Paradoxical and bimodal immune-mediated dermatological side effects of TNF-α inhibitors: A comprehensive review.

INTRODUCTION: Due to the increasing prevalence of immune-mediated diseases such as psoriasis, lichen planus, rheumatoid arthritis and inflammatory bowel disease, dermatologists have turned to new biologic drugs known as DMARDs (disease-modifying anti-rheumatic drugs) in recent years. AREAS COVERED: In this study, we evaluate the immune-mediated dermatological side effects of DMARDS by reviewing and analyzing previous peer-reviewed research on the effects of TNF-α inhibitors in the treatment of skin diseases, as well as adverse effects of these drugs and some of the main causes of these effects. EXPERT OPINION: DMARDs are very effective in improving control of the above diseases. TNF-α inhibitors are an important group of DMARDs that are widely used. The paradoxical adverse events (PAEs) associated with the use of TNF-α inhibitors are divided into three categories: true paradoxical, borderline paradoxical, and non-paradoxical. True PAEs include conditions for which TNF-α inhibitors are approved for treatment. Borderline PAEs are considered to occur with this class of drugs for which there is no definite approval but for which there is sufficient evidence. Although these events are rare, early recognition of the accused drug and appropriate decision-making may prevent progression of complications and irreversible side effects.

A systematic review of case series and clinical trials investigating systemic oral or injectable therapies for the treatment of vitiligo.

AIMS AND OBJECTIVES: The purpose of this study is to investigate the effectiveness and safety of oral and injectable systemic treatments, such as methotrexate, azathioprine, cyclosporine, tofacitinib, baricitinib, corticosteroids, statins, zinc, apremilast, etc., for treating vitiligo lesions. METHOD: Databases including PubMed, Scopus, and Web of Science were meticulously searched for studies spanning from 2010 to August 2023, focusing on systemic oral and injectable therapies for vitiligo, using comprehensive keywords and search syntaxes tailored to each database. Key data extracted included study design, treatment efficacy, patient outcomes, patient satisfaction, and safety profiles. RESULTS: In a total of 42 included studies, oral mini-pulse corticosteroid therapy (OMP) was the subject of six studies (14.2%). Minocycline was the focus of five studies (11.9%), while methotrexate, apremilast, and tofacitinib each were examined in four studies (9.5%). Antioxidants and Afamelanotide were the subjects of three studies each (7.1%). Cyclosporine, simvastatin, oral zinc, oral corticosteroids (excluding OMP) and injections, and baricitinib were each explored in two studies (4.8%). Azathioprine, mycophenolate mofetil, and Alefacept were the subjects of one study each (2.4%). CONCLUSION: Systemic treatments for vitiligo have been successful in controlling lesions without notable side effects. OMP, Methotrexate, Azathioprine, Cyclosporine, Mycophenolate mofetil, Simvastatin, Apremilast, Minocycline, Afamelanotide, Tofacitinib, Baricitinib, Antioxidants, and oral/injectable corticosteroids are effective treatment methods. However, oral zinc and alefacept did not show effectiveness.

The efficacy, satisfaction, and safety of carbon dioxide (CO2) fractional laser in combination with pulsed dye laser (PDL) versus each one alone in the treatment of hypertrophic burn scars: a single-blinded randomized controlled trial.

The tendency to use less-invasive laser-based methods with far more obvious effectiveness has been taken into consideration today for improvement of burning scars. The present study thus aimed to assess the efficacy of two laser-based techniques including pulsed dye laser (PDL) and ablative fractional CO2 laser (AFCL) and its combination on improving different aspects of burning scars regardless of the types of scar as hypertrophic or keloid scars. This randomized single-blinded clinical trial was performed on patients suffering hypertrophic or keloid burning scars. The patients were randomly assigned into three groups scheduling for treatment with PDL alone, AFCL alone, or its combination. All patients were visited before and 40 days after the last treatment session, and their scars were assessed. In all groups, significant improvement was revealed in the Vancouver scar scale (VSS) score, the color of scar, vascular bed in the scar, the and height of scar and its pliability; however, the improvement in each item was more highlighted in the group receiving a combination therapy with PDL and AFCL techniques. In this regard, the highest improvement was found in vascular bed and pliability in the combination therapy group as compared to other groups. Although the superiority of the combined group was not statistically significant, due to the high percentage of improvement in total VSS and most of its indicators, it can be clinically significant. The efficacy of the treatment protocols was different considering subgroups of mature and immature scars (less than 1 year), so that more improvement in pliability of scar, vascularity, and color of scar was found in the group scheduling for PDL + AFCL as compared to those who were treated with PDL alone in immature scar group but not in mature scar group. Combined treatment can be much more effective in improving the appearance and pathological characteristics of scars than each individual treatment. This effectiveness can be seen mainly in immature scars.

