Dd in facial skin with one session.

Morphea secondary to interferon beta1b injection: a case and review of the literature.

Interferon beta (IFNß) is a drug used successfully in the treatment of multiple sclerosis (MS). Although IFNß is a safe and well-tolerated drug, dermatological side effects are common. The most common dermatological adverse effect is a local reaction at the injection site. It may also cause inflammatory and immune-mediated dermatological side effects. However, morphea induced by IFNß1b injection is very rare.

Evaluation of ocular findings in patients with lichen planus.

INTRODUCTION: Lichen planus (LP) is a chronic, inflammatory disease of unknown etiology. AIM: To evaluate the tear functions and the retinal and choroidal thickness (CT) in patients with LP. MATERIAL AND METHODS: In total, 33 patients and 30 healthy controls were enrolled. All participants were evaluated using the Ocular Surface Disease Index (OSDI) questionnaire, Schirmer 1 test (with anesthesia), tear break-up time (TBUT) test, intraocular pressure (IOP), axial length (AL), and central corneal thickness (CCT). The measurements of retinal thickness (RT) and CT were obtained by spectral domain optical coherence tomography. RESULTS: No significant difference was observed between the groups in IOP, AL, CCT, or RT (p > 0.05 in each group). There was a significant difference in the Schirmer 1 test, TBUT, and OSDI questionnaire (p < 0.05 in each group). Choroidal thickness in LP patients was thinner than that in the controls (p = 0.001 in each location). There was a moderate negative correlation between the disease duration and Schirmer 1 test, TBUT, and subfoveal CT (r = -0.426, r = -0.555, r = -0.637; p = 0.001, p = 0.001, p = 0.001, respectively). There was a moderate negative correlation between the oral mucosal involvement and Schirmer 1 test, TBUT, and subfoveal CT (r = -0.345, r = -0.392, r = -0.467; p = 0.006, p = 0.001, p = 0.001, respectively). There was a positive correlation between disease duration, oral mucosal involvement and OSDI score (r = 0.717, r = 0.345; p = 0.001, p = 0.006, respectively). CONCLUSIONS: Lichen planus may influence tear function tests and may cause dry eye. Patients with LP had lower CT values than healthy controls. Further studies are needed to clarify the effect of LP on the eyes.

Evaluation of oxidative stress via protein expression of glutathione S-transferase and cytochrome p450 (CYP450) isoenzymes in psoriasis vulgaris patients treated with methotrexate.

INTRODUCTION: Oxidative stress is the imbalance between oxidant-antioxidant systems and may play a major role in the psoriasis pathogenesis. Cytochrome (CYP) is a family of enzymes that are responsible for the metabolism of various endogenous and exogenous substances such as drug metabolism. Most importantly, the antioxidant system is the glutathione S-transferases (GST), which decrease oxidative stress by reducing oxidative products. AIM: We aimed to evaluate the expressions of isoenzymes of GST and CYP families and the beneficial role of metotrexate (MTX) in this process. MATERIAL AND METHODS: This study included 21 patients with psoriasis and 22 healthy subjects. We treated all the patients with 10-15 mg/week of MTX for minimum 12 weeks. Expressions of GST and CYP enzymes were assessed by immunohistochemical staining. RESULTS: GSTK1, GSTM1 and GSTT1 expressions were significantly higher in the psoriasis tissues than in the control tissues (p < 0.05; p < 0.05; p < 0.05, respectively). In the psoriasis patients, GSTO1 expression was similar the control group. CYP1B1 and CYP2E1 expressions were significantly higher in the pre-treatment and post-treatment psoriasis tissues than in the control tissues (p < 0.05; p < 0.05; p < 0.05; p < 0.05, respectively). CONCLUSION: We found a significant increase in the tissue levels of, either expression of GST, or CYP, which has important role in drug metabolism and oxidative stress. MTX treatment resulted in marked clinical improvement, yet we found that MTX did not have any significant effect on these parameters. CYP2E1 is especially the most important enzyme for MTX metabolism since it is the primarily responsible of the toxic metabolism of various drugs. The other experimental studies involving greater number of patients and other different drug are needed to enlighten the role of oxidant and antioxidant systems and the other possible mechanisms for the pathogenesis of psoriasis.

