Value of silicone gel in prevention of cobblestoning following punch minigrafting in vitiligo.

BACKGROUND: Cobblestoning is the most common complication of minipunch grafting. OBJECTIVE: To assess the value of silicone gel application following minipunch grafting and the histopathological and immunohistochemical changes in cases with cobblestoning. METHODS: Minipunch grafting was performed in two similar vitiligo lesions in 27 cases with stable vitiligo. After healing, silicone gel was applied twice daily on one lesion while zinc oxide ointment was applied to the other lesion serving as a control. Four biopsies were taken from each case; normal, vitiliginous skin before treatment and the two treated lesions 3 months after therapy, for histopathology and immunohistochemical staining for MMP9 & tenascin-C. RESULTS: Repigmentation occurred in 19 cases (70.7%). The number of lesions showing excellent and good response was significantly higher on the silicone gel side (p < .001). In 20 cases, cobblestoning either occurred or was absent on both sides. Histopathologically, cobblestoning was similar to hypertrophic scarring. Both markers were elevated after therapy on both sides with no significant difference in percentage change between lesions showing positive and negative cobblestoning. CONCLUSION: Silicone gel application after minigrating improved the final response with no significant effect on the occurrence of cobblestoning. Cobblestoning resembled hypertrophic scarring histopathologically.

Recipient site preparation by cryoblebbing in melanocyte keratinocyte transplantation procedure over the fingers in vitiligo: A pilot study.

Surgical treatment of vitiligo lesions over the fingers has poor outcome. In this intra-patient comparative study, 12 patients with stable non-segmental vitiligo (NSV) affecting the middle three fingers of one hand were included. Three variations were used in treatment of finger vitiligo lesions: minipuch grafting, melanocytes keratinocyte transplantation procedure (MKTP) preceded by cryoblebbing or full CO2 laser resurfacing of the recipient site. Liquid nitrogen was used to create blebs in one finger 24 hours before therapy. On the following day, the second finger was treated by minipunch grafting and the third finger was resurfaced by CO2 laser. A suspension was prepared and 0.1 mL was injected into each cryobleb. It was also applied to the resurfaced skin. All patients underwent topical PUVA therapy and were followed-up for 12 months. Ten cases with 52 lesions completed the follow-up period. About 4/18 lesions treated by cryoblebbing followed by MKTP showed ≥75% repigmentation while only 1/17 lesions treated by laser resurfacing + MKTP and 1/17 lesions treated by minipunch grafting showed 30% and 10% repigmentation, respectively. No complications occurred in MKTP treated lesions. Cryoblebbing of the recipient site seems to improve the outcome of MKTP in lesions over the fingers in stable NSV.

In vivo visualization of hair follicles by ultrasound biomicroscopy in alopecia areata and its correlation with histopathology.

Ultrasound biomicroscopy (UBM) is a non-invasive imaging technique used in examination of several skin diseases but never in imaging hair and scalp diseases. Main objective of this investigation was assessment of the efficacy of UBM for in vivo visualization of hair follicles in cases of alopecia areata (AA) and correlation of findings with histopathological findings. This study included 30 patients with AA. Two areas, one with AA and a control area, were marked, examined by UBM and then biopsied for histopathological examination. In patients with alopecia totalis (AT) or universalis (AU) only an AA area was examined. Non-echogenic conical shadows reaching the epidermal entrance echo (probably corresponding to the hair follicles) were seen and were wider and fewer in number in areas of AA than in normal control areas. No significant difference was found regarding number and width of hair follicles between UBM and histopathological examination. However, a significant increase in length of follicles in histopathology was detected, indicating that the UBM image was probably unable to reach the deepest part of the follicle. Main limitation of the study is small number of cases. No significant difference was found between UBM and histological measurements of hair follicle number and width in patients with AA, making UBM a useful tool for in vivo visualization of hair follicles.

PTPN22 gene polymorphism in Egyptian alopecia areata patients and its impact on response to diphencyprone immunotherapy.

