Corticosteroid Therapy in Combination with Antibiotics for Erysipelas.

BACKGROUND: Erysipelas, an acute infection of the dermal and subcutaneous tissue, is normally treated with antibiotics. Previous data indicated that treatment with prednisone in combination with antibiotics results in significant acceleration of the healing phase. OBJECTIVES: To investigate the effectiveness of corticosteroids combined with antibiotics for the treatment of erysipelas. METHODS: A retrospective study was conducted on hospitalized patients diagnosed with erysipelas between 2004 and 2011 at the Department of Dermatology at Sheba Medical Center, Israel. Data included epidemiology, medical background, and course of the disease as documented at admission and during hospitalization. RESULTS: Data were collected on 173 patients (66% males) who were divided into two groups: a control group treated with antibiotics only (97 patients) and a study group treated with antibiotics and prednisone (76 patients). The study group presented with a more severe form of erysipelas (bullous) and those patients were hospitalized for a longer period (8.5 vs. 7 days). Nevertheless, the study group exhibited a 71% clinical improvement shortly after being treated with prednisone, without significant side effects. Short-term follow-up revealed more edema in the study group; however, long-term follow-up revealed a higher incidence of erythema and recurrence of erysipelas in the control group. The return to full function was faster in the study group than in the control group. CONCLUSIONS: Combining prednisone with antibiotics for the treatment of erysipelas should be considered, especially in severe cases. In addition, a prospective double-blind study should be conducted to verify these conclusions.

The Histopathology of Urticaria Revisited-Clinical Pathological Study.

BACKGROUND: The classic histopathological findings of urticaria include dermal edema and a sparse perivascular infiltrate of neutrophils, eosinophils, macrophages, and lymphocytes. However, this pattern is inconsistently described. OBJECTIVE: To describe the histological and immunofluorescence characteristics of urticaria and to identify distinctive patterns. METHODS: A retrospective study was performed in which the medical files and biopsy specimens of 58 patients with acute and chronic classical urticaria were reviewed. Pathological parameters were quantified. RESULTS: We recognized 2 distinctive patterns of urticaria: lymphocyte and neutrophil predominant; the former was characterized by a perivascular location, whereas the latter was associated with an interstitial location and a denser infiltrate. Mast cells were relatively sparse, better demonstrated with special stains. Tryptase stain demonstrated more mast cells than Giemsa stain. Extravasated erythrocytes were present in 50% of the cases, but vasculitis was not observed. CONCLUSIONS: Histological findings in classical urticaria show a spectrum of findings from a sparse superficial perivascular to a deep perivascular and interstitial infiltrate. Distinctive groups based on the dominant cell type can be identified, accounting for the similarity to neutrophilic urticarial dermatosis. Lesions may have a purpuric appearance, but leukocytoclastic vasculitis is never present.

Efficacy of Dapsone in the Treatment of Pemphigus Vulgaris: A Single-Center Case Study.

BACKGROUND: Pemphigus vulgaris (PV) is a chronic autoimmune blistering disease. Most patients require long-term therapy with systemic steroids, and a steroid-sparing agent is usually also utilized. Dapsone is a chemotherapeutic agent with anti-inflammatory properties that is used as a steroid-sparing agent in PV. OBJECTIVE: The aim of the present study was to evaluate the efficacy of dapsone as an adjuvant therapy in patients with PV. METHODS: A retrospective analysis of patients' files was performed. All 26 patients included in the study group were treated with dapsone as an adjuvant to systemic steroids for at least 3 consecutive months and were followed up during their dapsone treatment period. RESULTS: After 3 months of treatment with dapsone, 13 patients were in the consolidation phase, 4 patients demonstrated partial remission on minimal therapy, 7 patients demonstrated complete remission on minimal therapy, and 2 patients were defined as treatment failures. The trend of clinical improvement continued after 6 months of treatment and at the study end point. CONCLUSION: This retrospective case series, one of the largest reported, indicates that dapsone is efficacious and safe for patients with PV in whom it is well tolerated soon after the initiation of treatment.

9-cis-rich ß-carotene powder of the alga Dunaliella reduces the severity of chronic plaque psoriasis: a randomized, double-blind, placebo-controlled clinical trial.

