Percutaneous ethanol sclerotherapy is a promising treatment for recalcitrant angiolymphoid hyperplasia with eosinophilia.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare benign vascular proliferation, which manifests as characteristic red nodules and papules, mostly located on the scalp and periauricular regions. Patients seek treatment for both aesthetic and functional reasons, as lesions may ulcerate, bleed and itch. Many therapeutic approaches have been reported, with variable success, and relapse remains a troublesome issue. The aim of this study was to report our experience treating ALHE using percutaneous ethanol sclerotherapy (PES). We present a retrospective case series of three patients treated with PES (1-2 treatment sessions each). All patients had tried and failed other treatments prior to this intervention, but following PES treatment, all patients demonstrated significant improvement, which was sustained at follow-up (range 8-17 months after first treatment). Adverse effects were tolerable and transient. This case series demonstrates PES as a promising treatment for recalcitrant ALHE.

Epidemiology of cutaneous porphyria in Israel: a nationwide cohort study.

BACKGROUND: From a dermatologist's perspective, there are four major types of cutaneous porphyrias (CPs): porphyria cutanea tarda (PCT), erythropoietic protoporphyria (EPP), variegate porphyria (VP) and hereditary coproporphyria (HCP). Scarce data are available regarding the epidemiology of CPs. OBJECTIVES: To describe the epidemiology of CPs in Israel, including distribution, incidence and prevalence rates of major types. METHODS: This retrospective study includes all patients who were diagnosed with CPs between the years 1988-2018. It is based on data from Israel's National Service for the Biochemical Diagnoses of Porphyrias, and Israeli patients' nationwide electronic medical charts. Incidence and prevalence rates were calculated. RESULTS: Of 173 patients with CPs diagnosed during a 30-year period, 65 (38%) had VP, 62 (36%) had PCT, 31 (18%) had HCP and 15 (9%) had EPP; with incidence rates of 0.29, 0.30, 0.17, 0.07, and prevalence rates of 6.3, 4.8, 2.9, 1.6, respectively, per million population. Characteristics of patients with PCT differed from those with other CPs with regard to lack of family history, older mean age at diagnosis [51 vs. 36 (VP), 35 (HCP) and 25 (EPP) years] and male predominance (81% vs. similar distribution). All patients with PCT were diagnosed at adulthood, while 20%, 19% and 15% of patients with VP, HCP and EPP, respectively, were diagnosed during childhood or adolescence. CONCLUSIONS: Variegate porphyria and PCT were found to be the most prevalent in Israel; however, CPs might be underdiagnosed, thus dermatologists' awareness of these rare disorders is highly important.

Real-life experience in the treatment of solar urticaria: retrospective cohort study.

BACKGROUND: Solar urticaria (SU) is a rare photodermatosis causing a significant impact on patients' quality of life (QoL), and treatment is often challenging. AIM: To analyse clinical experience with a tailored stepwise therapeutic approach. METHODS: A retrospective cohort design was used. Patients with suspected SU underwent laboratory investigations and photoprovocation. Those with a high minimal urticaria dose (MUD) were treated with a single antihistamine (protocol 1), and those with a lower MUD received three types of antihistamines (protocol 2); both protocols included a leucotriene receptor antagonist (LRA). In cases of failure, treatment was switched to omalizumab at doses of < 300 mg/month with incremental dosage increases as necessary (monthly dose range, 150-600 mg/month). Symptom relief and photoprovocation under treatment were evaluated. RESULTS: In total, 30 patients (10 men, 20 women) were enrolled. Most (87%) were sensitive to visible light (1-70 J/cm2 ) with or without extension to ultraviolet A. Of the 30 patients, 23 opted for our stepwise approach: 22 achieved complete remission on protocols 1 or 2 (n = 17) or after switching to omalizumab (n = 5), and another patient achieved partial remission under omalizumab. There were no treatment-related severe adverse effects. CONCLUSIONS: Symptoms of SU can be well controlled by treatment with antihistamines and an LRA tailored to the degree of photosensitivity, followed by omalizumab in refractory cases. This has important implications for patient QoL.

