Comparison of Intralesional Vitamin D with Intralesional Triamcinolone Acetonide in the Treatment of Keloids.

Background: Hypertrophic scars and keloids are disorders caused by the excessive growth of connective tissue, associated with the accumulation of collagen and cellular matrix components. These scars are caused by abnormal wound healing and can have a great impact on patients' lives. Therefore, we aimed to compare the effect of intralesional injection of vitamin D with triamcinolone acetonide in the treatment of keloid. Methods: This study was a one-sided blind clinical trial, conducted on 22 patients (44 samples) with keloid. It was a randomized, blinded clinical trial, conducted in Imam Khomeini Hospital in Ahvaz, Iran in 2022. In each group, triamcinolone or vitamin D was injected at the lesion site with an interval of three weeks and an average of 6 sessions. The patients were re-evaluated 3 months after the end of the treatment in terms of recurrence. Results: By examining the VSS scale in each of the groups, this scale decreased significantly in both groups after the intervention (P=0.001), which was greater in the group receiving triamcinolone (P=0.001). Conclusion: It seems that the injection of vitamin D at the site of the lesion helps to treat it, but the effectiveness of the usual triamcinolone treatment was still higher, it is suggested to use vitamin D as an adjunctive treatment in these patients.

Clinical evaluation of liposome-based gel formulation containing glycolic acid for the treatment of photodamaged skin.

Background: Long contact of UV causes skin damage. Glycolic acid (GA) as an alpha hydroxy acid is used to treat photodamaged skin. However, GA leads to side effects including; burning, erythema and peeling.Purpose: The aim of this study was to develop a controlled delivery systems loading GA in order to increasing its efficacy and lowering its side effects.Methods: Liposomes were evaluated for encapsulation efficiency, size and morphology. Optimized formulation was dispersed in HPMC gel bases and drug release kinetics were also studied. Clinical efficacy and safety of GA-loaded liposomal gel and GA gel formulation were evaluated in patients with photodamaged skin.Results: The EE% and average particle size of liposomes were 64 ±2.1 % and 317±3.6 nm, respectively. SEM image showed that liposomes were spherical in shape. In vitro release kinetics of GA from both formulations followed Weibull model. Clinical evaluation revealed that GA-loaded liposomal gel was more effective than GA gel formulation. Treatment with GA-loaded liposomal gel resulted in a statistically significant reduction in the scores of hyperpigmentation, fine wrinkling and lentigines. Moreover, liposomal gel formulation was able to minimize side effects of GA.Conclusion: According to the obtained results, the liposome-based gel formulation can be used as potential drug delivery system to enhance permeation of GA through skin layers and also reduce its side effects.

Evaluation of the effectiveness of microneedling with tranexamic acid in comparison with microneedling with vitamin C in the treatment of melasma: A prospective and single-blind clinical trial.

Background and Aims: Melasma is a common skin condition. Microneedling acts as a dermal delivery system that facilitates the penetration of lightening agents such as vitamin C and tranexamic acid (TXA) into the deeper layers of the skin. Therefore, this study aimed to compare the effectiveness of microneedling with TXA with microneedling and vitamin C in treating melasma. Methods: In patients with melasma, microneedling was performed at 2-3 mm depth. During that, TXA and vitamin C were poured on the skin of each side of the face, and then each ampoule was soaked for 15 min. This method was performed three times in 2-week intervals, and the results were compared by measuring the Melasma Area and Severity Index (MASI) score before, during, and 2 months after the completion of the treatment. Results: The average MASI score in the baseline in the TXA group was 4.61, and in the vitamin C group was 4.58. The average MASI score in the patients treated with TXA in the last treatment session was 2.40, and the group treated with vitamin C was 2.44. The study results showed that the treatment was effective in both groups based on MASI score. Although there was a difference between the responses of the two groups, it was not significant. Conclusion: Microneedling with vitamin C and TXA is a safe and effective treatment option without side effects for treating melasma.

The assessment of suture spacing on the esthetic and functional outcomes of skin closures in different age groups.

