Aquagenic acrokeratoderma due to frequent handwashing during the COVID-19 pandemic outbreak.

Aquagenic acrokeratoderma (AK) is a rare, transient type of acquired palmoplantar keratoderma resulting from short-term contact with water and characterized by white, transparent papules and plaques usually localized in the palmar regions of the hand. The pathogenesis of aquagenic acrokeratoderma is not fully understood and is assumed to be related to an increased salt concentration in the epidermal cells with an increase in the ability of stratum corneum to bind water. This report of patients developing AK following increased frequencies of handwashing in the COVID-19 Pandemic Outbreak is intended to contribute to our understanding of the pathogenesis.

Annual pattern and clinical characteristics of herpes zoster in immunocompetent children in a rural area.

This study aims to investigate the clinical signs, symptoms, complications and seasonal distribution of herpes zoster for otherwise healthy children and to demonstrate the outcome of varicella vaccinations on the herpes zoster incidence in a pediatric population. A retrospective study was conducted by using the data of the pediatric patients who were referred to two rural cities of Turkey, clinically diagnosed as Herpes Zoster (HZ). All participants were evaluated for clinical-epidemiological factors, signs, symptoms, complications and varicella vaccination status for HZ. This study was comprised of 69 pediatric patients (29 [42%] female and 40 [58%] male) who were diagnosed with HZ. The mean age was 10.57 (6 months-17) years old. The rash of HZ mostly appeared on the thoracic dermatome as seen in 29 patients. The findings revealed that among 56 unvaccinated patients of all, 25 (44.6%) had a painful rash, in comparison among vaccinated patients none reported pain as the characterization of shingles (P = .001). Annual distribution of cases showed two peaks (March and September), whereas in August no cases were detected. Of all participants, one patient had postherpetic neuralgia, who also had ophthalmic dermatomal involvement, and this was the only complication observed in this study cohort. In immunocompetent children, the most common involvement site was the thoracic dermatome. Our findings show that varicella vaccination has a protective role in the herpes zoster clinic, both by decreasing the prevalence and by making the infection course less severe.

CD123 immunoexpression in cutaneous lupus erythematosus, polymorphous light eruption, pityriasis rosea, and mycosis fungoides.

INTRODUCTION: CD123-positive plasmacytoid dendrocytes are prominent in the infiltrate of cutaneous lupus erythematous. AIM: To determine the significance of the CD123 immunostain, which labels plasmacytoid dendritic cells (PDC), in cutaneous lupus erythematous (CLE), polymorphous light eruption (PLE), pityriasis rosea (PR) and mycosis fungoides (MF). MATERIAL AND METHODS: A total of 76 cases, including MF (n = 27), CLE (n = 19), PR (n = 19), and PLE (n = 11), were included in the study after reviewing their diagnostic clinical features and pathologic findings. The primary antibody against CD123 was performed in all cases. RESULTS: CD123+ immunostaining in PDCs was positive in all cases. The highest mean percentage was noted in CLE (15.2%), followed by PLE (15%), PR (8.8%), and MF (2%). Besides, the clustering of CD123-positive cells was significant in CLE and PLE compared to MF and PR. CONCLUSIONS: PDC may have an important role in the aetiology of PLE and CLE cases. CD123 is a useful marker for differentiating CLE and PLE from MF and PR.

Levels of TNF-α, IL-6, IL-17, IL-37 cytokines in patients with active vitiligo.

OBJECTIVES: Vitiligo is an autoimmune disease, and its pathogenesis involves changes in cytokine levels in the affected patients. Tumor necrosis factor-alpha (TNF-α), interleukin (IL)-6, and IL-17 from pro-inflammatory cytokines, IL-37 in a recently detected anti-inflammatory activity. The aim of our study was to determine serum TNF-α, IL-6, IL-17, IL-37 levels in patients with vitiligo to understand their possible roles in the disease etiology and to compare the results with the healthy controls. METHODS: The study included 48 generalized vitiligo patients who were diagnosed with vitiligo, had an increase in the lesions within the last 3 months, and did not receive any systemic or topical treatment during this period; furthermore, 18 healthy controls were included. RESULTS: Patient group: n = 48, mean age = 30.48 ± 9.86 years; control group: n = 18, mean age = 28.27 ± 9.66 years. Individuals in the patient group had significantly higher serum levels of IL-37(t = 3.90, p < .001), IL-6 (t = 3.39, p < .05), IL-17 (t = 2.08, p < .05), and TNF-α (t = 4.69 p < .001) than in the control group. CONCLUSION: The high levels of (pro-anti) inflammatory cytokines in vitiligo patients draw attention to the importance of cytokines in the pathogenesis of the disease.