Safety profile during initiation of propranolol for treatment of infantile haemangiomas in an ambulatory day-care hospitalization setting.

BACKGROUND: Propranolol is the mainstay of treatment for infantile haemangioma. Despite its good safety profile, it is not risk-free. Guidelines for propranolol initiation and monitoring have been suggested, but protocols vary among practitioners. OBJECTIVE: This study sought to assess the prevalence of adverse events and clinically significant fluctuations in haemodynamic parameters in children with infantile haemangioma during initiation of treatment with propranolol in a day-hospitalization setting. METHODS: Children with infantile haemangioma treated with propranolol in a day-hospitalization department of a tertiary paediatric medical centre in 2008-2014 were identified retrospectively. The pretreatment evaluation included clinical examination by a paediatric dermatologist and electrocardiography, echocardiography and clinical examination by a paediatric cardiologist. The propranolol dosage was escalated from 0.5 mg/kg/day to 2 mg/kg/day, divided into three doses/day, over 3 days. Heart rate, blood pressure and blood glucose level were measured before treatment onset and 60 min after the first two doses each day. The third dose was given at home. RESULTS: The cohort included 220 children aged 1 month to 5 years. No severe treatment-related adverse events were documented; 27 patients had minor side-effects. There was a significant decrease in heart rate each day after the first two doses (P < 0.001), and in systolic blood pressure, on day 2 (1 mg/kg/day) after the first dose (P = 0.01). Blood glucose level remained stable. The haemodynamic changes were clinically asymptomatic and did not require intervention. CONCLUSIONS: Propranolol treatment (2 mg/kg/day in three doses) for infantile haemangioma is well tolerated and safe and may be administered and monitored in an ambulatory setting.

Integrated cooling-vacuum-assisted 1540-nm erbium:glass laser is effective in treating mild-to-moderate acne vulgaris.

Acne treatment by a mid-infrared laser may be unsatisfactory due to deeply situated acne-affected sebaceous glands which serve as its target. Skin manipulation by vacuum and contact cooling may improve laser-skin interaction, reduce pain sensation, and increase overall safety and efficacy. To evaluate the safety and efficacy of acne treatment using an integrated cooling-vacuum-assisted 1540-nm erbium:glass laser, a prospective interventional study was conducted. It included 12 patients (seven men and five women) suffering from mild-to-moderate acne vulgaris. The device utilizes a mid-infrared 1540-nm laser (Alma Lasers Ltd. Caesarea, Israel), which is integrated with combined cooling-vacuum-assisted technology. An acne lesion is initially manipulated upon contact by a vacuum-cooling-assisted tip, followed by three to four stacked laser pulses (500-600 mJ, 4 mm spot size, and frequency of 2 Hz). Patients underwent four to six treatment sessions with a 2-week interval and were followed-up 1 and 3 months after the last treatment. Clinical photographs were taken by high-resolution digital camera before and after treatment. Clinical evaluation was performed by two independent dermatologists, and results were graded on a scale of 0 (exacerbation) to 4 (76-100 % improvement). Patients' and physicians' satisfaction was also recorded. Pain perception and adverse effects were evaluated as well. All patients demonstrated a moderate to significant improvement (average score of 3.6 and 2.0 within 1 and 3 months, respectively, following last treatment session). No side effects, besides a transient erythema, were observed. Cooling-vacuum-assisted 1540-nm laser is safe and effective for the treatment of acne vulgaris.

Noninvasive in vivo confocal laser scanning microscopy is effective in differentiating allergic from nonallergic equivocal patch test reactions.

