Evaluation of severe adverse cutaneous drug reactions in patients admitted to tertiary care center: A cross-sectional study.

Background and Aims: Adverse cutaneous drug reactions (ACDRs) are common and potentially life-threatening, while also hindering patient compliance to medications. Given the regional differences in patterns and prevalence of ACDRs, it is important to study the epidemiology, as well as the clinical and outcome patterns of patients with ACDRs in Iran. Methods: This cross-sectional study on ACDRs was conducted among hospitalized patients in a referral university hospital in the city of Isfahan, Iran. The patients' demographics, clinical information, and outcomes, including age, gender, past medical history, medication history, drug reaction with eosinophilia and systemic symptoms (DRESS) diagnosis, Steven-Johnson Syndrome (SJS) diagnosis, toxic epidermal necrosis (TEN) diagnosis, treatment regimen (steroids or intravenous immunoglobulin [IVIG]) and outcome information, including intensive care requirements, severe medical complications, or death, were obtained from medical records. Results: A total of 195 patients with a mean age of 40 years and consisting of 61% females were included. Carbamazepine, lamotrigine, sodium valproate, and phenytoin are the most commonly reported medications. Rate of complications was 45% with DRESS, SJS, and TEN diagnosed in 26%, 47%, and 19%, respectively. Treatment was carried out with steroids and IVIG in 81% and 19%, respectively. Among patients, 15% required intensive care and 5% died. Diagnosis of TEN, older age, and baseline heart disease were predictors of mortality. Patients with SJS were younger and more likely to be males, and they were more likely to have eye complications. On the other hand, patients with the diagnosis of TEN were more likely to receive IVIG and intensive care, and had a higher mortality rate. Conclusion: Our study provides insight into the demographics and clinical patterns of Iranian patients with ACDRs. This will help in predicting rates of complications, treatments, and outcomes in patients and therefore make proper management decisions.

Comparison of the effect of topical triamcinolone 0.1% cream with sulfur 2.0% cream in the treatment of patients with hand eczema: A randomized controlled trial.

BACKGROUND: Hand eczema (HE) is a common and heterogeneous condition. It has a wide range of etiologies and clinical manifestations. In this study the efficacy of triamcinolone 0.1% cream and sulfur 2% creams was compared in treating patients with HE. METHODS: This randomized, triple-blind clinical trial was performed on 70 patients with HE (including 70 right and 70 left hands). In this study, two creams were used including triamcinolone 0.1% and sulfur 2.0%. Patients were treated with these creams twice a day (once in every 12 h) for 4 weeks. Follow-up was 4 weeks after treatment. Hand Eczema Severity Index (HECSI), itching, dryness, burning sensation, and erythema scores were collected three times during the study and compared between treatment regimens. RESULTS: Findings showed that both triamcinolone (0.1%) and sulfur (2.0%) creams could significantly reduce the scores of HECSI, itching, dryness, burning sensation, and erythema, and the therapeutic effects lasted for at least 4 weeks after cessation of topical treatment. CONCLUSION: Topical sulfur cream (2.0%) is as effective as triamcinolone (0.1%) cream in treatment of HE without any prominent adverse reactions.

Evaluation and comparison of Q-switched Nd: YAG laser 1064 nm and Er: YAG laser 2940 nm in the treatment of macular amyloidosis.

Macular amyloidosis (MA) is one of the most common types of primary localized cutaneous amyloidosis (PLCA), distributed predominantly over the trunk and extremities. Due to the vast therapeutic options, this study aims to compare the effectiveness of Q-switched Nd: YAG laser 1064 nm and Er: YAG laser 2940 nm in treating MA. This clinical trial was performed in 2020-2021 on 33 women with MA. In each patient, the lesion was randomly divided into two areas, A and B. Area A underwent four treatment sessions with 4-week intervals of Q-switched Nd: YAG laser 1064 nm. Area B underwent four treatment sessions with an Er: YAG laser 2940 nm at 4-week intervals. Degree of basal pigmentation and degree of pigmentation after treatment, pruritus intensity, before and after the treatment, and patient and physicians' satisfaction were measured and compared. The pruritus in patients improved significantly after the study (P < 0.001), but no significant differences could be observed between the two groups regarding the improvements (P > 0.05). We also found no significant differences between the two groups of patients regarding patient and physicians' satisfaction rates (P > 0.05). The use of both Q-switched Nd: YAG laser and Er: YAG laser resulted in improvements in terms of pruritus, patient and physicians' satisfaction, and total improvement in pigmentation of the lesions.