The role of serum vitamin D levels in vitiligo.

INTRODUCTION: Vitiligo is a common acquired pigmentary skin disorder. Vitamin D is responsible for skin pigmentation, increases tyrosinase activity and melanogenesis, and exhibits immunoregulatory functions. Low levels of vitamin D are associated with many autoimmune diseases, including systemic lupus, diabetes mellitus, rheumatoid arthritis, multiple sclerosis and alopecia areata. Few reports have evaluated serum vitamin D levels in vitiligo patients, and their results are conflicting. AIM: To evaluate serum vitamin D levels of vitiligo patients and compare the results with controls. MATERIAL AND METHODS: In total, 50 vitiligo patients and 47 controls were enrolled in the study. Vitamin D levels were measured from blood samples. Group comparisons were performed using appropriate statistical methods. RESULTS: The patients had lower serum vitamin D levels than the controls, but this difference was not significant (p = 0.570). CONCLUSIONS: It remains unknown whether vitamin D deficiency causes vitiligo. Larger controlled studies are required to prove whether low circulating vitamin D is a causative factor in vitiligo.

Dermatoscopic Features of Early Erythema Chronicum Migrans.

Dear Editors, A 37-year-old man from a Lyme disease-endemic area presented with a one-week old rapidly expanding rash on his right calf. He lacked other comorbidities or symptoms such as fever, weakness, lack of appetite, or joint pain, but recalled removing a tick from the same region three weeks earlier. Inspection revealed a round, bluish-red erythematous patch with a central clearing (Figure 1). The patient experienced no discomfort, but the rash was warm and faded easily when palpated. Dermatoscopic inspection revealed collarette-shaped white scales encircling the punctum of the tick bite in the center (Figure 2, left inset). There were three distinct background zones towards the periphery: skin-colored, bluish-red, and bright red. The transitions between the zones were not fully discernable. Red purpuric dots and clods were randomly distributed over these backgrounds, gradually increasing towards the periphery (Figure 2). The rash was diagnosed as erythema chronicum migrans (ECM), and the patient was started on doxycycline 100 mg BID. The expansion of the rash was stopped, while the speed of central clearing was increased. Half of the rash had healed by the third day (Figure 1, left inset), and it had completely disappeared by the seventh (Figure 1, right inset). Anti-Borrelia burgdorferi antibodies were initially negative for IgM and positive for IgG, but both tested positive two weeks later. ECM is the hallmark of early-stage lyme disease, but it is not always present. In addition to the classically described bull's eye appearance, ECM may appear as homogenous erythematous patches, interrupted annular patches, or patches with hemorrhagic or purpuric components (1). It can manifest anywhere except in the palmoplantar region, but it is more common around large joints. Despite the morphological variations of ECM, the clinical presentation is often clear and distinct enough for dermatologists to correctly diagnose more than 90% of patients (1). Diagnostic procedures such as ELISA or Western blot are employed in cases when the ECM is absent or atypical. However, their reliability is low due to the lack of standardization, limited coverage of Borrelia spp., and significant false-positive and false-negative rates (1). Seropositivity owing to previous asymptomatic infection in individuals residing in endemic areas may result in incidental positive findings. Alternative methods, including isolating the pathogen or PCR testing from biopsy samples have similar drawbacks (1). Histopathological investigations are another practical method that yields supportive findings. ECM exhibits diffuse perivascular and interstitial inflammation, including lymphocytes, eosinophils, and plasma cells (2), which corresponds to background erythema in dermatoscopy. As the inflammation develops, the newly-developed regions are superficial and brilliant red, but the surface inflammation fades over time, leaving bluish erythema, which correlates to deeper inflammation (2,3) dermoscopy is gaining appreciation in assisting the diagnosis of nonneoplastic diseases, especially inflammatory dermatoses (inflammoscopy). Extravasated erythrocytes combined with perivascular inflammation (2) generate purpuric pinkish-red dots and clods. Given the greater efficacy of early treatment and the ambiguity surrounding diagnostic methods, clinical findings should be deemed adequate to commence therapy, particularly in endemic regions (1). Dermatoscopic examination of ECM offers a quick and low-cost alternative approach for supporting the diagnosis. However, as emphasized by Errichetti, dermatoscopic examination in non-neoplastic diseases should be regarded as the second step of a "2-step procedure", with differential diagnoses established first by history and clinical examination (3). A systematic investigation of early and late, typical and atypical lesions would improve the reliability and utility of this method.

Myoclonic Astatic Resistant Epilepsy and Disproportionate Overgrowth Carrying a Duplication in 2q13 and Deletion in the 6p21.32 Chromosomal Regions.

