Comparative efficacy of intralesional 5 flurouracil and intralesional triamcinolone acetonide in localized plaque psoriasis.

Psoriasis is a papulosquamous disorder that causes significant social and psychological trauma to the patient. It is characterized by the presence of erythematous, indurated plaques covered with silvery-white scales. Despite the availability of several systemic agents that have been approved for the treatment of psoriasis, usually there are some residual lesions and there is a need to treat them for cosmetic reasons or symptomatic control. 1. Treatment of resistant localized psoriatic plaques or residuals after systemic treatment. 2. Recently, some intralesional agents have been used successfully for the treatment of psoriatic plaques as 5-FU, methotrexate, and botulinum toxin type-A, and nearly for four decades, no study focused on the effect of intralesional corticosteroids in the treatment of these psoriatic plaques. We decided to highlight their role and compare intralesional Triamcinolone to intralesional 5-FU regarding efficacy and safety in the treatment of plaque psoriasis. This study included 24 patients with localized plaque psoriasis. Each patient was treated by split-body therapy where one psoriatic plaque was treated with intralesional 5FU and another plaque with intralesional TAC. A total of three injections were given at 2-week intervals and follow up was regularly every 2 weeks up to 12 weeks. There was a statistically significant difference between both groups (p = 0.008) as the response rate on 5-FU side was 12.5% with no response, 29.2% with a moderate response, 41.7% with an excellent response, and 16.7% with a complete clearance, while on the TAC side it was16.7% with a moderate response, 20.8% with an excellent response and 62.5% with a complete clearance. Hyperpigmentation was the most irritating side effect of 5-FU that occurred. Pain, during and after injection, was greater in 5-FU group. Hypopigmentation and atrophy only occurred in TAC group in some patients but it seems to be reversible and not disfiguring. 1-Intralesional TAC injection may have more efficacy and less side effects than 5-FU injection in the treatment of localized plaque psoriasis. Hyperpigmentation and pain were the most irritating side effects of 5-FU 2-Intralesional TAC can be effective in the treatment of localized psoriatic plaques with minimal side effects, especially in patients not suitable for systemic agents.

Intralesional cryotherapy versus cryotherapy spray for the treatment of recalcitrant plantar warts: a prospective, randomized study.

BACKGROUND: Recalcitrant plantar warts are representing a therapeutic challenge. Intralesional cryotherapy (ILC) has emerged as a promising therapeutic option in recalcitrant plantar warts treatment. OBJECTIVE: To compare the clinical efficacy, safety and tolerability of (ILC) versus Cryotherapy spray (Cryo-sp) for treatment of recalcitrant plantar warts. METHODS: One hundred-thirty patients with recalcitrant plantar warts were assigned equally to two groups. Group A received ILC and group B treated with Cryo-SP. Both groups received one session at 2 weeks intervals until complete clearance or for a maximum of 5 sessions. The main outcome was complete clearance of warts guided by dermoscopy. Follow-up was carried out for 6 months after the treatment. RESULTS: Complete clearance occurred in 80.3% in group A compared to 50.8% in group B with a highly significant difference between both groups (p < .001). The clearance rate was faster in group A (1.5 ± 0.40) than group B (4 ± 1.3) (p < .001). The adverse effects were mild in group A than group B (p < .001). The recurrence rate was 2% in group A versus 23.3% in group B (p < .007).patients satisfaction was higher in ILC (p < .001). CONCLUSION: Intralesional cryotherapy is more effective, requiring few sessions with a low recurrence rate than cryo-sp.

Serum YKL-40 and IL 17 in Psoriasis: Reliability as prognostic markers for disease severity and responsiveness to treatment.

YKL-40, a mammalian chitinase 3- like protein that was associated with multiple inflammatory and immune diseases. Previous studies have suggested a role for YKL-40 in psoriasis based on its significantly higher levels in the serum of psoriatic patient compared with healthy controls. The aim of this study was to determine the correlation between serum YKL-40, psoriasis severity using PASI score and serum levels of IL-17 before and after narrow-band UVB therapy. 28 patients with moderate to severe plaque psoriasis, as defined by PASI scores, were enrolled in this prospective cohort study. All cases received NB-UVB phototherapy twice weekly for 3 months. Serum YKL-40 and IL-17 levels were evaluated before and after 3 months of treatment. Clinical photographs were taken both at baseline and after 3 months. There was a statistical positive correlation between serum levels of YKL-40 and serum IL-17 levels as well as PASI score in patients with moderate to severe psoriasis before and after treatment. YKL-40 represents a reliable marker for psoriasis severity estimated by PASI and positively correlated with IL 17 as an inflammatory marker in psoriasis.

