Gliptin-induced bullous pemphigoid.

OBJECTIVES: Bullous pemphigoid (BP) is a rare, autoimmune, blistering disease in elderly patients that can be triggered by external factors including drugs. Drug-induced bullous pemphigoid (DIBP) does not always follow a self-limiting course after the withdrawal of the offending drug. Dipeptidyl peptidase-4 (DPP-4) inhibitors or gliptins seem to be associated with a significant risk of inducing BP. CASE PRESENTATION: We report 2 cases of BP attributed to the DPP-4 inhibitor linagliptin. In both cases, the clinical manifestation was strongly suggestive of BP. The diagnosis was verified by histology and direct immunofluorescence (DIF). Linagliptin and all other possible drug triggers of BP were discontinued after consultation with an endocrinologist and a cardiologist. Systemic treatment of BP consisted of methylprednisolone and tetracycline. During the follow-up period, one of the patients suffered a fatal brain stroke while the other was managed with reduced doses of corticosteroids. CONCLUSION: The proper management of autoimmune bullous skin disorders in elderly patients includes a scrupulous assessment of plausible drug triggers. Systemic corticosteroids for treating severe cases of DIBP can worsen concomitant diseases which often necessitates multidisciplinary care.

Serum concentrations of 25-OH vitamin D and the pro-inflammatory interleukins IL-17, IL-23, and IL-18 in patients with plaque psoriasis.

AIMS: The present study aimed to assess vitamin D status and serum concentrations of pro-inflammatory cytokines IL-17, Il-23, and IL-18 in patients with chronic plaque psoriasis and their association with various demographic and clinical characteristics. METHODS: The study was conducted during the autumn/winter period on 48 patients with chronic plaque psoriasis and 48 controls. Total serum 25(OH)D level was determined with Roche Elecsys® 2010 Vitamin D total assay. Commercial ELISA kits were used for quantifying the serum levels of IL-17A, IL-18, and IL-23. RESULTS: Serum 25(OH)D had a median value of 16.95 ng/mL (IQR 10.8-23.50) for patients with psoriasis and 18.80 ng/mL (IQR 15.45-25.85) for the control group (P=0.09). A moderate negative correlation was found between PASI score and 25(OH)D levels (rs=-0.34; P=0.02). The serum levels of IL-17 (P=0.001), IL-23 (P=0.01) and IL-18 (P=0.02) were significantly higher in the patient group compared to controls. IL-17 concentrations were higher in patients with moderate to severe psoriasis compared to patients with mild psoriasis (P=0.003). No significant correlations were detected between the serum concentrations of 25(ОH)D and IL-17, IL-23, and IL-18. CONCLUSION: It was confirmed that IL-17 serum level is associated with psoriasis severity. Measurement of 25(OH)D serum concentration can be useful in patients with moderate to severe psoriasis with or without comorbidities. A direct association between 25(OH)D serum concentration and the serum concentrations of IL-17, IL-23, or IL-18 was not identified in this study.

Hidradenitis suppurativa from the typical patient to the new clinical phenotypes.

Hidradenitis suppurativa (HS) is a clinically heterogeneous disease with a broad spectrum of clinical features. Attempts to classify HS into distinct clinical phenotypes could lead to a better understanding of the condition and the development of individualized treatment protocols. We summarize some of the existing phenotype classifications and present our experience with 250 patients and their many clinical presentations. We have emphasized the pathophysiologic and clinical overlap between HS and pyoderma gangrenosum. The more severe presentations can include erosive and ulcerative lesions, sometimes associated with vegetative changes leading to diagnostic quandaries. We propose a new phenotype of pyoderma gangrenosum-like HS in which painful ulcerative or vegetative lesions appear in sites affected by HS, their activity coincides with the flareups of classic inflammatory manifestations of HS, and they heal with cribriform or atrophic scars.

Dietary supplements - use and safety perception: A study among hospitalized dermatology patients.

OBJECTIVES: Evidence suggests that the use of dietary supplements in patients with various disorders is growing. The study aims to examine the use of drug supplements in patients with dermatological disorders, regarding their type, the reasons and predictors of their use, and the safety beliefs and communication attitude of users. MATERIALS AND METHODS: A cross-sectional study of patients hospitalized in the Clinic of Dermatology and Venereology at the University Нospital in Stara Zagora, Bulgaria, was carried out from October 2018 to December 2019. Data were collected using a specially designed and validated questionnaire. Statistical analysis included the χ2-test, the Mann-Whitney U test, and logistic regression. RESULTS: Overall 348 patients (204 females and 144 males) were involved in the study. The patients who reported having used dietary supplements were 67% of the study population. Various combinations ranked first among the dietary supplement types, and vitamins/minerals presented a substantial part (75.9%). The majority of the patients (61.6%) used dietary supplements for more than one reason, mainly for organ-related disorders. Most of the respondents (76.4%) considered them to be completely safe. Higher education (OR = 1.91; CI: 1.14 - 3.19), being a non-smoker (OR = 1.81; CI:1.14 - 2.88), and sporting activities (OR = 1.71; CI: 1.03 - 2.83) increased the odds of using dietary supplements. CONCLUSION: The examined cohort of dermatology patients presented a dietary supplement user profile similar to the general population. The study confirmed that these products are considered to be safe by the majority of participants. Factors indicative of a healthy lifestyle and higher education were predictive for their use.

Epidermal barrier and oxidative stress parameters improve during in 311 nm narrow band UVB phototherapy of plaque type psoriasis.

