Disease burden, clinical management and unmet treatment need of patients with moderate to severe alopecia areata; consensus statements, insights, and practices from CERTAAE (Central/Eastern EU, Russia, Türkiye AA experts) Delphi panel.

Objectives: This study aims to update the understanding of Alopecia Areata (AA) in Poland, Czechia, Russia, and Türkiye, focusing on the disease burden, clinical management, and patient journey. It seeks to establish a consensus on optimal management strategies for AA in these regions. Methods: A modified 2-round Delphi panel was conveyed with 23 Dermatologists (Russia; 4, Türkiye; 7, Poland; 6, and Czechia; 6). The Delphi questionnaire consisted of 61 statements and 43 questions designed to obtain an overall understanding of the perception and acceptance of available information regarding the care of patients with alopecia areata. Results: The study revealed that moderate-to-severe AA significantly impacts patients' and their families' QoL, consistent with previous studies. AA was found to cause more substantial impairment when additional lesions appeared in visible areas besides the scalp. Work and productivity impairment were notably higher in adults with moderate-to-severe AA. Diagnostic consensus highlighted the importance of skin biopsies and trichoscopy, while the need for more practical severity scoring systems was emphasized. Current treatments, including topical therapies, corticosteroids, and systemic immune modifiers, were deemed insufficient, highlighting the unmet medical need. Conclusion: The Delphi study underscores a significant disease burden and unmet medical needs in patients with moderate-to-severe AA. It highlights the necessity of access to novel treatments and further research to develop more effective therapies with a tolerable safety profile. The findings align with global research, emphasizing the psychosocial impact of AA and the need for standardized, effective treatment protocols.

Comparison of Survival and Retention Rates between Infliximab and Adalimumab for Psoriasis: 10-Year Experience at a Single Tertiary Center.

BACKGROUND: Ten-year survival and retention rate data on biologics are extremely limited, and there is a need to evaluate these metrics based on real-world data as well as on the results of clinical studies. OBJECTIVE: The objective of this study was to assess the long-term survival rates of adalimumab and infliximab in real-life practice. METHODS: This study is based on data from the Turkish Psoriasis Registry and the digital records of the Medical School of Bezmialem Vakif University. Baseline data including demographic characteristics, duration of treatment, use of combination treatments, modified regimens, and reasons for treatment termination were extracted. RESULTS: In total, 404 patients (228 on adalimumab and 176 on infliximab) treated between July 1, 2005, and December 31, 2020, were identified. The retention rate was 7.4% for infliximab and 3.5% for adalimumab after 10 years (p = 0.85). CONCLUSIONS: The efficacy of infliximab and adalimumab diminishes over time. There were no significant differences in the retention rate between the two drugs, but the survival time was longer for infliximab according to Kaplan-Meier analysis.

Clinical and histopathological improvement of scleromyxedema-induced microstomia after hyaluronidase injection.

INTRODUCTION: Scleromyxedema is a rare primary cutaneous mucinosis characterized by numerous firm, waxy, confluent papules. Recently, intravenous immunoglobulin (IVIG) is accepted by many authors as the first-line treatment option for severe cases. We report a 69-year-old male patient who has been suffering from scleromyxedema, with reduced mouth opening. He has been on a high-dose IVIG regime for 5 years. METHODS: The patient stated that he had difficulty in wearing and removing his dentures because of reduced mouth opening lately. Before considering to add any other immunosuppressants to his regime, we injected 1500 IU of hyaluronidase in total in one session periorally. The patient has been told open his mouth maximum and photographs have been taken before injections and after one month. We used a photo measurement application when evaluating microstomia to increase accuracy. We also took punch biopsies in order to evaluate effect of hyaluronidase histopathologically before and one month after injections. RESULTS: One month later, he was able to reattach and remove his dentures without adding any adjuvant immunosuppressants other than hyaluronidase. Mouth opening was increased in measurements and histopathologically, mucin deposition, fibroblastic proliferation, and perivascular lymphocytic infiltration were decreased. CONCLUSIONS: We think hyaluronidase is a safe, easily accessible, and effective treatment option for microstomia caused by scleromyxedema.

Effects of TNF inhibitors and an IL12/23 inhibitor on changes in body weight and adipokine levels in psoriasis patients: a 48-week comparative study.