BACKGROUND: Synthetic retinoids are one of the mainstay treatments of psoriasis. However, their use is occasionally limited by adverse effects, especially mucocutaneous, hepatic, and lipid profile toxicity. Thus, a search for retinoid metabolites that are both safe and active is essential. The alga Dunaliella bardawil is a natural source of the retinoid precursor 9-cis ß-carotene that has a good adverse effect profile. OBJECTIVE: To test the effect of the alga Dunaliella bardawil on psoriasis. METHODS: Thirty-four adult patients with mild, chronic, plaque-type psoriasis were included in this monocentric, prospective, randomized, double-blinded pilot study. Patients received either capsules of the alga D. bardawil or starch powder capsules, as the placebo, for 12 weeks. The response to treatment was evaluated by changes in Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) scores. Safety of the treatment was evaluated. RESULTS: At the end of 6 weeks, the reduction in the mean PASI score was significantly higher in the Dunaliella group than in the placebo group (61.3% vs 34%, respectively, p = 0.002). The DLQI change did not reach significance (8.5% and 5.9% in the Dunaliella and in the control group, respectively, p = 0.9). We observed no significant change in the liver function tests or in the lipid profile. CONCLUSIONS: 9-cis ß-carotene, in the form of D. bardawil, is an effective and safe treatment for patients with mild, chronic, plaque-type psoriasis. A larger study is warranted.

Treatment of erosive oral lichen planus with local ultraviolet B phototherapy.

BACKGROUND: Oral lichen planus (OLP) is a chronic inflammatory disease that can significantly affect the patient's quality of life. OBJECTIVE: We sought to demonstrate the therapeutic efficacy of local ultraviolet (UV) B phototherapy in OLP. METHODS: Patients with biopsy-confirmed erosive OLP recalcitrant to previous medical therapy were treated with the TheraLight UV 120-2 system (TheraLight Inc, Carlsbad, CA). Lesions were accessed directly using a flexible fiber guide. Local phototherapy was delivered 3 times a week, with gradual increase in UVB dose every other session. Affected oral mucosa was defined as the area showing erosions or symptomatic reticular lesions. Complete response was defined as reduction of at least 80% in the affected mucosal area, and partial response was defined as a reduction of 50% to 80% in the affected mucosal area. The primary end point was efficacy after 8 weeks of treatment. RESULTS: Fourteen patients were included in the study. Nine achieved complete response and 5 partial response after 8 weeks. Ten patients were continued on maintenance therapy and were able to maintain their response for another 29 weeks. None of the patients showed any serious side effects from local UVB therapy. LIMITATIONS: The study was performed in a small series of patients at a single medical center. Further studies with larger patient samples are required to validate our findings. CONCLUSION: Local UVB phototherapy may be a promising treatment modality for erosive OLP.

Methotrexate is an effective and safe adjuvant therapy for pemphigus vulgaris.

BACKGROUND: Pemphigus vulgaris (PV) is a chronic, autoimmune blistering disease. Most patients require long term therapy with systemic steroids as a first line of treatment. Immunosuppressive agents such as methotrexate (MTX) are administrated as second line therapy. Only a few reports have assessed MTX efficacy, with contradictory results. OBJECTIVE: The aim of this study was to evaluate MTX as an adjuvant therapy in patients with PV. METHODS: A retrospective study of 30 PV patients treated with MTX as an adjuvant therapy. Disease severity score and prednisone dosage served as assessing measures. RESULTS: All patients were treated with 15 mg MTX per week. Of the 25 patients defined as severe or moderate disease at the beginning of treatment, 21 (84%) improved and downgraded their severity status at 6 months of treatment. In 21 patients (76.6%) we were able to reduce the prednisone dose. There was a significant improvement in the severity score (p=0.00001) and in prednisone dose (p=0.0001). Four patients (13%) suffered from mild side effects. CONCLUSION: MTX treatment is safe and beneficial as a steroid-sparing agent in PV.

[Rituximab (Mabthera) for treatment of rare autoimmune bullous skin disorders].