BACKGROUND: Psoriasis is a multi-systemic inflammatory disease that results from dysregulation between epidermal keratinocyte homeostasis and both innate and acquired immunity. Epidermal barrier defect has been described in psoriatic lesions. Furthermore an imbalance between pro-oxidative stress and antioxidant defense mechanisms are known in psoriasis patients. AIM: The aim of this study was to address the link between disease activity, epidermal barrier and systemic oxidative stress in the course of 311 nm narrow band ultraviolet B (NB-UVB) therapy of psoriasis. The dynamic of systemic oxidative stress parameters as well as local transepidermal water loss (TEWL) and stratum corneum hydration (SCH) was characterized before and after 311 nm NB-UVB therapy on the plaques of psoriasis vulgaris in comparison to untreated non-affected volar forearm sites of the same patients. MATERIAL AND METHODS: 22 patients with plaque type psoriasis vulgaris and 25 gender- and age-matched healthy controls were enrolled. We assessed the psoriasis area and severity index (PASI) and the dermatology life quality index (DLQI) for monitoring disease activity, severity and self-perceived DLQI impact as patient related outcome parameter. We measured non-invasively TEWL (Tewameter TM 300) and SCH (Corneometer CM 825) and the end product of lipid peroxidation - malondialdehyde (MDA), Reactive oxygen species (ROS), ascorbyl radicals (Asc) and detoxifying activity of catalase (CAT) were measured in the peripheral blood with spectrophotometric and EPR spectroscopy methods. RESULTS: Disease activity improved in all patients compared to baseline witnessed by significant decrease in PASI; (from 14.1 to 10.4; p < 0.0001) and DLQI (from 11.7 to 8.1; p < 0.0001). At baseline TEWL-values were significantly (p < 0.0001) higher on psoriatic plaques (16.8 g/h/m2) in comparison to uninvolved skin (5.3 g/h/m2); with a decrease at both sites after NB-UVB phototherapy. SCH was significantly lower at psoriatic plaque s (4.7AU) compared to uninvolved sskin (42.4AU) and increased after treatment (8.6AU) (p < 0.0001). Interestingly, SCH decrease slightly during therapy at uninvolved skin (40.6AU). ROS and Asc declined during therapy in parallel to a decrease in MDA. A mild decrease in the antioxidative enzyme CAT activity which did not reach the significance was observed. CONCLUSION: The presented data is shows that a clinical improvement of psoriatic plaques under NB-UVB therapy, shown in with a decreased PASI and reflected by an increase in quality of life has beneficial effects on epidermal barrier function, SCH and improvement of systemic oxidative stress parameters (ROS, MDA and Asc). We assume that the general improvement in the oxidative stress parameters along with epidermal barrier parameters reflects mainly the improvement of disease activity which overwrites the possible negative pro-oxidative effects of the UV treatment.

Clinical relevance of drug-drug interactions in hospitalized dermatology patients.

BACKGROUND: Potential drug-drug interactions (DDIs) are known to be a risk factor for the development of adverse drug reactions (ADRs). Data on the occurrence of ADRs related to DDIs is scarce and comes from different groups of patients. OBJECTIVES: The aim of the study was to evaluate the frequency, nature and determinants of potential DDIs in hospitalized dermatology patients and assess their contribution for the development of ADRs. MATERIAL AND METHODS: A prospective observational study comprising all consecutive inpatients admitted to the Clinic of Dermatology and Venereology, University Hospital, Stara Zagora for the period March 2009 - August 2011 was carried out. Systemic medication was screened for potential DDIs using an electronic drug interactions checker. DDIs were then verified with Stockley's Drug Interactions and divided into "clinically important" and "clinically unimportant". ADRs were classified by clinical manifestation, type and severity. Causality was scored according to Naranjo et al. (1981). RESULTS: The study included 674 patients, 513 (76.1%) of them with established comorbidities. Totally, 504 potential DDIs were identified (441 "clinically important" and 63 "clinically unimportant") in 236 patients. Hypotension was the most common expected clinical presentation of the potential DDIs. The strongest predictor for the development of DDIs was the number of systemic drugs (OR 2.25, 95% CI 1.97-2.58). Overall 43 ADRs were recorded, 53.5% "type B" and 46.5% "type A" reactions, most commonly with cutaneous and cardiovascular manifestations. The development of ADRs was attributed to 13 DDIs (2.6% of all detected potential DDIs) in 10 of these cases (23.25%). CONCLUSIONS: Potential DDIs were frequent in hospitalized dermatology patients. The drug groups most commonly involved were cardiovascular drugs. The proportion of DDIs associated with the occurrence of ADRs was relatively low, but close monitoring of patients on multiple drug regimens is essential because these reactions may be severe.

Carbamazepine-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: report of four cases and brief review.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare but severe drug reaction, most commonly to aromatic anticonvulsants with a delayed onset, variable clinical presentation and protracted course. The exact incidence of DRESS syndrome is not known because of the variability in clinical presentation, lack of strict diagnostic criteria and universally accepted nomenclature. We report four cases of DRESS syndrome associated with the use of carbamazepine. The clinical manifestation was similar: a maculopapular eruption progressing to exfoliative erythroderma, fever, and lymphadenopathy. Leukocytosis, atypical lymphocytes and liver injury (in 2 patients) were also observed. Assessment of causality using the Naranjo algorithm established a "probable" relationship with carbamazepine in three of the cases and a "possible" relationship in one case. Detection of DRESS syndrome is dependent on the exclusion of a variety of diseases with similar manifestations and may be delayed in time. DRESS syndrome is a potentially life-threatening multisystem adverse drug reaction, and accidental reexposure or drug provocation tests must be avoided.