Background and Aims: Dermatological surgeons must master the factors affecting wound healing. Suturing is the most common method of wound closure. One of the significant factors in suturing that affects wound healing and cosmetic results is the distance between sutures, which has been studied very little to date. The aim of the current study was to investigate the effect of simple interrupted suture with a distance of 2 and 5 mm on the esthetic and functional results of suture closure in different age groups. Methods: In patients with two skin lesions, one wound was sutured with a distance of 2 mm and the other with a distance of 5 mm, and the wounds were evaluated 1 and 3 months after the operation using the POSAS scale. Results: Patients' opinions indicate that, in the suture intervals of 2- and 5-mm and at 1 and 3 months, the average was lower in the younger group than it was in the older group and also, as per the physician's opinion, the average in the age group under 50 years was significantly lower than that in the age group over 50 years. Conclusions: According to the results of the present study, a suture of 2-mm and a suture of 5-mm would result in different esthetic and functional outcomes depending on the patient's age. The average in the age group less than 50 years was significantly lower than that of the age group greater than 50 years.

The efficacy of adding topical 5-fluorouracil to micro-needling in the treatment of vitiligo: A randomized controlled trial.

BACKGROUND AND AIM: Vitiligo is an autoimmune skin disorder characterized by circumscribed depigmented macules and patches caused by the loss of functional melanocytes. Although there is no definitive treatment for vitiligo, several treatment options have been associated with relative satisfactory outcomes. The purpose of this study was to compare the efficacy of micro-needling in conjunction with topical 5-fluorouracil (5-FU) versus topical tacrolimus ointment in treating vitiligo patches. PATIENTS AND METHODS: This study included nineteen participants, each of whom received both treatments on two randomly selected vitiligo patches of approximately the same size and location. On one patch, a combination of weekly micro-needling and topical application of 5-FU solution was used every other day, while on the other, 0.1% tacrolimus topical ointment was applied twice daily. The G-score was used to compare treatment outcomes after 3 months. RESULTS: The median duration of the disease in our population was 7 years. Six patients (32%) in the micro-needling plus topical 5-FU treated group showed a moderate to excellent response, indicating a significant improvement between both treatments (p-value = 0.019). In contrast, all other patches treated with topical tacrolimus showed poor improvement. Lower extremity and trunk responded more to treatment with micro-needling plus topical 5-FU than upper extremity and acral areas. Moreover, none of those who have had the disease for more than ten years have responded to treatment. Mild erythema, pinpoint bleeding, and irritation were detected only in the micro-needling treated group. CONCLUSION: The current study showed that using micro-needling in conjunction with 5-FU could treat vitiligo patients more efficiently than tacrolimus monotherapy. Despite showing moderate to excellent improvement in patches treated with micro-needling and 5-FU, this well-tolerated office-based modality still requires additional research.

Neutrophilic Dermatosis of the Hands: A Case Report.

