Topical Oxybutynin 3% Gel Versus Aluminum Chloride 15% Lotion in Treatment of Primary Focal Hyperhidrosis.

INTRODUCTION: Hyperhidrosis is excessive sweating beyond thermoregulatory needs. It is a potentially disabling condition with challenging management. Aluminum chloride is the established topical treatment; however, response remains unsatisfactory. Oxybutynin is an anticholinergic drug that stands as a therapeutic chance for hyperhidrosis. OBJECTIVES: comparing the efficacy of topical oxybutynin 3% gel versus aluminum chloride 15% lotion in treatment of primary focal hyperhidrosis. METHODS: Forty patients with hyperhidrosis were randomly distributed into 2 equal groups treated by either topical oxybutynin 3% gel or topical aluminum chloride 15% lotion once daily night application for 4 weeks (both groups). Evaluation was done at 2 and 4 weeks of treatment and after 1 month of the end of treatment for follow up by Minor iodine starch test, hyperhidrosis disease severity scale (HDSS) and dermatology life quality index (DLQI). RESULTS: Both treatment modalities were effective with insignificant differences between patients of both groups regarding improvement in Minor iodine starch test and HDSS after 2 weeks of treatment (P = 0.561, 0.33 respectively). Oxybutynin 3% gel yielded significantly better improvement of Minor's test, HDSS and patient's quality of life at the end of 4 weeks of treatment with lower recurrence rate than aluminum chloride 15% lotion at 1 month follow up. Minimal adverse effects were noted in both studied groups. CONCLUSIONS: Oxybutynin 3% gel could be considered as a promising treatment modality for hyperhidrosis with higher efficacy than aluminum chloride 15% lotion and lower recurrence rate.

Efficacy and Safety of Topical Tranexamic Acid Alone or in Combination with Either Fractional Carbon Dioxide Laser or Microneedling for the Treatment of Melasma.

INTRODUCTION: Tranexamic acid (TXA) is a promising treatment modality for melasma. Microneedling (MN) and fractional carbon dioxide (CO2) laser were reported to enhance TXA transepidermal delivery. OBJECTIVES: To compare efficacy and safety of topical TXA alone or in combination with either fractional CO2 laser or MN for treatment of melasma. METHODS: Thirty females with facial melasma were divided randomly into 3 equal groups after excluding pregnant and lactating women and those using oral contraceptives or other hormonal therapy. Patients of group A were treated with fractional CO2 laser and those of group B were treated with MN (4 sessions, 3 weeks apart for both) with immediate topical application of TXA 5% solution after sessions and daily application of 5% TXA cream for both groups. Patients of group C were treated by topical daily application of TXA 5% cream. Evaluation was done by modified melasma area and severity index scores (mMASI), patient satisfaction and dermoscopy. RESULTS: Statistically significant improvement of mMASI was reported in all studied groups with a significantly better improvement in patients of groups A and B than those of group C, meanwhile the difference between groups A and B was statistically insignificant. CONCLUSIONS: Topical TXA is a safe and fairly effective treatment modality for facial melasma. Combining TXA with either fractional CO2 laser or MN yielded significantly better improvement than when used alone. Fractional CO2 laser carries the risk of post-inflammatory hyperpigmentation in patients with skin types III and IV and requires meticulous patient selection.

Combined intralesional triamcinolone acetonide and platelet rich plasma versus intralesional triamcinolone acetonide alone in treatment of keloids.

BACKGROUND: Keloids are benign fibro-proliferative growths occurring after skin injury or spontaneously. Intralesional triamcinolone acetonide (TA) is their first-line therapy, but commonly associated with side effects or recurrence. Platelet rich plasma (PRP) is an autologous blood-derived product with promising results in improving wound healing with lower keloid occurrence. OBJECTIVE: To compare the efficacy of combined intralesional TA and PRP versus TA alone in keloids treatment. METHODS: Forty patients with keloids were divided randomly into two equal groups (A and B). Both groups received intralesional TA (20 mg/ml) for four sessions, 3 weeks apart. Group A patients received additional intralesional PRP 1 week after TA injections. Evaluation was done after 3 months of follow up by Vancouver scar scale (VSS) and verbal rating scale (VRS) for pain and itching. RESULTS: Both groups showed significant improvement in all parameters of VSS and VRS in comparison with baseline. Significantly better improvement in height, pigmentation, and pliability and overall VSS was detected in patients of group A. A significantly higher incidence of post-TA atrophy and hypopigmentation was observed in group B. CONCLUSION: Combining intralesional PRP with TA could yield cosmetically better outcomes in keloid treatment with lower incidence of TA-induced side effects especially atrophy and hypopigmentation.