The efficacy of the combination of topical minoxidil and oral spironolactone compared with the combination of topical minoxidil and oral finasteride in women with androgenic alopecia, female and male hair loss patterns: A blinded randomized clinical trial.

INTRODUCTION: Androgenic alopecia (AGA) is the most common cause of hair loss in women, affecting their quality of life. The present study was conducted with the aim of comparing the combined effect of topical minoxidil and oral spironolactone with the combined effect of topical minoxidil and oral finasteride in women with AGA, female and male hair loss patterns. METHOD: This clinical study was performed on 60 women suffering from AGA. The patients were divided into two groups receiving spironolactone 100 mg/day and finasteride 5 mg/day. In addition, a 2% minoxidil solution was used in all patients in addition to treatment with finasteride or spironolactone. At 2 months after initiation and at the end of treatment, patients were evaluated using the Ludwig/Norwood-Hamilton scale and the degree of physician and patient satisfaction. RESULTS: After 2 months, hair density, hair thickness, and hair loss had improved in both groups; however, statistically, there was no significant difference between the two groups with respect to these parameters (p > 0.05). After 4 months, a significant difference was found between the two groups in terms of treatment response (physician satisfaction), hair density, and hair loss severity. So that, the drugs used were ineffective in 6.7% of cases in the minoxidil-spironolactone group and in 16.7% of cases in the minoxidil-finasteride group. In addition, 43.3% of cases in the minoxidil-spironolactone group and 53% in the minoxidil-finasteride group responded well to treatment. The treatment effect was excellent in 56.7% and 0% of the mentioned groups, respectively, and the mentioned difference was statistically significant (p: 0.01). The response to treatment in female pattern hair loss (FPHL) was not statistically significant (p: 0.52), but there was a significant difference in the response to both treatments in male pattern hair loss (MPHL; p: 0.007). In terms of patient satisfaction, minoxidil-spironolactone treatment was significantly better than minoxidil-finasteride regarding hair density and severity of hair loss (p: 0.01). Finally, in terms of treatment complications, the patients in two groups did not have any serious adverse effects. CONCLUSION: The combination of minoxidil and spironolactone could be considered a more effective treatment than the combination of minoxidil and finasteride in women with AGA, FPHL, and MPHL.

A systematic review of the efficacy, safety and satisfaction of regenerative medicine treatments, including platelet-rich plasma, stromal vascular fraction and stem cell-conditioned medium for hypertrophic scars and keloids.

The primary objective of this study is to examine the efficiency of various regenerative medicine approaches, such as platelet-rich plasma, cell therapy, stromal vascular fraction, exosomes and stem cell-conditioned medium, in the process of healing hypertrophic and keloid scars. Major databases including PubMed, Scopus and Web of Science were systematically searched, and based on the content of the articles and the inclusion and exclusion criteria, eight articles were selected. Out of these eight articles, there were two non-randomized clinical trial studies (25%), one randomized, single-blinded comparative study (12.5%), one retrospective clinical observational study (12.5%) and four randomized clinical trial studies (50%). We employed EndNote X8 and Google Sheets to conduct article reviews and extract relevant data. Following the review phase, the studies underwent analysis and categorization. In all eight reviewed studies, the effectiveness of regenerative medicine in treating hypertrophic scars and keloids has been proven. Out of these studies, five (62.5%) focused on the effectiveness of platelet-rich plasma, two study (25%) examined the effectiveness of stromal vascular fraction and one study (12.5%) explored the efficacy of stem cell-conditioned medium. In two studies (25%), the treatment methods were added to standard treatment, while in six studies (75%), regenerative medicine was used as the sole treatment method and compared with standard treatment. The use of these treatment methods did not result in any serious side effects for the patients. Regenerative medicine is an effective method with minimal side effects for the treatment of hypertrophic scars and keloids. It can be used as a monotherapy or in combination with other treatment methods. However, further studies are needed to thoroughly evaluate the effectiveness of all sub-branches of this method.