Patch testing is the gold standard for the validation of contact dermatitis. It relies on the subjective scoring by an evaluator of the inflammatory reaction induced by an allergen applied to the skin. Equivocal reactions imply faint erythema and could represent allergic, irritant, or negative reactions. They constitute approximately 1 % of the positive reactions encountered in patch test practice. Histological evaluation of the equivocal reaction has proven helpful for the correct interpretation but is however time consuming, and its invasive nature is often unacceptable to the patient. In vivo confocal laser scanning microscopy (CLSM) is a novel, noninvasive imaging technique which permits real-time visualization of skin structures and lesions at a resolution close to that obtained by conventional histology. CLSM has been successfully applied for the differentiation between clinically clear-cut allergic and irritant patch test reactions. The objective of this study is to determine the relevance of CLSM in differentiating between allergic, irritant, and negative equivocal patch test reactions. Fifteen patients who underwent patch testing in our clinic were observed as having 20 equivocal reactions. All 20 reactions were evaluated using in vivo CLSM and compared with adjacent normal skin. In vivo CLSM evaluation revealed that 8 of the 20 equivocal reactions (40 %) showed confocal patterns consistent with the patterns encountered in positive allergic reactions. Anamnestic exposure, i.e., detailed assessment of previous related contact with these allergens, confirmed high relevance rates. In vivo CLSM is useful in differentiating between allergic, irritant, and negative equivocal patch test reactions, a differentiation that cannot be made by conventional clinical patch test reading.

Hypertrichosis in Becker's nevus: effective low-fluence laser hair removal.

Becker's nevus is cosmetically bothersome both due to the hyperpigmentation and due to the hypertrichosis which can accompany it, particularly in males. Laser hair removal can be considered, but the pigmented background of the Becker's nevus makes the treatment more challenging. Fifteen patients with Becker's nevus underwent eight sessions of hair removal with low-fluence high-repetition-rate diode lasers (808-810 nm). All participants experienced significant hair reduction at 6 and 12 months. No adverse events were reported. The study supports the use of low fluence with high-repetition-rate diode laser hair removal as a safe and effective method for the management of hypertrichosis in Becker's nevus.

Treatment of verrucous epidermal nevus: experience with 71 cases.

OBJECTIVE: The aim of this study was to evaluate the clinical results of 71 cases with verrucous epidermal nevus (VEN) treated by cryotherapy or CO2 laser. METHODS: The files and photographs of patients with VEN who were treated in the laser unit of a tertiary hospital between January 2005 and December 2011 were evaluated. Pretreatment and 12-month follow-up photographs were evaluated using a 5-point scale: 'excellent' (75-100% clearance), 'good' (50-75% clearance), 'fair' (25-50% clearance), 'poor' (<25% clearance) or 'worse'. RESULTS: Of 71 patients, 62 responded well to cryotherapy alone, and 9 facial VEN required CO2 laser treatment. Small VEN required relatively few treatments (mean 3.4) with 90% scoring 'excellent' and 10% scoring 'good'. Larger VEN required more treatments (mean 7.4) and did not respond as well, with 71% scoring 'excellent', 14% scoring 'good' and 14% scoring 'fair'. CONCLUSION: Our experience suggests that cryotherapy is the ideal treatment for small facial VEN, while ablation by CO2 laser should be considered an option for resistant facial lesions.

Effects of 420-nm intense pulsed light in an acne animal model.

BACKGROUND: Blue light in the 400-420 nm range has been shown to reduce the levels of Propionibacterium acnes (P. acnes) in the skin. P. acnes has been postulated to be a critical trigger for inflammatory acne. Thus, treatment with 420 nm-intense pulsed light should reduce inflammatory activity in acne. AIM: To evaluate the clinical and histological effects of 420 nm-intense pulsed light treatment on acne in animal model. METHOD: Inflammation acne animal model was constructed by intradermal injection of P. acnes of rat auricular. Levels of tumour necrosis factor alpha (TNF-α) and matrix metalloproteinase 2 (MMP-2), markers of inflammation implicated in acne, were assessed in treated and untreated animals by immunohistochemistry and quantitative polymerase chain reaction (PCR). RESULT: Treatment with 420 nm intense pulsed light led to marked improvement after 6 biweekly treatments. Immunohistochemistry and PCR showed that TNF-α and MMP-2 levels correlated with the extent of acneiform activity and were reduced by treatment with 420 nm light. CONCLUSION: A 420-nm intense pulsed light may exert its beneficial effects on inflammatory acne by reducing the levels of P. acnes and secondarily reducing inflammation induced by the bacteria.