Comparative study between topical tranexamic acid alone versus its combination with autologous platelet rich plasma for treatment of melasma.

BACKGROUND: Tranexamic acid is a promising drug for melasma treatment, but its topical formulation has limited efficacy. Its use as liposome based cream or in combination with other modalities might help to achieve better results. OBJECTIVE: Comparing efficacy of topical tranexamic acid 5% in liposome base alone versus its combination with intradermal platelet rich plasma (PRP) for melisma treatment. METHODS: Forty female patients with melasma were divided randomly into 2 equal groups who were treated with topical tranexamic acid 5% cream twice daily for 12 weeks and group B received additional intradermal injections of PRP every 3 weeks throughout the treatment period. Evaluation was done through modified MASI score and patient satisfaction after one month from the end of treatment. RESULTS: Both groups showed significant improvement of modified MASI score after treatment. Significantly better treatment response and patient satisfaction were detected in patients of group B (p = .024, .029). The side effects of PRP were mild and tolerable and tranexamic acid was well tolerated. CONCLUSION: 5% topical tranexamic acid in liposome base is thought to be safe and effective modality for treatment of melasma. PRP is advisable as an autologous safe elixir which boosts the therapeutic effect of tranexamic acid.

Intralesional pentoxifylline, triamcinolone acetonide, and their combination for treatment of keloid scars.

BACKGROUND: Keloids are common fibroproliferative tumors, and their treatment still represents a dilemma. Intralesional triamcinolone acetonide (TAC) injection is effective, but frequently associated with side effects. Pentoxifyllin (PTX) is a vasodilator, anti-inflammatory, and antifibrotic agent. Its intralesional injection in keloids has not been evaluated yet. AIMS: Evaluating the efficacy and safety of intralesional PTX versus intralesional TAC and their combination for treatment of keloids. PATIENTS/METHODS: Thirty patients with keloids were divided into three equal groups and treated by intralesional injection of TAC, PTX, or their combination (admixed in 1:1 ratio). Injections were repeated every 3 weeks until lesional flattening or for maximum of 5 sessions. The evaluation was done using the Vancouver Scar Scale and the Verbal Rating Scale for pain and itching. RESULTS: A significant improvement in VSS was detected in all groups. Significantly better improvements in keloid height, pliability, pain, and itching were detected in the TAC and combination groups than in the PTX group. There was a significantly higher incidence of side effects (atrophy, hypopigmentation, telangiectasia, and precipitation of TAC) in the TAC group than in the combination group, while no side effects were reported in the PTX group. A statistically significant reduction in the number of treatment sessions (required to achieve best results) was detected in patients in the combination group. CONCLUSIONS: Intralesional injection of PTX is a potentially helpful, safe, and well-tolerated therapeutic tool for keloids, but with lower efficacy than intralesional TAC when used solely. Combining PTX and TAC produces significantly better results for keloid treatment and lowers the risk of TAC-induced side effects.

Intralesional injection of Candida albicans antigen versus measles, mumps, and rubella vaccine for treatment of plantar warts.

INTRODUCTION: Many therapeutic modalities have been used for management of plantar warts; however, no optimal treatment with high efficacy and no or low recurrence has been explored to date. Intralesional immunotherapy has shown promising results in the treatment of different types of warts.Here we compare the efficacy of Candida albicans-specific antigen versus measles, mumps, and rubella (MMR) vaccine for treatment of plantar warts by intralesional injection. METHODS: Sixty patients with refractory or recurrent plantar warts were randomly divided into two equal groups. Group A was treated with C. albicans antigen and Group B with MMR vaccine. Both groups were injected intralesionally in a single wart every 3 weeks until complete clearance of the wart or for a maximum of five sessions. The patients were followed up for an additional 2 months. RESULTS: C. albicans antigen yielded a statistically significant higher cure rate (80,0%) than MMR vaccine (26.7%) in the treatment of plantar warts through a mean of 3.98 sessions versus 4.24 sessions, respectively (p = 0.002), and both modalities were well tolerated, with no remarkable side effects and no recurrence in cured patients during follow-up. CONCLUSIONS: Intralesional C. albicans antigen injection is an easy and effective treatment tool for plantar warts, even resistant and recalcitrant ones, with no post-procedural downtime and only transient occasional side effects. MMR vaccine is thought to be less effective.