BACKGROUND: Psoriasis is a chronic inflammatory disease associated with obesity and metabolic syndrome. Adipokines are thought to be a link between psoriasis and obesity. Leptin, adiponectin, and omentin are bioactive adipokines thought to play a role in both metabolic comorbidities and inflammation. Anti-tumour necrosis factor alfa (anti-TNF-α) agents are effective for psoriasis treatment, although significant weight gain has been reported during anti-TNF-α therapy. The interleukin 12/23 (IL 12/23) inhibitor ustekinumab is also effective for psoriasis treatment. We compared the effects of three anti-TNF-α drugs and an IL-12/23 inhibitor on adipokines and weight gain during treatment. PATIENTS AND METHODS: This prospective study included 80 patients (37 women, 43 men) with moderate to severe plaque psoriasis whose age and weight were matched. The patients were divided into four equal groups: etanercept, infliximab, adalimumab, and ustekinumab treatment groups. Psoriasis Area Severity Index (PASI) score, body weight (muscle and fat compartments), and leptin, adiponectin, and omentin levels were evaluated at baseline and weeks 4, 12, 24, and 48 of treatment. RESULTS: There were no differences between drug groups in terms of weight parameters or biochemical parameters at baseline. At the end of 48 weeks, there was significant weight gain in the adalimumab group. Patients who received infliximab showed significant weight gain by week 12, but in the following weeks they returned to their initial weight. Body weight reached a maximum level by week 12 in patients using etanercept, but they lost weight in the following weeks and finished the study below their initial weight. Patients using ustekinumab did not demonstrate significant weight change during the 48 weeks except at week 12. At the end of week 48, PASI75 (improvement in PASI ≥75%) response rates were approximately 85% for the ustekinumab group, 80% for the adalimumab group, 75% for the infliximab group, and 50% for the etanercept group. Leptin, adiponectin, and omentin levels were higher in the ustekinumab group at all weeks except baseline. The lowest levels were observed in the etanercept group. The treatment response rate was also lower in the etanercept group. LIMITATIONS: We did not evaluate visfatin and resistin levels, insulin sensitivity, and cardiovascular risk that may be associated with weight gain and adipokine levels. CONCLUSIONS: Unlike TNF inhibitors, ustekinumab does not cause significant weight changes and it increases adipokine levels more than TNF inhibitors. Adipokine levels seem to be related to the treatment response.

Demographic characteristics, treatment, and outcome of patients with Kaposi sarcoma: Ten-year follow-up results of a single center.

BACKGROUND: Clinical features, types of Kaposi sarcoma, and treatment outcomes have not been well-defined in Turkey. In this study, we reviewed records of the patients who had been diagnosed with Kaposi sarcoma in the last decade in a single center and evaluated treatment results. METHODS: Medical records of the Kaposi sarcoma patients seen in the last decade in a single tertiary center were evaluated in detail. RESULTS: A total of 27 patients were identified; 18 patients had been checked for HHV8; and 16 of those patients were positive for HHV8. One patient was positive for HIV. Two patients having mycosis fungoides and myasthenia graves developed iatrogenic KS after immunosuppressive treatments. Interferon α was used in 21 patients; 8 patients achieved complete response; and 11 patients achieved a partial response. No serious side effects were observed. Systemic involvement did not develop in any patients except lymph node involvement in a patient with widespread skin lesions.

Do nonobese patients with Behçet's disease have insulin resistance?

BACKGROUND: Some studies have investigated the relationship between Behçet's disease (BD) and insulin resistance; however, since they did not exclude obese patients from their sample, it remains unclear whether BD itself causes insulin resistance independently of obesity. METHODS: The study included 60 patients with BD and 45 age-, gender-, and body mass index (BMI)-matched healthy controls. Obese patients with a BMI of ≥30 kg/m² were excluded. Insulin resistance according to the homeostasis model assessment for insulin resistance (HOMA-IR) and quantitative insulin sensitivity check index (QUICKI), fasting plasma glucose, and one-hour and two-hour plasma glucose in the oral glucose tolerance test (OGTT 1-h and OGTT 2-h PG, respectively) were evaluated in all patients. RESULTS: The mean fasting plasma glucose levels and the rate of those with impaired glucose tolerance according to OGTT 2-h PG were significantly higher in the BD patients compared to the controls. The rates of those with insulin resistance according to HOMA-IR and QUICKI were significantly higher in the BD patients than in the controls. When compared to the control group, the rates of those with impaired fasting glucose and impaired glucose tolerance were significantly higher, and the mean QUICKI value was significantly lower in the active group, in contrast to the inactive group. CONCLUSIONS: Insulin resistance occurs in BD patients independently of obesity. In the follow-up of BD patients, especially in the active phase, not only fasting blood glucose but also other diagnostic tests for insulin resistance should be added to the examination panels.