Behçet Disease: New Developments in the Etiopathogenesis of an Old Silk Road Disease.

Behçet disease (BD) is a systemic inflammatory disorder that affects the skin, mucosa, eyes, joints, blood vessels, brain, and gastrointestinal tract. The etiopathogenesis of BD has not yet been fully elucidated, but disorganized immune responses against the stimuli of environmental triggering factors have been considered to play a major role in the pathogenesis of the disease in individuals with genetic susceptibility. Human leukocyte antigen (HLA)-B*51 is known to be the main factor involved in genetic susceptibility to BD. Among the environmental factors, infectious agents in particular are thought to be important. Immunological abnormalities could thus be the cornerstone in the development of BD. Along with cytokines that play a role in disease pathogenesis, numerous other cytokines have been recently identified or have been the focus of recent studies. This contribution sheds light on the etiopathogenesis and immunology of BD in relation to the current literature.

Evaluation of platelet parameters and neutrophil/lymphocyte ratio during omalizumab treatment in patients with severe chronic spontaneous urticaria

Background/aim: Spontaneous wheals and/or angioedema lasting longer than six weeks are described as chronic spontaneous urticaria (CSU). Omalizumab is used for the treatment of antihistamine-resistant CSU. The neutrophil­lymphocyte ratio (NLR), platelet­ lymphocyte ratio (PLR), mean platelet volume (MPV), and platelet distribution width (PDW) are considered important indicators of inflammation and platelet activation in chronic diseases. We aimed to determine the NLR, PLR, MPV, and PDW levels in patients with CSU compared with healthy controls. We also aimed to investigate the effects of omalizumab therapy on these parameters in CSU patients. Materials and methods: This hospital-based, retrospective study included 143 patients with CSU and 132 healthy controls with a mean age of 40.0 ± 13.17 and 42.0 ± 16.34, respectively. Patients with equal or higher-than-baseline UAS scores at week 12 of omalizumab treatment were considered nonresponders, others were considered responders. We analyzed the neutrophils, lymphocytes, platelet counts, NLR, PLR, MPV, and PDW before, during, and after omalizumab treatment and compared the results with those of healthy controls. Results: CSU patients presented higher baseline MPV (P = 0.035) and lower baseline PDW values (P < 0.001) than healthy controls. There were statistically significant increases in the MPV (P < 0.001), MPV/platelet count (P = 0.005), and PDW (P = 0.003) and there was a statistically significant decrease in the NLR (P = 0.018) during omalizumab treatment. The percent increase of MPV was low in nonresponders (P = 0.009). Nonresponders had lower PDW values than responders (P = 0.040). Conclusion: The increase in the MPV and PDW may be due to platelet activation during omalizumab treatment. The decrease in the NLR may be regarded as an antiinflammatory effect of omalizumab. The effect of omalizumab on platelet and inflammatory markers may be used to discriminate the responders from nonresponders.

The investigation of antimicrobial peptides expression and its related interaction with methotrexate treatment in patients with psoriasis vulgaris.

BACKGROUND: Psoriasis is a chronic, inflammatory and immune-mediated disease. Recently, the role of antimicrobial peptides (AMPs) such as human beta defensins (hBDs) in the pathogenesis of psoriasis has been investigated. We aimed to evaluate the expression profiles of hBD-1 and hBD-2 in psoriatic skin before and after methotrexate (MTX) therapy and to compare healthy controls. METHODS: Immunohistochemical expressions of hBD-1 and hBD-2 were assessed in 16 patients with psoriasis vulgaris and 20 normal skin biopsies from healthy controls. The patients were administered a 12 week of MTX and skin biopsy samples were obtained from the lesional skin of the patients pre-/posttreatment and normal body of the healthy controls. RESULTS: The median (range) Psoriasis Area and Severity Index (PASI) value was 21.6 (8.2-27.7) before the treatment whereas; 3.05 (1-23.4) after the treatment. hBD-1 expression in psoriasis patients was significantly higher as compared to the healthy controls before treatment (p < 0.01). No significant difference was observed between psoriasis patients and healthy controls in terms of hBD-2 expression before treatment (p > 0.05). No significant difference was observed between before-after MTX treatment in terms of hBD-1 and hBD-2 expression levels in psoriasis patients (p > 0.05). CONCLUSIONS: These findings suggest a role for hBD-1 in psoriasis pathogenesis. But MTX treatment does not affect on hBD-1 and hBD-2 expressions. Further studies are needed to assess the roles of these AMPs in psoriasis etiopathogenesis.