A comparative study of intralesional injection of Candida albicans antigen, bleomycin and 5-fluorouracil for treatment of plane warts.

BACKGROUND: Several therapeutic modalities for the treatment of verruca plana (VP) are available, but none has achieved complete cure in all cases with associated risk of side effects. OBJECTIVE: To evaluate efficacy and safety of intralesional injection of Candida albicans (C. albican) antigen, bleomycin and 5-fluorouracil (5-FU) in treatment of VP. METHODS: Sixty patients with VP were randomly divided into three equal groups who were treated using C. albicans antigen, bleomycin or 5- FU injections every 2 weeks till complete clearance of the lesions or for a maximum of four sessions and followed up for additional 8 weeks. RESULTS: A statistically significant higher incidence of complete response was achieved with bleomycin (85%) than C. albicans antigen (60%) which was higher than 5-FU (45%) with a significantly less number of required sessions to achieve best results with bleomycin and candida antigen than 5-FU. CONCLUSIONS: Candida albicans antigen, bleomycin and 5-FU are helpful modalities for treatment of VP. Bleomycin was the most effective, followed by C. albicans antigen then 5-FU (least effective). Single injection site, clearance of distant warts and decreased incidence of new lesion development - in situ or elsewhere - are additional merits of C. albicans immunotherapy. These modalities are cheap with only transient adverse effects.

Platelet-rich plasma in alopecia areata: intradermal injection versus topical application with transepidermal delivery via either fractional carbon dioxide laser or microneedling.

INTRODUCTION: Alopecia areata (AA) is a common cause of non-scarring alopecia with variable response to treatment. Platelet-rich plasma (PRP) stimulates proliferation and differentiation of stem cells in the hair-follicle bulge via multiple mechanisms. Although beneficial, pain during injection in addition to unequal delivery and coverage is a major drawback of intralesional PRP in alopecia, particularly for extensive lesions and in patients with a low pain threshold. This study evaluates intradermal injection of PRP versus its topical use with enhanced transepidermal delivery through either fractional CO2 laser (FCL) or microneedling in treatment of AA. METHODS: Sixty AA patients were randomized into three equal groups to receive monthly sessions of either PRP intradermal injection, FCL followed by topical PRP, or microneedling followed by topical PRP for 3 consecutive months. Assessment was done through the Severity of Alopecia Tool (SALT) score and patient satisfaction at the end of sessions (2 weeks after the last session) and after 3 additional months of follow-up. RESULTS: Patients in all groups showed satisfactory results of PRP treatment, with statistically insignificant differences in the degree of improvement among patients of the three groups studied according to the two assessment parameters. Intralesional PRP injection was associated with significantly higher pain scores. CONCLUSIONS: PRP is potentially effective and safe for treatment of AA. FCL and microneedling could facilitate topical PRP delivery and considerably decrease pain associated with intradermal injection while preserving PRP efficacy. These methods could be helpful for extensive lesions and in children.

Fractional carbon dioxide laser and topical tioconazole in the treatment of fingernail onychomycosis.

Onychomycosis is a common chronic-resistant nail disease. Traditional treatment has its limitations and side effects. This study aimed to evaluate the role of fractional CO2 laser and topical tioconazole 28% nail lacquer in the treatment of fingernail onychomycosis, as sole treatment modalities and in combination. Thirty patients with culture-proven onychomycosis were included and randomly divided into three equal groups. Laser group received six fractional carbon dioxide (CO2) laser sessions at monthly intervals; topical group received topical tioconazole 28% nail lacquer twice daily for 6 months, and combined group received six fractional CO2 laser sessions at monthly intervals with topical tioconazole twice daily for 6 months. Treatment outcome was evaluated through physician's evaluation of improvement using onychomycosis severity index score (OSI), patients' satisfaction, side effect evaluation, and mycological culture (assessed after the end of treatment). At the end of treatment, both laser and combined groups showed significantly better degrees of improvement (P = 0.036, 0.024, respectively) and patient's satisfaction (P = 0.046, 0.003, respectively) in comparison with topical group. Mycological clearance in fungal cultures was significantly higher in combined group than topical group after the end of treatment (P = 0.007). Fractional CO2 laser is a safe and effective treatment modality for onychomycosis. Its efficacy approximates that of fractional CO2 laser combined with topical tioconazole 28% nail lacquer and surpasses that of topical tioconazole 28% monotherapy. It is expected to be an excellent choice for patients in whom systemic antifungals are contraindicated or who are unresponsive or intolerant to topical antifungals.