A generalized pustular psoriasis flare after CoronaVac COVID-19 vaccination: Case report.

CoronoVac is a non-viable vaccine for severe acute respiratory syndrome coronavirus 2 (SARSCoV-2). Nowadays, there has been vaccination program for at-risk groups and older adults in Turkey. We here present 72-year-old male psoriasis patient who developed generalized pustular psoriasis flare after administration of CoronoVac. The COVID-PCR test was negative and investigations for flare etiology were all normal. He was first (to the best of our knowledge) psoriasis patient who developed an erythrodermic flare after the first dose of CoronaVac vaccine.

Retention and survival rate of etanercept in psoriasis over 15 years and patient outcomes during the COVID-19 pandemic: The real-world experience of a single center.

There have been a number of investigations of the efficacy and safety of etanercept. This study was performed to obtain long-term drug survival data (ie, time to drug discontinuation) for etanercept, and the reasons for its discontinuation. The study population consisted of patients with psoriatic arthritis and psoriasis followed up by our clinic, registered in the Turkish Psoriasis Registry (PSR-TR) and treated with etanercept for at least 4 weeks between January 1, 2005, and January 31, 2020. The efficacy of etanercept was evaluated in terms of the Psoriasis Area and Severity Index (PASI) 75, PASI 90 and PASI 100 response rates at 12, 24, 36, and 48 weeks, and annually thereafter. The behaviors of the patients with respect to the use of etanercept, and the outcomes of those who continued to use it during the COVID-19 pandemic, were also investigated.

Prognostic factors of patients with mycosis fungoides.

INTRODUCTION: Mycosis fungoides (MF) is the most common type of primary cutaneous T-cell lymphoma. Prognostic factors may help to evaluate the course of the disease and may also be useful in selecting appropriate treatment plans for patients. AIM: To investigate the potential prognostic factors of MF and their correlations with MF stage. MATERIAL AND METHODS: We evaluated the records of patients with MF who were followed in our lymphoma clinic between 1998 and 2015. Age, sex, disease stage, peripheral blood eosinophilia, eosinophil cationic protein, serum total IgE, lactate dehydrogenase (LDH), and ß2-microglobulin levels were investigated and recorded at the time of diagnosis. RESULTS: There was a statistically significant positive correlation between high ß2-microglobulin levels and the advanced stage of disease (p < 0.001). The older group of patients had statistically significantly higher levels of ß2-microglobulin compared to the younger group (p = 0.001). We found strong, significantly positive correlations between disease stage and ß2-microglobulin, LDH, and total IgE levels (p < 0.001, rho = 0.335; p = 0.001, r = 0.302; p = 0.001, r = 0.311, respectively). Additionally, there were significantly positive correlations between LDH levels and ß2-microglobulin, total IgE levels (p < 0.001, rho = 0.484; p = 0.001, r = 0.212, respectively). Study limitations: A limited number of patients and the retrospective nature of the study. CONCLUSIONS: We found that ß2-microglobulin was a significant prognostic factor in our study population of MF patients. Also, elevated LDH, ß2-microglobulin, and total IgE levels were correlated with advanced disease. Thus, these parameters can be used together to identify patients who have progressed to the later stages of the disease and who require more aggressive treatment.

Challenges in early diagnosis of primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma: a case series of four patients.

BACKGROUND: Primary cutaneous aggressive epidermotropic CD8+ cytotoxic T-cell lymphoma (AECTCL) is a rare and aggressive lymphoma characterised by ulcerated lesions and a poor prognosis. OBJECTIVES: To present a case series of four previously misdiagnosed AECTCL patients and discuss the importance of early diagnosis. MATERIALS AND METHODS: All patients in this study were identified from the database of the Dermatology Department of the Medical School of Bezmialem Vakif University, based on clinical and histopathological diagnosis of AECTCL between 2010 and 2018. RESULTS: AECTCL cases may mimic many benign dermatoses and accurate diagnosis may be delayed. CONCLUSION: Because of its poor prognosis, early diagnosis of AECTCL may be helpful in improving the likelihood of patient survival, but further study is needed to address the challenges in diagnosing this rare and aggressive lymphoma.

The effect of at least 1-year use of omalizumab without interruption on relapse in patients with chronic spontaneous urticaria.