Autoimmune bullous skin disorders are characterized by a severe and potentially lethal course and may require aggressive long-term treatment with systemic corticosteroids and other immunosuppressive drugs, which can lead to serious adverse events. Recently, anti-CD20 antibody, Rituximab, was reported to be beneficial as an adjuvant therapy in these diseases. Herein, we present 2 case reports of patients suffering from resistant rare diseases from the aforementioned spectrum: linear IgA dermatosis and Pemphigoid gestationis. The patients were successfully treated with Rituximab (Mabthera). This is one of the first reports of this kind of treatment for these rare life-threatening diseases. These case reports emphasize the role of Rituximab as a crisis therapy in autoimmune blistering diseases.

Evidence for methotrexate as a useful treatment for steroid-dependent chronic urticaria.

Chronic urticaria is a relatively common disorder that can be severe and may impair quality of life. The management of recalcitrant chronic urticaria that is not responding to histamine antagonists includes short-term systemic corticosteroids, anti-inflammatory drugs (colchicine, dapsone and sulfasalazine) and immunomodulatory agents, such as cyclosporine, methotrexate, plasmapheresis and intravenous immunoglobulin. We report here our retrospective experience with the use of methotrexate in 8 patients (2 males and 6 females) with recalcitrant chronic urticaria who were not responding to high-dose first- and second-generation antihistamines. The mean duration of the disease prior to methotrexate treatment was 12 ± 8 months. Patients were treated for a mean duration of 4.5 months with a mean dose of 15 mg methotrexate/week. A complete response was achieved in 7 out of 8 patients (87%). Five out of the 7 patients were disease-free during a period of 1-10 months follow-up after discontinuing methotrexate and prednisone therapy. No serious adverse effects were reported. Methotrexate is an effective and safe treatment for chronic urticaria in patients who are not responsive to conventional therapy.

Onychomycosis in psoriatic patients - rationalization of systemic treatment.

Nail changes in patients with psoriasis have been reported with varying prevalence. Onychomycosis has been reported in up to 47% of the psoriasis patients. The purpose of this study was to determine the prevalence of nail abnormalities, onychomycosis in psoriasis and response to itraconazole treatment. We evaluated 312 patients suffering from psoriasis for nail changes and onychomycosis. Patients having laboratory confirmation of onychomycosis were treated with three courses of itraconazole (400 mg day(-1) for 1 week). Of 312 patients with psoriasis, 67 (21.5%) patients had nail changes, 23 (34%) of them suffered from onychomycosis. Complete cure (clinical and mycological) was achieved in 30% of the patients with onychomycosis. The response to treatment of onychomycosis with itraconazole in psoriasis patients was found to be lower than in the general population. Considering the low response to onychomycosis systemic therapy in psoriatic patients and the potential side-effects of the treatment, the rationality of this treatment is questionable.

Iontophoretic terbinafine HCL 1.0% delivery across porcine and human nails.

BACKGROUND: Onychomycosis is a common disease. Topical treatment is usually not effective due to limitation of trans-nail delivery of antifungal drugs. Successful treatment of deep-seated nail infections remains elusive as the delivery of efficacious levels of antifungal drug to the site of action is very difficult. OBJECTIVES: To evaluate the influence of several parameters including; the effect of low electrical current, incubation time and the presence of electrolyte (NaCl or KCl) on the penetration of terbinafine through the nail plate into the nail bed, using various formulations and concentrations of terbinafine HCl. METHODS: Iontophoresis was applied across porcine and human nail in vitro to assess its efficiency in enhancing delivery of terbinafine HCl. RESULTS: In this study, we have demonstrated that an optimal electrolyte concentration (1% NaCl or KCl) is required for an effective delivery. There is a significant increase in drug delivery into the nail and into the receiving compartment in the presence of 3% DMSO. CONCLUSIONS: This study demonstrates the efficacy of iontophoresis in enhancing the trans-nail delivery of terbinafine. Clinical studies are needed to evaluate the feasibility, efficacy and safety of iontophoresis of terbinafine in onychomycosis in human.

Seborrheic dermatitis-like eruption in patients taking isotretinoin therapy for acne: retrospective study of five patients.