Neutrophilic dermatosis of the hands (NDDH) is a localized variant of Sweet's syndrome which has been recently introduced. Strutton et al.in 1996 and then in Galaria et al. in 2000 reported cases with violaceous papulonodules on the dorsal surfaces of the hands with histopathological findings of a neutrophilic dermatosis in association with leukocytoclasia, but clinically and histologically without true vasculitis findings. Eventually, they proposed the term NDDH for these lesions (1,2). A 46-year-old man was referred to our outpatient dermatology clinic with a painful ulcerative lesion on the dorsal side of the left hand that had been present for one year. Initially, the lesion had appeared as a small purulent papule, which gradually extended to a large ulcer. The patient underwent frequent referrals to several physicians and had taken a variety of topical and systemic antibiotics, meglumine antimoniate (Glucantime), and amphotericin with the clinical diagnosis of cutaneous bacterial or fungal infections, or leishmaniasis. All of these therapeutic regimes were ineffective in eradicating the lesion. Given the history, he denied any trauma to the site of lesion; he also did not report any similar lesions in his family. The physical examination revealed an extensive tender ulcer of 4×7 cm2 in size, with a shallow violaceous border superimposed on an edematous region on the dorsal side of the left hand. Atrophic scars resulting from old similar lesions were visible on the dorsal aspects of the 3rd and 4th proximal and middle metacarpal joints (Figure 1). The examination of the other parts of the body was unremarkable. Laboratory tests showed an impaired white blood cell count and their differentiation, including leukocytosis (white blood cell count of 16.12/mm3) with neutrophilia (neutrophil percent at 65.9%). Additionally, altered liver function tests were remarkable for high serum levels of AST (SGOT) (105 IU/L) and ALT(SGPT) (355 IU/L), while the total bilirubin and alkaline phosphatase were within normal limits. Hemoglobin levels (13.90 g/dL) and platelet count (272/mm3) were within normal range. The other laboratory tests, including serological tests for fasting blood sugar, hemoglobin A1c, creatinine, BUN, and an immunoassay for ruling out vasculitis lesions (anti-MPO (P-ANCA) and anti-PR3 (C-ANCA)) revealed no remarkable results. An erythrocyte sedimentation rate of 16 mm/h was reported. A biopsy was performed. Histologic features demonstrated a dense, diffuse dermal infiltrate comprised almost entirely of neutrophils. The epidermis was slightly acanthotic and showed small foci of spongiosis, but the inflammatory infiltrate remained largely in the dermis. Sheets of neutrophils were present, admixed with karyorrhectic debris. The infiltrate did not appear to be peri-vascular, and most vessels that could be observed clearly appeared to be undamaged. However, some vessels appeared to show some neutrophils infiltrating vessel walls (Figures 2a, b). Based upon histopathologic examination, the diagnosis of neutrophilic dermatosis of the hands (NDDH) was suggested. The work-up findings for ruling out neoplastic diseases were unremarkable. Clinically, patients with NDDH show various morphologic patterns of the lesions on the dorsal aspect of the hands, including violaceous edematous plaques or ulcers with undermined borders, hemorrhagic bullae, necrotic pyoderma-like lesions with pseudovesiculation, and atypical pyoderma gangrenosum-like lesions (1). This disease is more common in women (70%) than in men (3). NDDH has been reported in association with malignancies (such as leukemia and lymphoma), myelodysplasia, inflammatory bowel diseases, seropositive arthritis, sarcoidosis, HCV infection, and medications (such as lenalidomide, thalidomide, vaccinations, fertilizer, etc.) (1). Among them, neoplastic diseases are the most common association, which has been reported in 27% of the cases. It may thus represent a paraneoplastic phenomenon (3). Histopathological study is mandatory for achieving a definite diagnosis of NDDH. Its pathological findings include subepidermal edema, a dense and diffuse dermal infiltration of neutrophils along with leukocytoclastic debris, and extravasated erythrocytes, which are not associated with true vasculitis (1,3). However, the presence or absence of some vasculitic features as a histopathological finding depends on the time of biopsy with regard to the evolutionary phases of the lesion (3). In our case, the diffuse nature of the infiltrate was somewhat indicative against the diagnosis of leukocytoclastic vasculitis. Additionally, the possibility of infection was excluded empirically (due to the ineffectiveness of previous therapies without doing cultures or PCR), and indirectly through biopsy. Cohen (4) and Cohen and Kurzrok (5) explained the presence of vasculitis in Sweet's syndrome and NDDH as an epiphenomenon in which the damaged vessel is as an "innocent bystander" in the background of an inflammatory dermatosis. Eventually, they concluded that the presence or absence of vasculitis has a secondary importance in the diagnosis of NDDH. The following entities should be considered in the differential diagnoses of NDDH: cutaneous infections, vesiculobullous pyoderma gangrenosum (atypical), bullous erythema multiforme, pustular drug reactions, rheumatoid neutrophilic dermatosis, bowel-associated dermatosis-arthritis syndrome, and erythema elevatum diutinum (1-3). In our case, based on the pathological examination, the differential diagnosis included neutrophilic dermatosis such as Sweet's syndrome or neutrophilic dermatosis of the dorsal hands. It is essential to exclude an infectious etiology that might include a bacterial infection, or less likely a fungal or atypical mycobacterial infection, given the lack of any granulomatous component. However, some atypical mycobacterial infections can demonstrate a brisk neutrophilic infiltrate and relatively sparse granulomatous responses (6). For the same reason (lack of significant histiocytes), we thought that palisaded neutrophilic and granulomatous dermatosis associated with connective tissue disease was less likely. The relationship between this disease entity and a superficial variant of pyoderma gangrenosum remains unclear. The treatment of NDDH includes systemic corticosteroids, dapsone, methotrexate, potassium iodide, colchicine, and minocycline (2). NDDH is often misdiagnosed as an infectious condition, which can result in inappropriate antibiotic therapy, surgical debridement, and even amputation (7). Therefore, early diagnosis and initiation of appropriate treatment should be mainstay of its treatment.

Efficacy of viable BCG vaccine paste in the treatment of common warts: a double-blind randomized control trial.