PTPN22 1858C>T gene polymorphism has been associated with several autoimmune disorders including alopecia areata. The aim of the current study was to investigate the effect of the inherited genetic polymorphism 1858C>T of PTPN22 gene on the predisposition to severe forms of alopecia areata and its effect on the response to DPC treatment. To achieve our aim, PTPN22 1858C>T genotyping was performed by PCR-based restricted fragment length polymorphism (PCR-RFLP) analysis. The study included 103 Egyptian patients with extensive alopecia areata treated by DPC. Hundred healthy age and sex matched blood donors were included in the current study as a control group. Results of genotyping showed that PTPN22 CT and TT mutant genotypes were significantly higher in AA patients compared to controls and conferred increase risk of AA (OR=2.601, 95% CI=1.081-6.255). Statistical comparison between AA patients with wild and mutant genotypes revealed that the duration of the illness was significantly longer in those harboring the mutant genotypes. Moreover, the association of other autoimmune diseases as atopy and diabetes mellitus was higher in patients with mutant genotypes. Furthermore, PTPN22 1858C>T genetic polymorphism did not affect the patients' response to DPC immunotherapy.

A comparative study on efficacy of UVA1 vs. narrow-band UVB phototherapy in the treatment of vitiligo.

BACKGROUND/PURPOSE: Narrow-band ultraviolet B (NB-UVB) is considered the most effective and safe initial treatment for moderate-to-severe vitiligo but phototoxicity and possible carcinogenicity are the reported side effects. Ultraviolet A1 (UVA1) phototherapy has overlapping biological effects to NB-UVB and is relatively free of side effects associated with other phototherapy regimens. METHODS: Forty patients with vitiligo were included in this prospective, randomized controlled comparative clinical trial. Twenty patients received NB-UVB and 20 received UVA1 three times weekly for 12 weeks. The UVA1 group was divided into two subgroups. Ten patients received moderate and 10 received low dose of UVA1. Serum samples were collected before and after 36 sessions to assess soluble interleukin 2 receptor level. Patients were clinically evaluated before therapy then monthly according to Vitiligo Area Scoring Index (VASI) and Vitiligo European Task Force (VETF) scores. In addition, extent of response was determined by a blinded dermatologist comparing before and after therapy photographs. Pattern of response and side effects were recorded. RESULTS: NB-UVB was superior to UVA1 with a significant difference in blinded dermatological assessment (P<0.001), percentage change in VASI score (P<0.001) and percentage change in VETF area score (P=0.001). No significant difference in side effects was observed between both groups. Comparing UVA1 subgroups, better response in moderate-dose group was found as regard to percentage change in VASI (P<0.001) and percentage change in VETF area score (P=0.001), while no significant difference was found in blinded dermatological assessment (P=0.121). CONCLUSION: NB-UVB phototherapy remains to be an effective and safe therapeutic option in vitiligo. Response to UVA1 in vitiligo seems to be dose dependent and seems to be of limited value in treatment of vitiligo as a monotherapy. Further studies combining it with other lines of therapy such as systemic steroids may prove beneficial.

Subcision versus 100% trichloroacetic acid in the treatment of rolling acne scars.

BACKGROUND: Acne scarring is common but surprisingly difficult to treat. Newer techniques and modifications to older ones may make this refractory problem more manageable. The 100% trichloroacetic acid (TCA) chemical reconstruction of skin scars (CROSS) method is a safe and effective single modality for the treatment of atrophic acne scars, whereas subcision appears to be a safe technique that provides significant improvement for rolling acne scars. OBJECTIVE: To compare the effect of the 100% TCA CROSS method with subcision in treating rolling acne scars. METHODS: Twenty patients of skin types III and IV with bilateral rolling acne scars received one to three sessions of the 100% TCA CROSS technique for scars on the left side of the face and subcision for scars on the right side. RESULTS: The mean decrease in size and depth of scars was significantly greater for the subcision side than the 100% TCA CROSS (p<.001). More side effects in the form of pigmentary alteration were observed with the 100% TCA CROSS method. CONCLUSION: For rolling acne scars in patients with Fitzpatrick skin types III and IV, subcision shows better results with fewer side effects than the 100% TCA CROSS technique, although further decrease in scar depth with time occurs more significantly after 100% TCA CROSS.