Plantar Fibromatosis in a Mentally Challenged Man Treated with Intralesional Corticosteroids.

A 21-year-old mentally challenged man presented with a fixed plaque lesion on the right foot, which had been present for 10 years. Dermatologic examination revealed an erythematous, painful, firm, fixed plaque-nodular lesion on the plantar aspect of the right foot (Figure 1A). Nothing of distinction was noted from his family history or his laboratory tests. An incisional biopsy revealed parallel, regular bundles composed of uniform, plump spindle cells. Thin collagen fibers were seen in contact with and located between the spindle cells. This mass was separated from the surrounding soft tissue by an irregular, unclear border (Figure 2A). Immunohistochemically, the spindle cells showed diffuse, strong reactivity to vimentin (Figure 2B) and smooth muscle actin.

Evaluation of Cardiovascular Risk Factors, Haematological and Biochemical Parameters, and Serum Endocan Levels in Patients with Lichen Planus.

BACKGROUND AND OBJECTIVE: The current study aimed to evaluate cardiovascular risk factors, haematological and biochemical parameters, and serum endocan concentrations in lichen planus (LP) patients. METHODS: This study was conducted with 86 cases, including 43 LP patients and 43 healthy controls. Cardiovascular risk factors, haematological and biochemical parameters, and endocan levels were evaluated. RESULTS: The serum endocan concentrations of LP patients were not significantly different from those of the healthy controls (p > 0.05). There were no significant differences in the serum endocan levels according to classification by cardiovascular risk factors and smoking history (p > 0.05). In the LP group, white blood cell count, platelet distribution width and monocyte count/high-density lipoprotein cholesterol ratios were significantly higher when compared to the healthy controls (p < 0.05). The LP group had a lower mean platelet volume than the healthy controls (p < 0.05). CONCLUSIONS: Serum endocan levels did not change significantly in patients with LP, and there were significant differences in haematological and biochemical parameters.

Neutrophil/Lymphocyte Ratio, Serum Endocan, and Nesfatin-1 Levels in Patients with Psoriasis Vulgaris Undergoing Phototherapy Treatment.

BACKGROUND Psoriasis is an autoimmune, inflammatory, and chronic disease. Recent studies have evaluated serum endocan and nesfatin-1 levels in patients with inflammatory disorders. The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory marker currently used in many diseases. The aim of the present study was to evaluate NLR, serum endocan, and nesfatin-1 levels in psoriasis vulgaris before and after narrow-band ultraviolet B (NB-UVB) phototherapy treatment and compared to healthy controls. MATERIAL AND METHODS This study was conducted on a total of 88 cases, 39 of which had psoriasis vulgaris and 49 were healthy volunteers. Thirty-nine psoriasis vulgaris patients underwent NB-UVB phototherapy treatment for 3 months. NLR, serum endocan, and nesfatin-1 levels were measured in all psoriasis patients before and after NB-UVB phototherapy and in the control group. RESULTS Compared with the control group, neutrophil count and NLR were significantly higher (p<0.001) in psoriasis patients before NB-UVB phototherapy. Serum endocan levels were significantly correlated with disease activity before treatment. There was no significant difference in NLR, serum endocan, and nesfatin-1 levels in psoriasis patients before and after NB-UVB phototherapy (p>0.05). CONCLUSIONS The current study shows that NLR was higher in psoriasis vulgaris patients when compared with the control group, whereas serum endocan and nesfatin-1 levels were not significantly different. In addition, NB-UVB phototherapy did not affect NLR, serum endocan, or nesfatin-1 levels. Further larger-scale studies are required on this subject.