Unusual presentation of pilomatricoma: A case report and comprehensive review of the literature.

Pilomatricoma is a benign proliferative lesion of skin appendages that often affects the head, upper limbs, and lower limbs. The clinical appearance of the lesions is that of asymptomatic nodules measuring less than 3 cm. pathologically, these skin lesions show the presence of basaloid cell islands, eosinophilic cytoplasmic cells without nuclei, as well as hemorrhage and calcification. In this study, we present the case of an 8-year-old girl with a 5 × 5 cm skin lesion on the forearm, which lacked the typical firmness associated with pilomatricoma lesions during examination. After biopsy, the lesion was confirmed to be pilomatricoma. Furthermore, we have reviewed studies documenting pilomatricoma lesions with atypical clinical features. Based on reports of different clinical manifestations of pilomatricoma in these studies, we suggest that the clinical diagnosis of pilomatricoma should not be limited to the typical presentation of these lesions. In cases where the lesions exceed 3 cm in size, display cystic characteristics, are painful, or resemble keloids, consideration should also be given to the possibility of pilomatricoma.

Evaluation of the effect of botulinum toxin injection in aggravating or improving seborrheic dermatitis symptoms: A prospective, single-arm clinical trial.

INTRODUCTION: Considering the proven therapeutic effect of botulinum toxin and the pathophysiology of seborrheic dermatitis, conflicting hypotheses have been put forward regarding the effect of injection of this toxin on the improvement or exacerbation of seborrheic dermatitis. Because of the lack of consistent studies investigating this relationship, we decided to conduct this study to investigate the effect of local botulinum toxin injection on sebum production and improvement or worsening of seborrheic dermatitis lesions. METHOD: This study was a prospective, single-arm clinical trial that involved the injection of botulinum toxin into 20 patients with complaints of skin wrinkles and simultaneous symptoms of seborrheic dermatitis. The trial was conducted at a dermatology clinic between March 2019 and March 2021. Two important characteristics of these patients were seborrheic dermatitis on the face or scalp and a referral for botulinum toxin injection to remove facial wrinkles. The Seborrheic Dermatitis Area and Severity Index (SDASI) was used to determine the severity of symptoms. RESULTS: In study of 20 patients with an average age of 40 years, despite the decrease in the average scores of all examined criteria of seborrheic dermatitis symptoms in study, 1 month after botulinum toxin injection, no significant effect of using this toxin was seen on the improvement of patients' symptoms (p value >0.05). CONCLUSION: Despite the emphasis of many studies on the effectiveness of botulinum toxin in reducing the activity of sebaceous glands, the use of botulinum toxin as a therapeutic modality for control the symptoms of seborrheic dermatitis is not suggested by this study. Conducting studies in which the location and technique of injection and the follow-up intervals of patients in them are based on the standard of other studies, are the suggestions made by comparing the results and method of the current study with other studies.

Successful treatment of resistant plantar ulcerative lichen planus with tofacitinib: A case report and comprehensive review of the literature.

Key Clinical Message: Ulcerative lichen planus, a challenging variant of lichen planus, has limited response to traditional treatments. Tofacitinib, a JAK-STAT pathway inhibitor, shows promise in effectively treating these lesions. Abstract: Lichen planus is a mucocutaneous disease that can cause various manifestations, such as itchy erythematous papules, cicatricial alopecia, erosion, and mucocutaneous ulcers. One uncommon manifestation of this disease is the occurrence of erosion and skin ulcers in the soles of the feet, which can cause many problems for patients. Tofacitinib, a Janus Kinase (JAK) inhibitor drug, has found a special place in the field of inflammatory diseases, especially inflammatory skin diseases. In this regard, studies on the effective role of this drug in the treatment of certain forms of lichen planus, including lichen planopilaris, and erosive lichen planus have been performed. In upcoming study, we introduce a 52-year-old woman with lichen planus who complained of ulcerative lesions on the sole of her foot, for whom a diagnosis of plantar ulcerative lichen planus was proposed. After the patient did not respond therapeutically to intralesional triamcinolone acetonide injection, as well as methotrexate and cyclosporine tablets, significant improvement was finally achieved with a 5 mg twice daily dose of tofacitinib. In the following, we will comprehensively review previous articles on the role of tofacitinib in the treatment of lichen planus lesions, as well as the proposed treatment options for erosive and ulcerative lichen planus lesions specifically located on the sole of the foot. Despite limited reports of the successful treatment of mucosal erosive lesions in the oral, esophageal, genital, and ocular mucosa areas with tofacitinib, no previous study has reported the successful treatment of ulcerative lichen planus lesions of the plantar area with tofacitinib. While reporting this case, we recommend considering tofacitinib as a treatment option for plantar ulcerative lichen planus. To confirm its effectiveness, it is necessary to conduct more extensive studies with a larger sample size.