'Cryo-immuno-therapy' is superior to intralesional Candida antigen monotherapy in the treatment of multiple common warts.

BACKGROUND: The treatment of multiple common warts can be challenging. Cryotherapy is commonly used for eradicating common warts with variable success. Intralesional Candida antigen has showed promising results in treating different human papillomavirus infections. OBJECTIVES: The aim of this study was to evaluate the safety and efficacy of combining cryotherapy with Candida antigen intralesional immunotherapy for the treatment of multiple common warts. PATIENTS AND METHODS: A total of 60 patients were randomly and equally assigined into three groups: Group Awho received intralesional Candida antigen monotherapy, Group Bwho was treated by cryotherapy alone, and Group Cwho was treated by a combination of cryotherapy with intralesional antigen immunotherapy or 'cryo-immuno-therapy.' The treatment sessions were done every 2 weeks to a maximum of five sessions. All patients were followed up for 3 months to detect possible relapses. Any adverse effects were recorded and patients' satisfaction was evaluated at the end of treatment. RESULTS: The 'cryo-immuno-therapy' group resulted in (40%) complete clearance of lesions which was significantly superior to immunotherapy monotherapy clearance rate (20%). CONCLUSIONS: 'Cryo-immuno-therapy' is a new combination therapy for multiple common warts. This combination is easy to apply, safe, of low cost, and higher efficacy in contrast to the traditional intralesional Candida antigen monotherapy.

Evaluation of the additional effect of topical 5-fluorouracil to needling in the treatment of localized vitiligo.

BACKGROUND: Microneedling is a valuable tool that can be used in transdermal drug delivery in vitiligo patients to improve drug permeability and efficacy with minor side effects. AIMS: The aim of this study is to assess the effectiveness of using microneedling prior to application of topical 5-FU in treatment of localized vitiligo and to compare its results with microneedling alone. METHODS: Twenty-seven patients with localized stable vitiligo are chosen. Two patches are determined in every patient: patch A treated with needling alone and patch B treated with needling followed by topical application of 5-fluorouracil once every 2 weeks for three months. Repigmentation was accessed by grades ranging from G0; no response to G4; >75% repigmentation. Side effects were reported in every visit. RESULTS: Microneedling followed by topical application of 5-fluorouracil showed better response than needling alone with minimal side effects. CONCLUSION: Combining microneedling with topical drug application yields better results in treating localized vitiligo.

Subcutaneous methotrexate versus oral form for the treatment and prophylaxis of chronic plaque psoriasis.

Psoriasis is a common inflammatory skin disorder with complex pathomechanisms. Methotrexate (MTX) is an antiproliferative and immunomodulating agent that control psoriasis. The aim of this study is to compare the efficacy of MTX and tolerability to MTX by oral route versus subcutaneous (SC) route. Twenty-eight cases were divided into two equal groups: Group I received a weekly dose of oral MTX and Group II received a weekly dose of SC MTX for 12 weeks. The starting dose was 7.5-10 mg and increased gradually by 2.5 mg every month till reaching 12.5-15 mg/week. Patients' clinical responses were evaluated according to Psoriasis Area and Severity Index (PASI) score. Results suggest that Group I patients showed reduction in PASI score of mean ± SD from 19 ± 7.4 before treatment to 11.2 ± 6.29 after treatment while Group II patients showed reduction from 23.4 ± 14.7 before treatment to 2.55 ± 2.6 after treatment with highly statistically significant difference between both groups. Clinical improvement was complete in 7.1% of Group I versus 57.1% of Group II. In conclusion, SC MTX has higher efficacy with lesser adverse effects and lower relapse rate when compared to oral form given by the same dose during the same duration.

Role of Atorvastatin in Treatment of Chronic Spontaneous Urticaria Patients: A Controlled Clinical Trial.