BACKGROUND: Isotretinoin therapy for acne is often associated with mucocutaneous reactions that are usually dose dependent. OBJECTIVE: To describe the characteristics of five patients who presented with a peculiar facial rash that developed during or after a successful course of isotretinoin therapy for acne. METHODS: In this retrospective study, five patients who were treated with isotretinoin and who developed, during or following treatment, a peculiar facial eruption that has not previously been reported, are described. The clinical characteristics, laboratory findings, therapy, and course of the eruption are presented. RESULTS: The rash was characterized by small, yellow, adherent, greasy scales, either flat-topped or spiky, mostly on the cheeks, that resembled seborrheic dermatitis. Cultures obtained in one case grew Staphylococcus coagulase-negative, Acinetobacter, and Pityrosporum ovale organisms. In another patient, microscopic study showed hyperkeratotic scales with many spores and Gram-negative coccobacilli. Topical administration of ointments containing chloramphenicol 3% for 2-3 weeks was curative. CONCLUSION: Seborrheic dermatitis-like eruption may be another adverse cutaneous effect of isotretinoin treatment. Its pathogenesis probably involves a minimal toxic retinoid effect on epidermal differentiation with overgrowth of commensal microorganisms in susceptible individuals.

Ultraviolet-B treatment for cutaneous lichen planus: our experience with 50 patients.

BACKGROUND: Previous small reports suggested the role of ultraviolet (UV)-B in the management of cutaneous lichen planus. OBJECTIVE: To summarize our experience with UVB in a relatively large study group looking specifically into predictive factors for complete response and the long-term relapse rates. METHODS: A retrospective analysis of 50 patients with generalized cutaneous lichen planus, treated by broad or narrow band UVB. RESULTS: Seven and 43 patients were treated by broad and narrow band UVB, respectively. Complete response was achieved in 70% and 85% of those were still in remission after a median of 34.7 months. The complete response rate and the need for higher cumulative exposure doses were not influenced by sex, age, skin type, presence of additional diseases, failure of previous treatment or disease duration. LIMITATIONS: This is a retrospective non-randomized analysis of a usually self-limiting disease. CONCLUSION: UVB is a safe and efficient treatment option for generalized cutaneous lichen planus.

Efficacy of a mucoadhesive patch compared with an oral solution for treatment of aphthous stomatitis.

OBJECTIVE: The purpose of this study was to evaluate the efficacy and tolerability of a mucoadhesive patch compared with a pain-relieving oral solution for the treatment of aphthous stomatitis. METHODS: Patients with active aphthous stomatitis were randomly treated either once a day with a mucoadhesive patch containing citrus oil and magnesium salts (n = 26) or three times a day with an oral solution containing benzocaine and compound benzoin tincture (n = 22). All patients were instructed to apply the medication until pain had resolved, and completed a questionnaire detailing multiple clinical parameters followed by an evaluation of the treatment. RESULTS: The mucoadhesive patch was found to be more effective than the oral solution in terms of healing time (mean +/- SD: 36.0 +/- 22.8 hours vs 134.7 +/- 57.7, p < 0.001) and pain intensity after 12 and 24 hours (3.7 +/- 2.8 vs 6.3 +/- 2.6, p = 0.003, and 2.3 +/- 2.7 vs 5.7 +/- 2.5, p < 0.001, respectively). Local adverse effects 1 hour after treatment were significantly (p < 0.01) less frequent among the mucoadhesive patch patients compared with the oral solution patients. CONCLUSIONS: The mucoadhesive patch was found to be significantly more effective and better tolerated than the oral solution in the treatment of aphthous stomatitis.

Onychomycosis: rationalization of topical treatment.

BACKGROUND: Fungal infection of the nail affects millions of people worldwide and has an estimated prevalence of more than 10% of the general population. OBJECTIVES: To determinate the prevalence of fungal infection in toenails, in order to decide the treatment policy for onychomycosis. METHODS: We evaluated 331 patients with suspected clinical toenail onychomycosis affecting at least two toenails. Mycological examination of the affected nails was performed; both the KOH test and fungal culture were used. RESULTS: Of 331 patients with suspected clinical toenail onychomycosis, 78.2% of the patients had at least three infected nails. The first toenail was the most affected. Trichophyton rubrum was by far the most common dermatophyte cultured from all samples. CONCLUSIONS: Most of the patients had at least three affected toenails. Topical treatment is not effective or practical, and systemic treatment should therefore be considered.

Treatment of moderate to severe facial seborrheic dermatitis with itraconazole: an open non-comparative study.