Are port wines stains a feature of tuberous sclerosis?

BACKGROUND: Tuberous sclerosis complex is a multisystem inherited disorder characterized by the development of tumour-like growths in brain, skin and other organs. Although cutaneous vascular anomalies are not considered a common manifestation, we have encountered co-occurrence of port wine stains and tuberous sclerosis. OBJECTIVE: To assess the prevalence of port wine stain in patients with previously diagnosed tuberous sclerosis. METHODS: All cases diagnosed with tuberous sclerosis at two tertiary care centres from 2000 to 2009 were reviewed. Cases with clinically documented port wine stains were included for evaluation. RESULTS: Of 24 patients diagnosed with tuberous sclerosis, three (12.5%) had clinically evident port wine stains. The prevalence of port wine stains in this series of tuberous sclerosis patients was significantly higher than the 0.3% prevalence of port wine stain in the general population. CONCLUSION: Port wine stain rate in this population was significantly greater than the expected rate. Further studies are needed to assess the frequency of port wine stains in tuberous sclerosis and to clarify whether the finding should be added to the list of cutaneous features of tuberous sclerosis.

Best practice options for hair removal in patients with unwanted facial hair using combination therapy with laser: guidelines drawn up by an expert working group.

Hirsutism is a common disorder affecting between 5 and 15% of the population. One of the most devastating consequences of hirsutism is the presence of unwanted facial hair. Treatment of hirsutism involves a two-pronged approach: treating the underlying cause and reduction of visible hair. Laser hair removal is one of the most effective options for reducing visible hair, however, it may not be wholly effective in all patients and combination therapy may need to be considered. Pharmacological therapy is often used in combination with mechanical hair removal due to the time needed for the drug treatment to demonstrate visible results. Clinical data investigating the use of laser treatment in combination with other treatments has focused on laser with topical eflornithine. The expert working group reviews existing data and provides guidance on the use of eflornithine in combination with laser for resistant hirsutism.

Classic Kaposi sarcoma: experience at Rabin Medical Center in Israel.

Classic Kaposi sarcoma is an indolent cutaneous proliferative disease affecting mainly elderly people of Mediterranean and Jewish origin. The authors review the epidemiologic and clinical findings in Israeli patients with classic Kaposi sarcoma treated at the Institute of Oncology, Rabin Medical Center. A total of 123 patients were identified. The average age at diagnosis was 68 years (range, 20-90 years) and, as expected, there was a strong predominance of men (2.4:1). All but two patients were Jewish. The distribution of Ashkenazic Jews and Sephardic Jews was almost equal. Twenty-three patients (19%) had secondary malignancies that were mostly solid tumors. The clinical course was indolent and rarely fatal (4% disease-related mortality). Multivariate analysis revealed that non-Ashkenazic origin, age over 70 years, multiple lesions (>10), and immunocompromised conditions adversely affected survival. Radiotherapy for localized skin lesions yielded an 88% objective response, with symptomatic relief in 95% of patients. Chemotherapy was similarly effective (76% response rate) in patients with disseminated disease. These data demonstrate the indolent nature of classic Kaposi sarcoma which usually requires a less aggressive therapeutic approach than in the African and AIDS-related types of Kaposi sarcoma.

Secondary milia following bullous erysipelas.

Secondary milia associated with bullous erysipelas developed in the right leg of a 64-year-old woman. The milia, measuring up to 6 mm, appeared one month after healing of the erysipelas. Findings of histopathologic and immunohistochemical studies showed that the milia were related to dilated eccrine ducts and not to the hair follicle. Topical treatment with 0.05 percent tretinoin cream resulted in almost full resolution of the lesions.

Targeted UVB phototherapy for psoriasis: a preliminary study.