Oral mucosal involvement and petechial lesions: a SDRIFE case with unusual findings.

Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) is a type IV hypersensitivity reaction characterized by a symmetrical erythematous rash in the gluteal and intertriginous areas. SDRIFE was previously considered to be the same presentation as Baboon Syndrome, however, has been suggested to be a different entity in the recent publications. The lesions are generally maculopapular and there is no mucosal involvement. To date, no case with petechial findings and mucosal involvement has been reported in the literature. The present study reports a SDRIFE case with a symmetrical erythematous petechial rash and oral mucosal involvement after taking oral amoxicillin.

Comparison of TLR-2, TLR-4, and antimicrobial peptide levels in different lesions of acne vulgaris.

CONTEXT: Recent studies have shown that tolls like receptors (TLRs) and antimicrobial peptides (hBD-1, cathelicidin) play an important role in the pathogenesis of acne vulgaris (AV). OBJECTIVE: To evaluate and report the expression of TLR-2, TLR-4, hBD-1 and cathelicidin in different regions of skin in AV. PARTICIPANTS: This study was performed in 80 patients with AV and a control group of 20 healthy individuals. MATERIAL AND METHODS: Skin biopsies were performed from 20 papular, 20 pustular, 20 comedonal and 20 nodular lesions of patients and 20 healthy volunteers. Expression levels of TLR-2, TLR-4, hBD-1 and cathelicidin in four separate areas (epidermis, dermis, inflammation region and skin appendages) were evaluated by immunohistochemical method. Further, these parameters were compared between different skin lesions. RESULTS: A significant difference was found between the levels of staining of TLR-2, TLR-4 and hBD-1 from the epidermis, inflammation region, dermis and skin appendages (p < 0.05). Levels of cathelicidin were different in only the inflammation region (p < 0.05). The level of TLR-2 in the epidermis with nodules was lower than the papules and comedones (p < 0.05). Levels of TLR-2 in the inflammation and dermis of the cases with papules were significantly higher when compared to pustules (p < 0.05). The levels of staining of TLR-4 in the dermis with comedones were significantly lower compared to the cases with papules (p < 005). The level of hBD-1 in the epidermis region of comedones was significantly higher compared to nodules (p < 0.05). The expression of cathelicidin in the inflammation region of comedones was significantly low (p < 0.05). CONCLUSION: It is thought that TLR-2, TLR-4, hBD-1 and cathelicidin play an important role in the pathogenesis of AV and in the development of different acne types. We think that, better results could be obtained in treatment of AV with different treatment options targeted in regulation of TLR-2, TLR-4, hBD-1 and cathelicidin release.

Acitretin-induced alopecia areata: a case report.

Alopecia areata is a common form of non-scarring hair disorder. The development of alopecia areata during anti-psoriatic treatment has been reported with the systemic therapies such as infliximab, etanercept, adalimumab, alefacept and efalizumab. Retinoid-induced alopecia areata on the eyelash and eyebrow has not been reported in the literature. We report a female patient who presented with alopecia areata of the eyebrow and eyelash one month after the initiation of acitretin therapy for psoriasis.

Cutaneous siderosis after intramuscular iron injections: a case report.

Skin reactions against injected or implanted foreign materials are not rare. Siderosis is a disease characterized by the accumulation of iron in various tissues. Brownish-gray discoloration of the skin can be seen as a side-effect on the injection area after the parenteral iron treatment. Here, we present cutaneous siderosis case developed after multiple intramuscular iron injection on the gluteal region for iron-deficiency anemia. Development of cutaneous siderosis after intramuscular iron injection rarely has been reported in the literature before.

The Psychosocial Impact of Chronic Facial Dermatoses in Adults.