BACKGROUND: Seborrheic dermatitis is a common chronic disease. Malassezia yeasts have been implicated in the pathogenesis of this disease. Antifungal agents are known to be effective in the treatment of Malassezia yeast infections. OBJECTIVES: To evaluate the efficacy of itraconazole in the treatment of mild to severe facial seborrheic dermatitis. METHODS: Sixty patients with moderate to severe seborrheic dermatitis were evaluated in an open non-comparative study. Patients were treated with oral itraconazole, initially 200 mg/day for a week, followed by a maintenance therapy of a single dose of 200 mg every 2 weeks. Four clinical parameters (erythema, scaling, burning, itching) were assessed using a 0-3 score. Mycological evaluation determined the presence of Malassezia spores in the scales using a direct smear. RESULTS: At the end of the initial treatment significant improvement was reported in three clinical parameters: erythema, scaling, itching. Maintenance therapy led to only slight further improvement. Burning sensation was only mildly improved during the treatment. The quantity of Malassezia spores present in the direct smear decreased throughout the treatment period. No blood test abnormalities were found during the treatment. CONCLUSIONS: In this study initial treatment with itraconazole was beneficial in patients with moderate to severe seborrheic dermatitis.

Expression of p53 in the evolution of squamous cell carcinoma: correlation with the histology of the lesion.

BACKGROUND: The evolution of squamous cell carcinoma (SCC) on sun-exposed areas is a multistep process triggered by ultraviolet radiation (UVR), in which precursor lesions exist. However, the exact classification of the various lesions in this process, mainly solar keratosis (SK), is still disputed, and its pathogenesis requires further clarification. OBJECTIVE: To further elucidate the evolution of SCC on sun-damaged skin by correlating the levels of p53 protein expression, a parameter that reflects UVR damage to cells, and the morphology of the lesions that develop on sun-exposed areas. METHODS: Biopsy specimens from normal skin (n = 4), normal skin with various degrees of solar elastosis (SE) (n = 16), various degrees of SK (n = 17) and SCCs from sun-exposed (n = 12) and sun-protected (n = 7) areas were stained with anti-p53 antibodies. A semiquantitative evaluation of the degree of staining was performed and correlated with the histological features. RESULTS: Nuclear staining in keratinocytes was observed already in normal skin with mild SE and was increased gradually to its highest level of expression in advanced SK. It was also expressed in SCCs, but to a lesser degree. Statistical analysis revealed association between the morphology of the lesion and the level of p53 expression (P < .01); it also showed that in general the level of p53 is correlated with the histology of the lesion (P < .001). Furthermore, with regard to p53 expression, two groups of lesions exist: one showing a low level of expression of p53 that includes normal skin, skin with various degrees of SE and SCC from sun-protected areas, and a second group showing a high level of expression that includes SK and SCC occurring on sun-damaged skin. LIMITATION: This is an immunohistochemical study of relatively few cases and in which the antibody detects all types of p53 protein. CONCLUSIONS: This study furnishes further evidence that the development of SCC on sun-damaged skin is a gradual process not only morphologically but also on the molecular level. The process starts already in normal-appearing epidermis with SE. In that respect, SK should be regarded as a part of the continuum in the development of SCC, analogous to the situation in other epithelia. The molecular events involved in the development of SCC on sun-exposed areas may be different from those involving the development of SCC on sun-protected areas.

Pigmented lesions clinic for early detection of melanoma: preliminary results.

BACKGROUND: Early detection of malignant melanoma of the skin is the most important factor in patient survival. Naked-eye diagnostic sensitivity and specificity are low. Patients with multiple nevi are at high risk to develop melanomas and the clinical follow-up of such patients is difficult, resulting in missed melanomas on the one hand and unnecessary biopsies on the other. OBJECTIVES: To describe the set-up of a special clinic aimed at early detection of melanoma and follow-up of high risk patients and preliminary results from 20 months of operation. METHODS: We established a pigmented lesions clinic based on a digital photography studio enabling documentation and comparison over time of full body photography and dermoscopy. RESULTS: In the first 20 months of work, 895 patients were seen, 206 of them for follow-up visits. A total of 29,254 photos were taken. Altogether, 236 lesions were suspicious (either clinically or dermoscopically) and the patients were advised to excise them. Seven melanomas were found in this initial examination (which did not include long-term follow-up). CONCLUSIONS: With multimode photographic cutaneous surveillance, early detection of melanoma in high risk patients has been reported. Our clinic utilizes the same techniques and diagnostic algorithm as other leading clinics throughout the world, thus enabling us to deliver better follow-up for those patients.