Sulfasalazine and pentoxifylline in psoriasis: a possible safe alternative.

BACKGROUND: Conventional therapy of extensive psoriasis is effective but has complications. Biologics are safer but expensive. OBJECTIVE: To assess the efficacy of sulfasalazine and pentoxifylline, which have TNF antagonizing and anti-proliferative action in the treatment of psoriasis. METHODS: In this randomized controlled trial, 32 patients with extensive psoriasis were divided into four groups: group A received sulfasalazine; group B received pentoxifylline; group C received both drugs; and group D received methotrexate. The Psoriasis Area and Severity Index (PASI) score was done at weeks 0, 2, 4, 6 and 8. RESULTS: A significant reduction in PASI score occurred in groups C and D (p = 0.043 and 0.018, respectively). A significantly higher percentage of PASI score reduction occurred in group D compared with groups A, B and C (p = 0.006, 0.003 and 0.030, respectively). An excellent response occurred in one patient (14.3%) in group D. A very good response occurred in two patients (22.2%) in group C, and in five patients (71.4%) in group D. A moderate response occurred in three patients (37.5%) in group A, one patient (12.5%) in group B, and one patient (14.3%) in group D. CONCLUSION: Although incomparable to methotrexate, combined sulfasalazine and pentoxifylline produced a good response in cases of extensive psoriasis. Multicentre studies are needed to validate these results.

Bcl-2 expression in mycosis fungoides before and after PUVA therapy.

PUVA is the first therapeutic choice in early stages of mycosis fungoides (MF). In this study the effect of PUVA on bcl-2 expression in MF was assessed in 15 patients (three stage Ia and 12 stage Ib) and 10 controls. Two biopsies were taken from each patient before and after 24 sessions of PUVA therapy. Histopathological assessment and immunohistochemical staining for bcl-2 was performed and showed positive bcl-2 staining of lymphocytes in 53% of MF cases (8/15) before PUVA, with no statistically significant difference in the bcl-2 level before and after PUVA therapy (P value 0.3). A statistically significant difference was found in the bcl-2 level between control samples and MF patients' biopsies before (P value 0.02) and after PUVA therapy (P value 0.011). In conclusion, a lack of decline in the bcl-2 level and the absence of clinical or histopathological correlation with the bcl-2 level before and after PUVA therapy in MF patients suggest that PUVA-induced apoptosis in MF cases may occur through pathways other than bcl-2 inhibition.

Combined trichloroacetic acid peel and topical ascorbic acid versus trichloroacetic acid peel alone in the treatment of melasma: a comparative study.

BACKGROUND: Melasma is a common acquired hypermelanosis that is difficult to treat. Several chemical peeling agents were used in treatment of melasma. Topical vitamin C was also used with minimal side effects. AIM: To compare the effect of 20% trichloroacetic acid (TCA) peel alone vs. 20% TCA peel combined with topical 5% ascorbic acid in cases of epidermal melasma. PATIENTS AND METHODS: Thirty women with bilateral epidermal melasma (Fitzpatrick skin types III and IV) were divided into two groups (A and B, 15 patients each). Before therapy, digital photography and a melasma area and severity index (MASI) score were done for each patient. Groups A and B were primed for 2 weeks before TCA peel. Group B also applied 5% ascorbic acid topically once daily; 20% TCA peel was done for all patients weekly until clearance of melasma or for a maximum of six peels. Group B continued to use 5% ascorbic acid topically in between peels and during the 16-week follow-up period. Patients were assessed at the end of peeling sessions and at the end of follow-up by photography, MASI score, and a global evaluation by the patient. RESULTS: Group B compared with group A showed a significant decrease in MASI score at the end of TCA peels (P < 0.001) and at the end of the 16-week follow-up period (P < 0.003). Global evaluation showed that 13 patients (87%) in group B improved or maintained their improvement compared with only 10 patients (67%) in group A. CONCLUSION: Topical ascorbic acid combined with 20% TCA peel in melasma improves the results and helps in maintaining the response to therapy.