BACKGROUND: Treatment of common warts may be painful or leaves scars, mainly using traditional destructive methods. This study aimed to evaluate the efficacy of the viable Bacillus Calmette-Guérin (BCG) vaccine in paste formula as an immunotherapeutic modality for common warts treatment. METHODS: This double-blind and randomized, parallel-group, placebo-controlled trial was conducted at the Ahvaz Imam Hospital Dermatology Department from November 2014 to 2015. Overall 80 patients with common warts in two groups (case and control) received BCG vaccine paste once weekly for eight consecutive weeks. Follow-up was done every two weeks during treatment and six months after the treatment to evaluate recurrence in patients with complete resolution. RESULTS: In group A, eight patients (20%) had a complete response, 15 patients (37.5%) partial response, four patients (10%) low response, and 13 patients (32.5%) no response (p < .001). All patients in group B had no response to treatment (p < .001). After six months of follow-up, no recurrence was seen. Duration of disease less than 12 months (p = .001) and the number of lesions less than three (p = .01) were determining factors of response to treatment. CONCLUSION: Topical BCG vaccine paste was an effective treatment for common warts, without recurrence and significant complications.

An evaluating of the relationship between body image, body satisfaction, depression, marital quality, and self-esteem in patients with psoriasis.

Psoriasis is a chronic skin condition that is associated with psychological disorders and can have a negative impact on the individual, family, and social aspects of affected people. The aim of this study was to determine the relationship between body image and satisfaction, depression, marital quality, and the mediating role of self-esteem in patients with psoriasis.This study is a correlational path-analysis has conducted on patients with psoriasis. A total of 165 patients were selected using a convenience sampling method for 6 months. Data collection was carried out using Fisher's Body Image Scale, Suoto and Garcia's Body image satisfaction Questionnaire, Rosenberg's Self-Esteem Questionnaire, Quality of Marriage Index (QMI), Depression subscale psychiatric Symptom Check-List 90, and a demographic questionnaire. Descriptive tests, Pearson correlation coefficient and path analysis were used to evaluate of the model.The mean age of patients was 36.62 ± 9.5. Based on the path analysis of eight direct paths, three following paths were not significantly related to each other and thus excluded from the model: body image-depression, body image-marital quality, and body satisfaction-marital quality (P>0.05). Another five paths were significant (P<0.05). The results of this study can help healthcare to providing a better intervention to patients with psoriasis.

Lower Lip Plexiform Schwannoma: Report of a Rare Case and a Literature Review.

Plexiform schwannoma is an uncommon benign neoplasm of the neural sheath characterized grossly and microscopically by multinodular growth. It is typically presented as a mobile, solitary, smooth-surfaced, and nontender mass. Histologically, schwannomas are classified into the following seven types: classical (Verocay), plexiform, cellular, cranial nerve, melanotic, degenerated (ancient), and granular cell schwannomas. In spite of the fact that plexiform schwannoma commonly occurs in the head-and-neck region, the involvement of the lip is considered to be extremely rare. Herein, we present the case of a 16-year-old boy with the schwannoma on the lower lip excised without any recurrence at 9 months after surgery.

Wound healing effects of topical Vitamin K: A randomized controlled trial.

BACKGROUND: The incidence of acute and chronic wounds has rapidly increased which treatment remains as health problem. Previously, we reported the healing effect of Vitamin K in experimental animal models. The aim of this study was to investigate the effects of topical Vitamin K on skin wound healing process in patients. MATERIALS AND METHODS: Sixty-three patients with indication for high-frequency electrocautery were enrolled in this randomized controlled trial. The patients were divided randomly into three groups. All the patients underwent high-frequency electrocautery treatment. Then, the patients in the A group received 1% Vitamin K cream, the patients in the B group received 1% phenytoin cream. Furthermore, the patients in the control group received Eucerin. The wound status (width and the time of recovery) and complications in the three groups were evaluated 2 weeks after procedure by a dermatologist. RESULTS: The effects produced by the topical Vitamin K showed a significant (P < 0.05) healing when compared with Eucerin group in parameters such as wound contraction and time to full recovery. Moreover, the healing time did not differ between phenytoin and Vitamin K groups (P = 0.16). CONCLUSION: A randomized, controlled trial suggests that topical application of Vitamin K significantly reduces healing time in patients.

Comparison of the efficacy of intradermal injected tranexamic acid vs hydroquinone cream in the treatment of melasma.