Nail sampling in onychomycosis: comparative study of curettage from three sites of the infected nail.

BACKGROUND: Onychomycosis is a common problem. Obtaining accurate laboratory test results before treatment is important in clinical practice since the treatment of onychomycosis requires expensive oral antifungal therapy with potentially serious side-effects. The purpose of this study was to compare results of curettage technique of nail sampling in the diagnosis of onychomycosis from three different sites of the affected nail to establish the best location of sampling. PATIENTS AND METHODS: We evaluated 194 patients suffering from distal and lateral subungual onychomycosis (DLSO) and lateral subungual onychomycosis (LSO) using curettage technique. KOH examination and fungal culture were used for detection and identification of fungal infection. RESULTS: The culture sensitivity improves significantly as the location of the sample is more proximal. Trichophyton rubrum was by far the most common pathogen detected from all sampling sites. CONCLUSIONS: We found that the culture sensitivity improved as the location of the sample was more proximal. More types of pathogens were detected in samples taken from proximal parts of the affected nails.

[Thalidomide therapy for discoid lupus erythematosus].

INTRODUCTION: Discoid lupus erythematosus (DLE) is a chronic form of cutaneous lupus. Thalidomide has been reported as an effective treatment in at least 200 cases of severe DLE. In this article we studied the efficacy and adverse effects of thalidomide in 10 patients with disseminated DLE. METHODS: This report presents the retrospective evaluation of 10 patients treated with thalidomide in our department during the period 1996-2005. RESULTS: All patients treated with thalidomide had been unresponsive to at least two other systemic treatments. The patients were treated with low-dose thalidomide of 50-200 mg per day. The dose was tapered after a clinical remission. All patients had a favorable response within 6 weeks. Of 10 patients 9 had complete regression of lesions. Four patients remain free of disease without maintenance treatment and 5 patients relapsed after cessation of thalidomide. All relapses responded after the reinstitution of the drug. The side effects of thalidomide treatment were mostly transient. The most common adverse effects were sedation and weight gain. Two patients developed peripheral sensory neuropathy resolved with discontinuation of thalidomide. Two patients of premenopausal age reported amenorrhea. CONCLUSION: Low-dose thalidomide treatment is an effective treatment option for discoid lupus erythematosus in cases resistant to other treatments. It is essential to be conversant with all the precautions in order to minimize the risks of side effects.

Epidemiological data of 290 pemphigus vulgaris patients: a 29-year retrospective study.

Pemphigus vulgaris (PV), an autoimmune blistering disease involving the skin and mucosa, is traditionally considered to be prevalent among Jews, particularly those of Ashkenazi origin. Israel, where the Ashkenazi and non-Ashkenazi Jewish population live alongside a large Arab minority, is a particularly interesting place for epidemiological studies of PV. To characterise the epidemiological and clinical parameters of PV patients from a single tertiary medical centre in Israel. Data was retrieved retrospectively from the medical records of newly diagnosed PV patients referred to the Sheba Medical Center between 1980 and 2009. A total of 290 PV patients were diagnosed during the study period. The mean age at diagnosis was 49.7 years (range: 10-92 years) and a female predominance was identified (1.54:1; p<0.001). Among the Jewish patients, the ratio of Ashkenazi to non-Ashkenazi was 1.23:1, which was not statistically significant in comparison to the ratio of the general Jewish population in Israel (p = 0.289). We describe the comorbidities found among the patients. Disease severity at diagnosis was not found to be related to the epidemiological parameters examined. Studies from different countries reveal variations in the clinical and epidemiological characteristics of the disease. The epidemiology of PV in Israel, a Middle-Eastern country with a Western lifestyle and a diverse ethnic population, shows some characteristics that represent an "admixture" between European and Middle-Eastern or Asian countries. The associated comorbidities of PV emphasize the need for dermatologists to keep a high index of suspicion and actively evaluate patients to determine their presence.