Efficacy of fractional CO2 laser in combination with stromal vascular fraction (SVF) compared with fractional CO2 laser alone in the treatment of burn scars: a randomized controlled clinical trial.

BACKGROUND: The appearance of skin scars is known as one of the main side effects of skin burns. Stromal vascular fraction (SVF), as a rich source of cell populations with tissue regeneration properties, plays an important role in the healing of skin lesions. Fractional CO2 lasers have occupied a special place in treating skin lesions, particularly skin scars, since their introduction. Our study aimed to compare the combination of SVF and fractional CO2 laser with fractional CO2 laser alone in the treatment of burn scars. METHOD: This double-blind clinical trial study was conducted on ten patients with burn scars that were treated three times with a fractional CO2 laser at site of burn lesions, and one of the two areas studied was randomly injected with SVF. Two months after completion of the procedure, patients' scars were assessed using the Vancouver scar scale (VSS), biometric criteria, and physician and patient satisfaction ratings. RESULTS: The results confirmed a significant improvement in VSS, cutometry, R7 criteria, complete density sonography, and skin density sonography in the fractional CO2 laser-treated group. The VSS criteria, epidermal thickness sonography, complete density sonography, and skin density sonography in the group treated with the combination of fractional CO2 laser and SVF also showed significant improvement. The VSS criteria and melanin index of Mexameter in the group treated with SVF in combination with fractional CO2 laser were significantly better than the group treated with fractional CO2 laser alone. Also, physician and patient satisfaction in the group treated with SVF injection in combination with fractional CO2 laser was significantly higher than the other group. CONCLUSION: The results confirm the efficacy of SVF injection in combination with fractional CO2 laser in the treatment of burn scars and can be considered as a treatment option for better management of these lesions. TRIAL REGISTRATION: The study protocol was retrospectively registered at Iranian Registry of Clinical Trials with code: IRCT20210515051307N1, Registration date: 2021-11-14, URL: https://www.irct.ir/trial/56337 .

Prevalence of positive findings of brain computed tomography scans in pediatric population.

Objectives: Computed tomography (CT) scans are used more frequently in medical centers, increasing unnecessary requests for it as a first-line evaluation. This study aimed to investigate the rate and prevalence of abnormal findings in a brain CT scan in children at the Children's Hospital of Tabriz, Iran. Materials &Methods: This study was a cross-sectional descriptive-analytical study that included all children under 15 years old undergoing a brain CT scan at the Children's Hospital of Tabriz, Iran. All patients who fulfilled the inclusion criteria and were referred to the Children's Hospital of Tabriz during the spring of 2018 entered the study. Age, gender, patient history, and clinical findings were examined. In the next step, the results of each patient's CT scan were evaluated. Results: In this study, 108 patients were studied with a median age of 18.0 months. CT scan results were normal in seventy-four cases (68.5%), hydrocephalus was seen in 15 (13.9%), and benign infantile hydrocephalus was seen in eight (7.4%). The study revealed a statistically significant relationship between patient history and CT scan results (p=0.017). A statistically significant relationship was observed between the clinical findings and CT scan results (p=0.042). Conclusion: Brain CT scans have more abnormal findings in patients with positive clinical findings. Although a CT scan is a highly sensitive and specificmodality in diagnosing central nervous system (CNS) abnormalities, its value depends on the underlying medical history and physical exam.