BACKGROUND: Melasma is a common benign acquired pigmentary dermatosis due to a disorder in the function of the melanogenesis process. Although several treatments are currently used, it remains a great challenge. AIM: The aim of this study is to compare the efficacy of intradermal injected tranexamic acid (TA) vs hydroquinone (HQ) cream in the treatment of melasma. MATERIALS AND METHODS: In this prospective split face controlled clinical trial, 49 patients were randomly divided into two groups of A (24 persons) and B (25 persons). Patients received TA intradermal injections every 2 weeks on the right side of the face with a concentration of 4 mg/ mL in group A and a concentration of 10 mg/mL in group B. The left side in both groups was treated twice daily with topical 4% HQ cream, and treatment continued for 12 weeks in both groups. Melasma Area and Severity Index (MASI) scores were measured for each side of the face at baseline and at weeks 4, 8, 12, and 24. SPSS, version 22, P<0.05, was used for data analysis. RESULTS: Forty-one patients (21 in group A and 20 in group B) completed the study. The MASI score in the 12th week significantly decreased compared to the baseline for group A, group B, and HQ cream. However, no statistically significant difference was observed between the MASI score of patients in groups A and B. Also, the comparison of TA at the concentration of 4 mg/ mL compared to the 4% HQ cream showed that the MASI scores in the eighth week (P=0.02) and the 12th week (P=0.02) were significantly less in the HQ group. However, no significant difference was observed between the MASI score changes in Group B (10 mg/mL) and the 4% HQ group. Also, patients in group A had higher satisfaction than patients in group B (P=0.001). CONCLUSION: Injection of TA intradermally can be an effective treatment for melasma.

Basal Cell Carcinoma of Vermilion Mucosa of Upper Lip: a Rare Case Report.

Although basal cell carcinoma (BCC) is a common skin tumor, very rare cases of BCC arising from upper vermilion mucosa of lip have been reported previously. This tumor basically, originates from pillar structures and the involvement of the vermilion lip contrasts this concept so it is devoid of hair follicles and sweat glands. The exact pathogenesis of vermilion lip BCC is not clear but it has been postulated that the neoplasm originates from the pluripotential epithelial cells of the oral mucosa and epidermis. On the other hand, some authors consider their origin from ectopic sebaceous glands. Herein, we report a 34- year-old man with an asymptomatic ulcerated lesion on the upper left lip vermilion mucosa .The diagnosis of BCC was confirmed with histopathological examination after incisional biopsy of the mucosal neoplasm. After surgery of lip lesion, no recurrency was seen after 3 months follow-up the patient.

Treatment modalities of palmoplantar lichen planus: a brief review.

Palmoplantar lichen planus is a localized and uncommon variant of lichen planus which is mostly resistant to treatment. Our purpose was to discuss all treatment modalities proposed and tested for palmoplantar lichen planus in the literature. A systematic review of the literature was conducted to evaluate evidence regarding all treatment modalities proposed and tested for palmoplantar lichen planus in the literature. Two major databases (PubMed, Google scholar) were searched. The review included all case reports, letters and original articles reporting any treatment for palmoplantar lichen planus but not treatment used in the other type of lichen planus, generalized lichen planus or other type of palmoplantar dermatoses. We have gone over more than 50 articles. There are many drugs that have been used in the treatment of lichen planus and generalized lichen planus but the palmoplantar type is a rare variety of lichen planus. That is why we could not find any clinical trial on the subject and just case reports have been described in this manuscript. In spite of plentiful investigations carried out on lichen planus, there is no treatment modality that has proved to be utterly satisfactory in treatment of palmoplantar lichen planus.

Adult Variant of Self-healing Cutaneous Mucinosis in a Patient with Epilepsy.

A 52-year-old woman was admitted with a 3 weeks history of periorbital edema and lips swelling. She developed several subcutaneous firm erythematous papules and nodules on the face, scalp and two indurated plaques on the upper back and left forearm. These lesions grew rapidly. The patient had a positive history of epileptic seizures since childhood. General examination was normal. There was a mild pitting edema on her hands and feet. Laboratory data were within normal limits. Histopathological examination revealed a well circumscribed accumulation of mucin in the dermis. Alcian blue stain was positive. Clinical and histopathological findings followed by spontaneous resolution of the lesions within a period of 4 months was compatible with diagnosis of self-healing cutaneous mucinosis. Herein we report the first case of self-healing cutaneous mucinosis associated with epilepsy.