Copy number variants have been increasing due to a rise in the availability of array comparative genomic hybridisation, which occupies an important place in diagnosis, especially in patients with epilepsy, dysmorphic findings, and intellectual disability. We detected 2q13 chromosomal duplication and 6p21.32 chromosomal deletion in a patient under follow-up due to epilepsy, developmental retardation, dysmorphic findings, and asymmetric overgrowth in our clinic since the age of six months. The parents had only 2q13 mutations. Copy number variation in 2q13 is associated with dysmorphic findings, psychiatric disorders, and developmental delays. However, the exact pathogenicity is not yet known. We think that 6p21.32 chromosomal deletion caused resistant epilepsy and lipodystrophy in this patient. We anticipate that this case will contribute to the literature by linking disorders caused by the current chromosomal abnormality to clinical findings. Key Words: Myoclonic astatic seizure, Resistant epilepsy, Dermal atrophy, Chromosomal microarray analysis.

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%.

Effects of climate and air pollution factors on outpatient visits for eczema: a time series analysis.

Eczema resulting from external and internal factors accounts for the biggest global burden of disability owing to skin disease. This study aimed to determine an association between environmental factors and outpatient clinic visits for eczema. We collected data on dermatology clinic outpatient visits for eczema between January 2013 and July 2019. Data concerning environmental factors during this period were collated using national air quality network and air monitoring measurement parameters, namely barometric pressure, relative humidity, air temperature, and air pollutant concentrations, such as sulfur dioxide (SO2) and particulate matter (PM10). A distributed lag nonlinear model was used to investigate the relationship among eczema, environmental factors, and lagged effects. In total, 27,549 outpatient visits for eczema were recorded. In both single-factor and multiple-factor lag models, the effects of a 10-µg/m3 increase in PM10 and SO2 values had significantly positive effects on the number of daily outpatient visits over a total 5 days of lag after adjusting for temperature, the number of daily outpatient visits increased with 0.87%, 7.65% and 0.69%, 5.34%, respectively. Relative humidity (RR = 1.3870, 95% CI 1.3117-1.4665) and pressure (RR = 1.0394, 95% CI 1.0071-1.0727) had significantly positive effects on the number of daily outpatients in single-factor lag models. However temperature had a significantly negative effect on them in the number of daily outpatients (RR = 0.9686, 95% CI 0.9556-0.9819). Exposure to air pollution exacerbated eczema. Outpatient visits for eczema were found to have strong positive associations with changes in PM10 levels.

[Relationship of Alexithymia, Rumination and Coping Style with Psoriasis and Their Effects on The Clinical Features]. / Aleksitimi, Ruminasyon ve Stresle Basa Çikmanin Psöriyazis ile Iliskisi ve Psöriyazis Klinigine Etkisi.

OBJECTIVE: A relationship has been demonstrated between stress and the increase in the skin plaques in psoriasis. In addition, psoriasis is observed in cases of severe alexithymia and stress. In depression and various psychiatric disorders, there is a relationship between rumination and both the onset and persistence of the disease. The role of rumination, being a stress related factor, was investigated in this study. METHOD: The study included 91 patients with psoriasis and 93 healthy controls. All participants were evaluated with the Toronto Alexithymia Scale, Coping Style Scale, the Ruminative Thought Style Questionnaire and the Hospital Anxiety and Depression Scale. Any increase in the plaque formation after the duration of 1 month was recorded by the clinician. RESULTS: In both the patient and the control groups, rumination scores were significantly correlated with the alexithymia severity scores (psoriasis group r=0.46, p<0.01; control group r=0.38, p<0.01) and the helpless coping styles scores (psoriasis group r=0.56, p<0.01; healthy r=0.57, p<0.01). When depression and anxiety scores were controlled, significant positive correlations were observed in the patient group between rumination scores and the scores on the difficulty of identifying feelings (r=0.42, p<0.01), the difficulty of describing feelings (r=0.25, p<0.05) and the scores on helpless coping styles (r=0.41, p<0.01); and also significant positive correlations were observed in the control group between the rumination scores and the scores on the difficulty of identifying feelings (r=0.27, p<0.05) and on helpless coping styles (r=0.42, p<0.01). Comparing the patients with and without increase in the plaques showed significant differences in the scores on rumination (p<0.01), difficulty of describing feelings (p <0.05) and total alexithymia scores (p<0.05). CONCLUSION: The relationship of alexithymia and of passive stress coping styles with rumination may have an effect on the course of psoriasis.

Novel mutation identified in the DDB2 gene in patients with xeroderma pigmentosum group-E.