Pulsed-dye laser versus intralesional Candida albicans antigen injection in treatment of genital warts.

INTRODUCTION: Genital warts are a troublesome therapeutic issue. Pulsed-dye laser (PDL) is a non-ablative therapeutic tool for viral warts. Intralesional Candida albicans (C. albicans) immunotherapy has yielded promising results in treatment of various types of warts. We aimed to evaluate the effectiveness of PDL versus C. albicans immunotherapy for treatment of genital warts. METHODS: Forty adult patients with genital warts were divided into two equal groups; the first was treated using PDL and the second using intralesional C. albicans antigen injection. Treatments were performed at 3-week intervals until complete lesion resolution or for a maximum of three sessions. RESULTS: PDL yielded higher complete clearance rates (95%) than C. albicans antigen (50%; p = 0.001), which in turn had the advantage of treating distant and internal genital warts. Apart from pain during the session in PDL, both modalities were well tolerated with no recurrence in cured patients during the 16-week follow-up period. CONCLUSIONS: PDL and C. albicans antigen injection are safe and effective treatment alternatives for genital warts. PDL yielded better frequencies of clearance, but C. albicans antigen has additional advantages, including a single injection site and treating distant and internal mucosal uninjected warts, which are usually difficult to treat.

Serum-soluble CXCL16 in juvenile systemic lupus erythematosus: a promising predictor of disease severity and lupus nephritis.

Juvenile systemic lupus erythematosus (jSLE) is a multisystem autoimmune disease of unpredicted course and prognosis. Rates of organ involvement in SLE are higher in children, and overt lupus nephropathy is more often a presenting manifestation of SLE in children than adults. Inflammatory soluble chemokine CXC motif-ligand 16 (sCXCL16) is an important pathogenic mediator in inflammatory diseases as SLE. Herein, we aimed to evaluate serum level of sCXCL16 in jSLE patients in comparison to healthy controls and to correlate it with disease activity and extent of cutaneous and renal affection, to detect its possible role in disease pathogenesis. Serum level of sCXCL16 was determined by ELISA in 27 patients with jSLE (mean age 12.35 years ± 2.26 SD) in addition to 30 age- and sex-matched healthy controls and correlated with clinical and laboratory parameters in lupus group. Serum sCXCL16 was significantly higher in jSLE patients than controls (P ≤ 0.001), and it correlated positively with SLE disease activity, severity of lupus nephritis, 24-h urinary protein, anti-dsDNA titre, blood pressure, and ESR, while it correlated negatively with serum C3 levels. Serum sCXCL16 was higher in jSLE patients with alopecia and malar erythema. Serum sCXCL16 might play a role in inflammatory pathogenesis of jSLE particularly in periods of disease activity. It might serve as a future useful laboratory test for detection of jSLE activity, renal insult, and its severity which might limit the need for invasive renal biopsies in such a delicate patient population.

Use of transcutaneous electrical nerve stimulation for chronic pruritus.

Pruritus is a distressing symptom in many dermatological as well as systemic conditions, and it is sometimes very chronic and relapsing. Transcutaneous electrical nerve stimulation (TENS) is an inexpensive form of analgesia that could also ameliorate itching. This study aimed to evaluate TENS efficacy in patients with pruritus due to some types of chronic eczema, and in patients with chronic hepatic disease. Ten patients with atopic dermatitis (AD), 20 patients with lichen simplex chronicus (LSC), and 16 patients with chronic liver disease having chronic distressing pruritus received three sessions of TENS weekly for 12 sessions, and the effect on the visual analogue scale (VAS) scores was recorded after 2 weeks of therapy, at treatment end, and after an additional month for follow up. There was a statistically significant decline in the mean VAS score for studied groups at weeks 2 and 4 of therapy compared to baseline, but the improvement was more significant in patients with AD, and LSC (p < 0.001 for both) than in those with chronic liver disease (p < 0.01) who also showed an early re-elevation of VAS score on follow up. TENS therapy holds promise as a palliative, alternative, safe and inexpensive treatment for patients with some chronic pruritic conditions.

Scabies among primary schoolchildren in Egypt: sociomedical environmental study in Kafr El-Sheikh administrative area.