Chronic spontaneous urticaria (CSU) is a popular disease, affects patients' life. Its etiologic agents are not well known so; treatment of the patients is difficult. CD203c is a marker that is only present on basophils. Statins are drugs used to lower cholesterol. Nowadays, it is well known that they have immunomodulatory effects. This study evaluated the efficacy of a statin, atorvastatin, in combination with antihistamines in treating CSU patients. Forty CSU patients were divided equally into two groups. The first group was treated with antihistamines and atorvastatin, while the second group was treated with antihistamines and placebo. Both groups received the treatment for three months. The effect of treatment on total severity score (TSS), autologous serum skin test (ASST), basophil histamine release (BHR) assay, in vivo basophil CD203c expression (%) and basophil activation test (BAT-CD203c) was assessed. We found statistically significant reduction in TSS, BHR assay, in vivo basophil CD203c expression (%) (P= 0.000 each), diameter of ASST and BAT-CD203c (P= 0.002, 0.017, respectively), in the patients that received the atorvastatin and antihistamines. In conclusion, atorvastatin is effective in treating CSU patients.

Classical Kaposi sarcoma: case reports with unusual presentation on the penis and scrotum.

BACKGROUND: Kaposi sarcoma (KS) is the most common vascular neoplasm. Any skin area could be involved, including the genitalia. Traditionally, classic KS lesions have a general distribution, often involving skin of the feet and legs, and to a lesser extent, that of the hands, arms, and trunk. KS limited to the external genitalia is extremely rare in HIV seronegative individuals. METHODS: We report six patients of classic KS with generalized dermal KS lesions. RESULTS: Two of them presenting with unusual KS lesions on the penis and scrotum beside the other dermal lesions. Patients were HIV negative and human herpes virus eight positive. Histological examination showed classical KS. CONCLUSIONS: Primary KS of the penis and scrotum is rare but could occur in HIV-negative patients.

Melasma treatment using an erbium:YAG laser: a clinical, immunohistochemical, and ultrastructural study.

BACKGROUND: Melasma is a common pigmentary disorder that remains resistant to available therapies. OBJECTIVES: The aim of the present study was to evaluate the efficacy of erbium:YAG lasers in the treatment of refractory melasma and investigate the histopathological and ultrastructural changes between melasma skin and adjacent control skin before and after surgery. METHODS: Fifteen Egyptian female patients with melasma unresponsive to previous therapy of bleaching creams and chemical peels were included in this study. Full-face skin resurfacing using an erbium:YAG laser was performed. Clinical parameters included physician and patient assessment, and melasma area and severity index score were done. Adverse effects after laser resurfacing were recorded. Biopsies of lesions and adjacent healthy skin were stained using hematoxylin-eosin, immunohistochemically marked for Melan-A, and evaluated by electron microscopy. RESULTS: The amount of melanin, staining intensity, and number of epidermal melanocytes are increased in melasma lesions as compared to normal skin. Electron microscopic analysis revealed an increased number of mature melanosomes in keratinocytes and melanocytes, with more marked cytoplasmic organelles in melasma skin than in biopsy specimens from normal skin, suggesting increased cell activity. After surgery, the number of melanocytes and concentration of melanin decreased in melasma skin, and the mean melasma area and severity index score decreased dramatically. CONCLUSIONS: Erbium:YAG laser resurfacing effectively improves melasma; however, the almost universal appearance of transient postinflammatory hyperpigmentation necessitates prompt and persistent intervention.

Over-expression of tumor necrosis factor-α in vitiligo lesions after narrow-band UVB therapy: an immunohistochemical study.

There is a growing evidence that cytokines are important in the depigmentation process of vitiligo, however, the exact mechanism is not fully understood. The aim of this work was to study the possible role of the tumor necrosis factor-α (TNF-α) cytokine in the depigmentation process of the disease. Twenty patients with generalized vitiligo were exposed to narrow-band ultraviolet B (NB-UVB) therapy thrice weekly for a total of 60 sessions. Immunohistochemical examination was done, to assess the TNF-α expression in lesional and perilesional skin as compared to normal control skin, before and after therapy. At baseline, positive lesional TNF-α expression was detected in 60 % of patients which was significantly higher as compared to perilesional skin (20 %) and negative expression in healthy control skin. Post-treatment, a statistically significant increase in TNF-α expression was detected in both lesional (90 %) and perilesional skin (70 %) as compared to baseline (P < 0.05). The significant increase of TNF-α in vitiligo lesions compared with perilesional and healthy skin suggests a possible involvement of this cytokine in the depigmentation of vitiligo. The increase in TNF-α expression after NB-UVB phototherapy suggests another role in repigmentation.