Clinical effectiveness of finasteride versus hydroxychloroquine in the treatment of frontal fibrosing alopecia: A randomized controlled trial.

BACKGROUND: Frontal fibrosing alopecia (FFA) is a cicatricial alopecia with rapid epidemic growth. However, there is no agreement on the best therapeutic approach. AIMS: To compare the therapeutic effects of finasteride as a first-line systemic treatment of FFA versus hydroxychloroquine as a relatively safe and effective immunosuppressive drug. METHODS: Thirty-four female FFA patients were randomly assigned to receive either 400 mg/day of hydroxychloroquine or 2.5 mg/day of finasteride for 6 months. Topical treatments in both groups include pimecrolimus, mometasone, and minoxidil. Treatment efficacy was evaluated using the Frontal Fibrosing Alopecia Severity Score (FFASS), photography, and trichoscopy after 3 and 6 months. RESULTS: Both the finasteride and hydroxychloroquine groups showed significant improvements in FFASS and trichoscopic scores (p < 0.01). However, there was no significant difference between the two groups during the study. Photographic assessment showed that more than 60% of patients in both groups had improved without statistically significant differences between the two groups. CONCLUSIONS: Both finasteride and hydroxychloroquine are equally effective, safe, and well-tolerable for treating FFA patients.

Clinical efficacy and safety of low-dose oral minoxidil versus topical solution in the improvement of androgenetic alopecia: A randomized controlled trial.

BACKGROUND: Topical minoxidil is the recommended first-line pharmacologic treatment for male and female pattern hair loss. However, low-dose oral minoxidil has been used off-label with good clinical efficacy and safety. AIM: To compare the effectiveness and safety of topical minoxidil as a first-choice treatment of androgenetic alopecia versus 1 mg daily oral minoxidil. METHOD: Sixty-five AGA patients were randomly allocated to receive either 5% topical solution or 1 mg/day oral minoxidil for 6 months. Treatment efficacy was evaluated by measuring hair diameter, photographic assessment, and patient self-assessment questionnaires. The safety of treatment was checked through history taking and physical examination. RESULTS: Both topical and oral minoxidil groups showed significant improvement in hair diameter after 6 months of treatment (p < 0.001). However, there was no significant difference between the two groups. The photographic assessment demonstrated a significant improvement in hair density in the topical minoxidil group in all marked points located at 12 cm (p = 0.025), 16 cm (p = 0.034), and 24 cm (p = 0.014) distance from the glabella but not in the oral minoxidil group. Nevertheless, the difference between the two groups was not significant. In each group, over 60% of patients expressed satisfaction with their treatments, and no significant difference was detected between the two groups. CONCLUSION: Although topical minoxidil has a better overall therapeutic effect than 1 mg oral minoxidil, the difference between the two groups was not significant. Therefore, 1 mg oral minoxidil may be as effective and safe as standard topical minoxidil in female and male pattern hair loss.

Effectiveness of oral tofacitinib treatment on patients with moderate-to-severe alopecia areata in Iran.