BACKGROUND: Xeroderma pigmentosum (XP) is a rare photosensitive syndrome, which is divided into eight complementation groups (XP-A to XP-G and XPV) and characterized by skin cancers diagnosed at early age. A family of seven members (age range between 5 and 47 years) with carriers of the novel nonsense mutation that causes XP-E type were included in the current study. METHODS: DNA was isolated from peripheral blood samples of the proband, and cancer predisposition genes were sequenced with next-generation sequencing. The demographic features and the laboratory, clinical, and histopathological findings of patients were evaluated. RESULTS: In the proband, squamous cell carcinoma was first diagnosed in the right-eye cornea at the age of 13 years and then in the left-eye cornea at the age of 15 years. Later, the patient was diagnosed with basosquamous cell carcinoma on the dorsum of the nose at the age of 18 years. After genetic analysis, a novel nonsense c.1063C>T(p.Arg355Ter) pathogenic variation that causes XP-E type was detected as homozygous in the DDB2 gene of the proband and her siblings, 11 and 5 years of age, and as heterozygous in her parents and a 22-year-old brother. CONCLUSION: Because of the occurrence of early termination codon, truncated nonfunctional proteins or proteins with deleterious loss or gain-of-function activities are synthesized in nonsense mutation. Thus, to avoid the development of pathological lesions, it is important that such patients with nonsense mutation stay away from agents that might cause DNA damage and develop an appropriate lifestyle according to this condition.

Keratoconus Could Be Associated With Psoriasis: Novel Findings From a Comparative Study.

PURPOSE: To explore the relationship between keratoconus (KC) and psoriasis. METHODS: One hundred ten eyes of 55 patients with psoriasis (study group, SG) and 110 eyes of age-sex-matched 55 healthy volunteers (control group, CG) were included in the study. All cases underwent a detailed dermatological and ophthalmological examination including corneal topography. Moreover, Psoriasis Area and Severity Index (PASI) scoring of the patients was carried out in the SG. A thorough comparison of pachymetric, aberrometric, and topometric values between the groups was performed, and the results were interpreted. A χ test, Mann-Whitney U test, and Pearson correlation test were used for statistical assessment. RESULTS: Although the average Kmax (44.6 in the SG; 44.5 in the CG; P = 0.613) and Belin/Ambrósio enhanced ectasia total deviation value (1.34 in SG; 1.20 in CG; P = 0.880) were similar between the groups, the mean index of vertical asymmetry value in the SG (0.14 mm) was significantly higher than that in the CG (0.11 mm) (P = 0.041). Moreover, 28 eyes from 16 patients with psoriasis were found to be associated with KC because 26 of those 28 eyes were KC suspects and 2 of them were definite KC. A positive correlation was found among topometric parameters, especially between duration of the disease and PASI score. A negative correlation was discovered between topometric parameters and the early beginning of psoriasis. CONCLUSIONS: Serious changes in topography maps may occur in psoriatic patients. The changes were found to be more evident in the presence of a higher PASI score and the early beginning and longer duration of the disease. The results hinted a potential relationship between psoriasis and KC.

Platelet-rich plasma administration to the lower anterior vaginal wall to improve female sexuality satisfaction.

OBJECTIVE: To investigate the effect of platelet-rich plasma (PRP) injection to the lower one-third of the anterior vaginal wall on sexual function, orgasm, and genital perception in women with sexual dysfunction. MATERIALS AND METHODS: Four sessions of PRP were administered to the anterior vaginal wall of 52 female patients with sexual dysfunction and orgasmic disorder [Female Sexual Function Index (FSFI) total score ≤26 orgasmic subdomain score ≤3.75]. Prior to the PRP administrations in each session, the FSFI validated in Turkish, the Female Genital Self-Image Scale (FGSIS), the Female Sexual Distress Scale-Revised (FSDS-R), and Rosenberg's Self-Esteem Scale were used and in the final follow-up, and the Patient Global Impression of Improvement (PGI-I) was performed and the results were analyzed. RESULTS: Following the application of the PRP, the total FSFI score was observed as 27.88±4.80 and the total score was 26 and above in 50% of the patients (p<0.001). Orgasm subdomain scores were found as 2.11±1.20 before the PRP treatment and 4.48±1.14 afterwards (p<0.001). A significant change was observed in all sub-domains after PRP and it was observed that this change started after the first administration (p<0.001). A statistically significant increase was determined in FGSIS genital perception scores, which was significant between the 1st and 2nd months (p<0.001). The FSDS-R scores showed a minimal increase in stress scores as the application number increased, but a statistically significant decrease was observed in the 4th administration (p<0.001). No statistically significant difference was found in Rosenberg Scale scores before and after treatment (p=0.389). High satisfaction was found in PGI-I scores. CONCLUSION: As a minimally invasive method, PRP administration to the distal anterior vaginal wall may improve female sexuality with high satisfaction.