Cowden's syndrome: a clinical, immunological, and histopathological study.

BACKGROUND: Cowden's syndrome is a rare, autosomal dominant condition characterized by hamartomas of the gastrointestinal tract and cancer of the breast and thyroid. This study describes the clinical, immunological, and histopathological status of four Cowden's syndrome cases from two different families. METHODS: Biopsies were taken from different skin, mucous membrane, and intestinal lesions in all patients. Blood samples from patients and their parents were also examined. RESULTS: Two brothers in the first family had more flexural distribution of papular and warty skin lesions as well as other manifestations of the syndrome, including recurrent pyogenic and fungal infections. Flow cytometric study revealed decreased total T and B-cell percentages and abnormal helper: suppressor ratios in these patients. The other two patients from the second family showed the classical picture of the syndrome and normal immunological parameters. Histopathologically, most skin lesions of the face showed trichilemmomas, and all oral and some of the other skin lesions showed benign fibromas with giant cells (Cowden's fibroma). Examination of intestinal biopsies revealed hamartomatous and hyperplastic polyps. CONCLUSIONS: Some cases of Cowden's syndrome may be associated with prominent flexural skin lesions, recurrent pyogenic and fungal skin infections, decreased total T and B-cell counts, and an abnormal helper:suppressor ratio.

Juvenile hyaline fibromatosis and infantile systemic hyalinosis: a unifying term and a proposed grading system.

BACKGROUND: It has been suggested that juvenile hyaline fibromatosis and infantile systemic hyalinosis represent different severities of the same disease. OBJECTIVE: We sought to redefine these disorders clearly to establish a common inclusive terminology. PATIENTS: The study included two children with early onset of similar pink papulonodular skin lesions and marked gingival hyperplasia. The first case was characterized by flexion contractures of the large joints, fractures, persistent diarrhea, recurrent chest infections, and retarded physical growth. The second patient had large swellings on the scalp and knees without systemic involvement. RESULTS: Radiologic examination revealed fractures and osteolytic bone lesions in the first case, and soft tissue masses in the second case. Laboratory tests showed anemia in both cases, and hypogammaglobulinemia, hypoalbuminemia, and electrolyte imbalance in the first case. Histopathological and ultrastructural evaluation demonstrated hyalinized fibrous tissue in the dermis in both cases. LIMITATIONS: Genetic studies were unavailable. CONCLUSION: Juvenile hyaline fibromatosis and infantile systemic hyalinosis share many common features that strongly support consideration of these conditions as different expressions of the same disorder. We propose a common term, "hyaline fibromatosis syndrome," which can be divided into mild, moderate, and severe subtypes.

Necrolytic acral erythema: a variant of necrolytic migratory erythema or a distinct entity?

BACKGROUND: Hepatitis C is a major health problem in Egypt. Necrolytic acral erythema (NAE) is a recently described necrolytic erythema that has a distinctive acral distribution and a uniform association with hepatitis C. Some authors believe that NAE is a distinct entity and others consider it as a variant of necrolytic migratory erythema (NME). METHODS: Five patients with clinical features consistent with NAE were included in this study. The patients were subjected to skin biopsy examination, CT scan of the pancreas and a liver biopsy. Liver function tests, serum glucagon, glucose, amino acids and zinc were measured. All patients were tested for hepatitis C by enzyme-linked immunosorbent assay (ELISA) and by polymerase chain reaction (PCR). RESULTS: Three patients presented with early (acute) lesions and two patients with chronic lesions. The distribution of the lesions was almost exclusively on the dorsae of the feet. Histopathological findings were similar to those of other necrolytic erythemas. Hepatitis C virus was uniformly detected in all patients. Serum glucagon was high in two patients, serum glucose was high in four patients, serum amino acids were low in three cases and serum zinc and albumin were low in two cases. Little or no improvement was reported after oral amino acid supplementation, while the response to oral zinc sulfate was moderate to good. CONCLUSION: Necrolytic acral erythema is closely associated with hepatitis C infection. Many findings indicate that NAE seems to be a variant of NME rather than a distinct entity. Hence, an alternative proposed term could be acral NME.