BACKGROUND/OBJECTIVES: Scabies is a major global public health issue that might affect people from all socioeconomic levels. The primary contributing factors in contracting scabies seem to be poverty and overcrowded living conditions. Scabies often spreads among schoolchildren quite rapidly, owing to their close contact and overcrowding within the schools. However, limited information is available about its risk factors and the socioeconomic correlates among schoolchildren in Egypt. This study aimed to assess the prevalence of scabies and its risk factors among primary schoolchildren in Kafr El-Sheikh administrative area, Egypt. METHODS: This cross-sectional descriptive study was performed on primary schoolchildren in urban and rural areas of Kafr El-Sheikh administrative area. A predesigned questionnaire was used for data collection from the randomly selected 2,104 children, and clinical dermatological examination was done for them. RESULTS: Out of 2,104 children studied, there were 92 cases of scabies with a prevalence of 4.4%. The prevalence of scabies infestation in male students was 3.9%, while it was 4.8% in females, with no statistical significance. The results showed significant variations in the risk of scabies infestation by factors such as residence, paternal education and occupation, maternal education, sleeping with others, having animals at home, dealing with animals outside the house, type of building for living, family history of itchy rash, and sharing clothes with others. CONCLUSION: In our community, scabies is still an important health problem affecting schoolchildren, especially in rural areas. It is characterized by a complex web of causation, particularly poor living conditions and low level of parents' education.

Cryoglobulinaemia in Egyptian Patients with Extrahepatic Cutaneous Manifestations of Chronic Hepatitis C Virus Infection.

Background. Hepatitis C is a global major health problem with extremely variable extrahepatic manifestations. Mixed cryoglobulinaemia (MC) shows a striking association with hepatitis C virus (HCV) infection, and it is sometimes asymptomatic. The skin is a frequently involved target organ in MC. Objective. To investigate the prevalence of cryoglobulinaemia in a sample of Egyptian patients with cutaneous manifestations of chronic HCV infection and to correlate its presence with clinical criteria and liver function tests. Methods. One hundred and eighteen patients with skin manifestations of chronic compensated hepatitis C were included. Venous blood was tested for liver function tests and serum cryoglobulins. Results. Twelve patients (10.169%) were positive for serum cryoglobulins (2 with pruritus, 4 with vasculitic lesions, 3 with livedo reticularis, one with oral lichen, one with chronic urticaria, and another with Schamberg's disease). Vasculitic lesions and livedo reticularis of the legs showed higher prevalence in cryoglobulin-positive than in cryoglobulin-negative patients. Presence of serum cryoglobulins did not relate to patients' demographic or laboratory findings. Conclusions. Fortunately, MC is not markedly prevalent among Egyptians with cutaneous lesions of chronic hepatitis C, and cryopositivity was commonly, but not exclusively, detected with cutaneous vasculitis and livedo reticularis. Laboratory testing for cryoglobulins in every HCV patient is advisable for earlier MC detection and management.

Decreased Circulating T Regulatory Cells in Egyptian Patients with Nonsegmental Vitiligo: Correlation with Disease Activity.

Background. Vitiligo is an acquired depigmentary skin disorder resulting from autoimmune destruction of melanocytes. Regulatory T cells (Tregs), specifically CD4(+)CD25(+) and Forkhead box P3(+) (FoxP3(+)) Tregs, acquired notable attention because of their role in a variety of autoimmune pathologies. Dysregulation of Tregs may be one of the factors that can break tolerance to melanocyte self-antigens and contribute to vitiligo pathogenesis. Methods. In order to sustain the role of Tregs in pathogenesis and disease activity of vitiligo, surface markers for CD4(+)CD25(+) and FoxP3(+) peripheral Tregs were evaluated by flow cytometry in 80 Egyptian patients with nonsegmental vitiligo in addition to 60 healthy control subjects and correlated with clinical findings. Results. Vitiligo patients had significantly decreased numbers of both peripheral CD4(+)CD25(+) and FoxP3(+) T cells compared to control subjects (11.49% ± 8.58% of CD4(+) T cells versus 21.20% ± 3.08%, and 1.09% ± 0.96% versus 1.44% ± 0.24%, resp., P < 0.05 for both). Peripheral numbers of CD4(+)CD25(+) and FoxP3(+) Tregs correlated negatively with VIDA score. Conclusion. Treg depletion with impaired immune downregulatory function might play a key role in the autoimmune conditions beyond nonsegmental vitiligo particularly in active cases. Effective Treg cell-based immunotherapies might be a future hope for patients with progressive vitiligo.