INTRODUCTION: Skin diseases have negative psychological and social consequences, especially when they are chronic and affect a visible area of the body, such as the face. OBJECTIVES: The purpose of this study is to investigate and compare the psychosocial impact of three common chronic dermatoses of the face: acne, rosacea, and seborrheic dermatitis. METHODS: The Dermatology Life Quality Index (DLQI), Hospital Anxiety and Depression Scale (HADS), and Social Appearance Anxiety Scale (SAAS) were used to compare acne, rosacea, and seborrheic dermatitis patients and healthy controls. The relationships between DLQI, HADS, and SAAS results were investigated, as well as their associations with disease duration and severity. RESULTS: The study included 166 acne patients, 134 rosacea patients, 120 seborrheic dermatitis patients, and 124 controls. The patient groups had significantly higher DLQI, HADS, and SAAS scores than the control group. Rosacea patients had the highest DLQI and SAAS scores, as well as the highest anxiety prevalence. Patients with seborrheic dermatitis had the highest rate of depression. The DLQI, HADS, and SAAS results were moderately correlated with each other, but their relationship with disease duration and severity was insignificant or weak at best. CONCLUSIONS: Chronic facial dermatoses have a detrimental impact on mood and quality of life. Although patients with acne, rosacea, and seborrheic dermatitis have distinct lesions, the outcomes in terms of quality of life, anxiety, and depression are largely similar. Furthermore, these patients report similar levels of social anxiety as a result of their overall appearance.

Dermatopathological Correlation of Clinically Challenging Cutaneous Lesions: a Single Center Experience of 2184 Cases.

Introduction: Although a trained eye can easily identify typical skin lesions, histopathological examination and clinicopathological correlation are critical in challenging cases. Objectives: The primary objective is to organize the final diagnoses reached following clinicopathological consensus in clinically challenging cutaneous lesions, identifying the most common diagnostic scenarios encountered by dermatopathologists and discussing their diverse differentials submitted by clinicians. The secondary objective is to investigate how the case profile and clinician decision-making processes evolved during the COVID-19 pandemic. Methods: Skin and mucosa samples collected by the dermatology department between 2016 and 2020 were classified based on pathology reports. For frequent diagnoses, preliminary diagnoses stated by clinicians on pathology requisition forms were reviewed. The years preceding and following the first nationally reported COVID-19 case were compared to investigate the pandemic's impact on the distribution of dermatology and dermatopathology cases. Results: One thousand nine hundred and eighty-nine reports were classified into 4 major categories: inflammatory (49.8%), neoplastic (30.1%), other diseases (7.1%), and non-diagnostic (12.8%). We further classified inflammatory diseases based on major tissue reaction patterns and neoplasms based on cell origin. We analyzed the leading diagnoses in each category, discussed their differential diagnoses, and provided clinicians with clues to reduce errors in practice. Following the pandemic, the overall number of pathology reports and patient admissions dropped dramatically, with significant changes in case profiles. Conclusions: We presented and discussed the frequently encountered confounding cases to sketch the diagnostic landscape. In the authors' experience, clinicopathological correlation can increase the rate of reaching the diagnosis by up to 75.3%.

Tissue expression of glutathione S transferase isoenzymes in vitiligo.

The association of glutathione S-transferase (GST) enzymes with vitiligo is inconclusive. To evaluate tissue expressions of GST isoenzymes in vitiligo patients and to compare these expressions with healthy controls, we used 26 active depigmented patches on the trunk of vitiligo patients and 20 healthy sex and age matched controls. Punch biopsies were taken from the lesioned or normal skin. Tissue expression of GST isoenzymes were analyzed immunohistochemically. Tissue expression of GSTT1, GSTA1 and GSTP1 was significantly higher in the patient group than controls. Tissue expression of GSTM1 was not significantly different between the two groups. The increased tissue expression of GSTT1, GSTA1 and GSTP1 may represent a response to excess free radical formation in vitiligo and may support the role of oxidative stress in the pathogenesis of vitiligo.