It is known that omalizumab (OMA) is an effective and safe treatment option in the treatment of chronic spontaneous urticaria (CSU). In the literature, there are vary studies about effect of OMA treatment in CSU such as different response rates to treatment, different dose / time regime and different relapse rates after treatment. To investigate the evaluate the effect of at least 1 year continuous OMA treatment on relapse in CSU patients. Fifty patients were included in this study. There was a significant decreased between UAS7 score before and after OMA treatment. There was no significant difference between the sixth and 12th month after OMA for UAS 7 scores. At the end of 12 month,84% of patients had complete or good response to OMA treatment. Twenty-three of 34 patients (67.6%) who discontinued treatment had relapse and 11 patients had no relapse. Duration of disease was significantly higher in patients who had relapse. Based on our study result we suggest that long disease duration may increase the risk of relapse. Although it is not statistically significant, without interruption OMA treatment for more than 1 year may decrease relapse risk in patients who respond well to the therapy.

Which dermatology patients attend to Dermatology Outpatient Clinics during the SARS-CoV-2 outbreak in Turkey and what happened to them?

Coronavirus disease, first emerged in Wuhan, rapidly spread all over the world since December 2019. There are concerns about elective dermatology appointments and its results. Herein, we aimed to find out which type of dermatologic patients attended to dermatology outpatient clinic. The patients visiting the clinics for elective dermatologic diseases between March 11 and 18, 2020, were included in this study. Their age, sex, diagnosis of disease, requirement for emergent intervention, and their medical records about COVID-19 were obtained. There were 390 patients attending to the dermatology outpatient clinic in this period. The most common disease was acne (N: 94, 24%), only 19% of patients need emergent interventions or dose adjustment. There were 40 (10%) patients over the age of 65. After their visits, five patients were diagnosed as COVID-19 in 2weeks. Dermatologic examinations may be a vector for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission since being closed to the patient. Five of our patients were diagnosed as COVID-19 after their elective visit to hospital. Since the asymptomatic course of some young patients, most of our patients were not screened for COVID-19. Our findings support the concerns of elective physician examinations.

Is rituximab therapy a risk factor for development of melanoma?

In the literature, there are reports about dermoscopic and size changes of nevi in patients undergoing biologic therapy and chemotherapeutics. There has not been any established data for melanoma and Rituximab therapy. Sixteen patients, with 94 nevi were included in this study. Dermoscopic images of follow-up visits, which were performed at baseline, 3, 6, and 12 months after treatment, were evaluated. Suspicious lesions were excised. There was no increase in total nevus count. Although 61.7% of the 94 nevi have shown a stable duration without size changes, 26.5% had enlarged, and 11.7% had become smaller during our 1-year experience of dermoscopic monitoring. There was not any pattern transformation. Atypical dots and clods appeared in 17% of nevi. All of the excised nevi were comparable with Clark nevi, there was no clue for melanoma development. According to our results, we found that Rituximab therapy influences nevus morphology, but there is no evidence that this was linked to melanoma development.

Three years dermoscopic follow-up of atypical nevi.

Atypical nevi are dynamic lesions and may progressively transform into more or less atypical lesions. We aimed to investigate the dermoscopic features of atypical nevi and dynamic changes in these lesions over a period of 3-years. Patients with 3-year dermoscopic follow-up records were enrolled in the study. We compared the dermatoscopic features of the nevus recorded in the first dermoscopic examination and at the end of the third year. Changes in size (mm), pattern, and color were investigated. The most common dermoscopic patterns were reticular (18 patients; 34%), reticular-homogeneous (17 patients; 32.1%), and reticular-globular (7 patients; 13.2%). The most common pigmentation patterns were central hyperpigmentation (28 patients; 52.8%), regular pigmentation (nine patients; 17.0%), and multifocal hypo/hyperpigmentation (eight patients; 15.1%). Twenty-one (39.6%) patients showed changes in pattern. The transformation from reticular-homogeneous pattern to the homogeneous pattern was the most frequent change in pattern (7 of 21 patients; 33.3%). The transformation from reticular pattern to reticular-homogeneous pattern was the second most common change in pattern (5 of 21 patients; 23.8%). Fourteen (26.4%) patients experienced symmetrical enlargement. Symmetrical enlargement was statistically more frequent in patients who showed dermoscopic changes in pattern than in those who did not show any changes in the pattern (p: .038). In this study, we did not observe any new dermoscopic clues for the diagnosis of melanoma during the follow-up. The nevi tended to turn into a homogeneous (structureless) pattern. We observed that the most common dermoscopic change in pattern was the transformation from reticular-homogeneous pattern to homogeneous pattern, and the lesions had symmetrical enlargement during this transformation. In conclusion, despite the known association between atypical nevi and the risk of developing melanoma, most atypical nevi do not transform into melanoma. Therefore, our study suggests that the excision of atypical nevi is not necessary and dermatoscopic follow-up can reduce the number of unnecessary excisions.