Excimer laser treatment for psoriasis has been associated with good results at a lower cumulative dose than narrowband ultraviolet (UV)B protocols. To examine the clinical performance of a new targeted UVB lamp (290-320 nm; BClear) in the treatment of plaque-type psoriasis, 28 consecutive patients attending a dermatology service were treated twice weekly with the UVB lamp for 6-18 sessions (median 10). UV doses were based on multiples of a predetermined minimal erythema dose (MED). MEDs ranged from 150 to 350 mJ/cm2; maximal dose was 8 MED. Mean cumulative fluence until remission was 12.63 J/cm2. The Psoriasis Severity Index (PSI) was measured every 2 weeks for 16 weeks. Mean PSI improvement during treatment peaked at 73% after 6 weeks, and declined to 63% at 16 weeks. At that point, 36% of the patients had a > 75% improvement in PSI, and 21% showed complete clearance. Targeted radiation with the UVB lamp is effective for the treatment of plaque-type psoriasis, requiring as few as six sessions and achieving moderately long remission. As treatment is selectively directed toward lesioned skin, normal surrounding skin is spared unnecessary radiation exposure.

Basal cell carcinoma arising over facial port wine stain: a single-centre experience.

BACKGROUND: A growing number of reports point to a possible connection between basal cell carcinoma (BCC) and port wine stain (PWS). Researchers suggest that either the elevated temperature induced by the increased dermal vasculature or an oncogenic factor produced by the ectatic vessels makes the overlying epidermis more susceptible to ultraviolet or ionizing radiation. OBJECTIVE: To check the prevalence of BCC in patients with PWS at a large national vascular amomalies centre. METHODS: The study group included 68 patients, 44 women and 24 men, with facial PWSs. Detailed data were collected on background features, past treatments and past exposure to radiation, and a comprehensive physical examination was performed. Biopsy samples were taken from suspect lesions for histological study. RESULTS: Four patients (5.9%) were found to have histologically proven BCC, 3 nodular and one multifocal. All had been exposed to radiation during childhood. Treatment consisted of excision; there was one recurrence. CONCLUSION: Although the co-occurrence of BCC and PWS is probably related to radiation treatment in childhood, these findings should alert physicians to regularly examine PWSs for cancerous changes, especially in patients at risk.

Effect of colchicine in the subcorneal pustular dermatosis type of IgA pemphigus.

BACKGROUND: IgA pemphigus of the subcorneal pustular dermatosis (SPD) type is characterized by subcorneal acantholysis and by an abundance of neutrophils, making colchicine a reasonable pharmacologic option for treatment. OBJECTIVE: We attempted to determine the efficacy of colchicine in the treatment of SPD-type IgA pemphigus. METHODS: Two patients with SPD-type IgA pemphigus were treated with colchicine 1.5 mg/day as monotherapy. RESULTS: A sustained clinical response was achieved within 2 to 3 weeks of therapy. Relapses were noted each time colchicine was stopped. CONCLUSION: Colchicine should be considered in the treatment of SPD-type IgA pemphigus.

In vitro release of interferon-gamma and macrophage migration inhibition factor in drug-induced urticaria and angioedema.

T-cells are involved in the pathogenesis of cutaneous drug reactions. T-cell phenotype and cytokine release pattern in rivo and in vitro might correlate with the type of immune response involved in cutaneous drug reactions. In vitro release of interferon-gamma and macrophage migration inhibition factor (MIF) from peripheral blood lymphocytes, following in vitro challenge with the suspected unmodified drugs, was studied in 12 patients with drug-induced urticaria and/or angioedema and in two group-matched controls. The occurrence of positive interferon-gamma and MIF responses was significantly higher in patients with drug-induced urticaria and/or angioedema than in controls. The sensitivity and specificity of the interferon-gamma test (50% and 92%, respectively) were similar to that of the MIF test (58% and 96%, respectively). Percentage agreement between both tests was 80.9 (kappa = 0.76). In vitro release of interferon-gamma and MIF in drug-induced urticaria and/or angioedema suggests a drug-specific immune response, and may implicate the drug as a possible inducer of the reaction.