The HLA-Cw12 Allele Is an Important Susceptibility Allele for Psoriasis and Is Associated with Resistant Psoriasis in the Turkish Population.

BACKGROUND: Psoriasis is a multifactorial immune-mediated inflammatory disease triggered by both genetic and environmental factors. The strong association between psoriasis and HLA-C⁎06 allele has been demonstrated in various races. The HLA-C⁎12 allele is closely related to the HLA-C⁎06 family of alleles and shares identical sequences. To the best of our knowledge, there is no information about the relationship between HLA-C⁎12 and psoriasis in the Turkish population. The present study aims to determine this relationship. METHODS: This case control study involved 150 patients with plaque-type psoriasis and 145 age- and gender-matched healthy individuals. Severity of psoriasis was measured using the PASI scores of all patients and joint involvement was investigated with CASPAR criteria. HLA-C alleles were determined with a Tepnel-Lifecodes system. RESULTS: HLA-C⁎06, HLA-C⁎12, and HLA-C⁎04 alleles were most commonly observed in psoriasis patients. HLA-C⁎06 and HLA-C⁎12 were significantly more frequent in the psoriasis group. HLA-C⁎06 was 4.11 times more common in psoriasis patients. An increase in PASI (Psoriasis Area Severity Index) scores was compatible with HLA-C⁎12 positivity. A need for systemic treatment was highly noticeable in patients with the HLA-C⁎12 allele. CONCLUSIONS: HLA-C⁎12 was found as the second most frequent allele with psoriasis in Turkish population and was associated with severe psoriasis. Our study is limited as we could not investigate other potentially related alleles other than HLA-C alleles and risk factors increasing severity of psoriasis.

A rare and severe cutaneous adverse effect of telaprevir: drug rash with eosinophilia and systemic symptoms.

Telaprevir is a specific inhibitor of the hepatitis C (HCV) serine protease 3. Cutaneous side effects have been reported with telaprevir. Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare yet severe adverse drug-induced reaction characterized by exfoliative dermatitis and maculopapular rash, lymphadenopathy, fever, eosinophilia, leukocytosis, and myriad internal organ involvement. We report a case of DRESS due to telaprevir. A 64-year-old Caucasian man with chronic hepatitis C developed a progressive diffuse, painful maculopapular exanthema with fever, facial edema, lymphadenopathy at week 11 of chronic hepatitis C therapy with telaprevir, Peg-Interferon alfa-2a, and ribavirin. He had no exposures to any other medications. He presented an eosinophilia (up to 6.29 X 109 cells/L), skin biopsy was consistent with a drug reaction. The HCV treatment was stopped and methylprednisolone 0.75 mg/kg/day was started. Cutaneous and systemic symptoms had a rapid resolution in few days. Telaprevir can activate severe skin reactions that can mimic an infectious disease, therefore early diagnosis and discontinuation of chronic hepatitis C treatment is mandatory.

Dermoscopic Evolution of Pediatric Nevi.

BACKGROUND: The incidence of pediatric melanoma is very rare. Dermoscopic features help to distinguish pediatric melanoma and common nevi. OBJECTIVE: To study the evolution of dermoscopic findings in benign nevi in childhood through serial observation and photography. METHODS: We examined 504 melanocytic lesions in 100 patients. From each participant, dermoscopic images of the nevi from 4-year dermoscopic follow-up were obtained, including randomly selected nevi. RESULTS: The most common dermoscopic patterns were homogeneous (193 nevi; 38.3%), globular (92 nevi; 18.3%), and reticular (86 nevi; 17.1%). Dermoscopic pattern changes were detected in 27% of patients aged 2~10 years and in 20% of patients aged 11~16 years. The main pattern changes consisted of the transition from homogeneous to globular-homogeneous (16%), from homogeneous to reticular-homogeneous (12%) and from globular to globular-homogeneous (10%). Although 257 of the 504 nevi (51.0%) have stable duration without size changes, 169 of the 504 nevi (33.5%) were enlarged, and 78 of the 504 nevi (15.5%) had become smaller. CONCLUSION: These results contrast with the prevailing view that dermoscopic patterns in pediatric nevi are usually characterized by globular patterns and that melanocytic nevi generally undergo a characteristic transition from a globular pattern to a reticular pattern. Fifty one percent of patients did not exhibit a size change. While 33% of patients had symmetrical enlargement, 15% of patients had involution. Therefore, enlargement is a common dermoscopic change in pediatric nevi, and is not a specific sign of pediatric melanoma.