INTRODUCTION: Alopecia areata is an inflammatory hair loss and a common autoimmune disease. Conducting treatment studies on alopecia areata is difficult due to unpredictable periods and even spontaneous recovery from the disease. In this study, the effectiveness of tofacitinib in treating alopecia areata was investigated. MATERIALS AND METHODS: The severity of the disease was evaluated using the Alopecia Severity Tool (SALT), and based on the medical history and patient's documents and photos, the score before and after the treatment was obtained. The patients were prescribed tofacitinib tablets at a dose of 5 mg twice a day for at least 6 months and were followed for a minimum of 18 months. RESULTS: No side effect was observed in 97.9% of the patients. After 6 months, except for three patients who did not need any maintenance dose, others needed an average daily intake of 7 mg of tofacitinib. After 18 months, the hair loss decreased by 6.45 times compared to the beginning and by 0.5 times compared to the end of 6 months (p < 0.05). In addition, it was found that body hair loss decreased 4 times compared to the beginning and 0.6 times compared to the end of 6 months (p < 0.05). The reduction of nail involvement after 18 months and 6 months was 1.2 times and 0.6, respectively, (p < 0.05). CONCLUSION: Treatment of alopecia areata with tofacitinib is recommended due to its effectiveness in reducing hair loss on the head, body, and nail involvement with few reversible side effects.

A Comparative Study on the Usefulness of Fractional CO2 and Fractional Er:YAG in Acne Scars: A Split-Face Trial.

Background: Acne is a dermatologic condition with a high burden in terms of psychosocial consequences as a result of scars remaining on the skin. Its effects are severe in adolescence and finding treatments with short therapy courses, superior results, and fewer adverse effects are of high importance. Materials and Methods: We included 30 individuals with acne vulgaris scars in Al-Zahra academic training hospital from June 2018 to Jan 2019. Each individual received both fractional CO2 and fractional Er:YAG lasers on right and left sides of the face, respectively. Three sessions of laser treatment were applied to each side with one-month intervals. Results were evaluated by patients according to subjective satisfaction and physicians' assessment and photo evaluation by two blinded dermatologists. Improvement was graded by a quartile grading scale: less than 25%: mild, 25% to 50%: moderate, 51% to 75%: good, and 76% to 100%: excellent response. Assessments were obtained at baseline and one month after the last visit. Results: Based on subjective satisfaction (p < 0.05) and physicians' assessment (p < 0.01), fractional CO2 laser was significantly more effective than Erbium:YAG laser. Also, Post-treatment side effects were mild and transient in both groups. Conclusion: Laser therapies are common in the treatment of scars and each modality has special advantages and disadvantages. Choosing among them should be based on various criteria. Fractional CO2 lasers have been revealed favorable results in most reports. Large comprehensive trials could help experts in choosing among alternatives for different subgroups.

Treatment of vulvar basal cell carcinoma with Slow-Mohs micrographic surgery A case report.

Vulvar Basal Cell Carcinoma (BCC) accounts for only 0.4% of all BCCs. We present a case of BCC that developed on the vulvar area with a pinkish lesion and pruritus for about 2 years and was successfully treated with Mohs micrographic surgery.

Comparative Efficacy Study Combination of Oral Methotrexate and Prednisolone versus Oral Methotrexate in Patients with Lichen Planopilaris.

Background: Lichen planopilaris (LPP) is a rare inflammatory disorder of the scalp that causes cicatricial alopecia. No therapeutic approach has been approved for this disease due to the rare frequency. Methotrexate and corticosteroid are commonly considered second- or third-line therapy. The efficacy of a combination of methotrexate and corticosteroid has been reported in some dermatological and immunological diseases. However, the efficacy of this combination in LPP is not clear. Therefore, this study aimed to compare the impact of methotrexate alone and in combination with corticosteroid on LPP. Materials and Methods: This randomized clinical trial was performed on 28 patients who referred to the dermatology clinic affiliated with Isfahan University of Medical Sciences, Isfahan, Iran during February 2015-December 2016, and 24 of them completed the trials. Fourteen patients received 15 mg methotrexate per week alone and the other fourteen subjects received 200 mg prednisolone plus 15 mg methotrexate per week. The primary outcome was Lichen planopilaris activity index (LPPAI) score. Moreover, we evaluated photographic changes and symptoms during the study. Results: The mean of LPPAI in both groups decreased during the follow-up with a similar pattern of LPPAI changes in both groups. No statistically significant difference was found between the two intervention groups regarding the LPPAI score. We found no difference in the symptoms and photographic assessments in methotrexate and combination therapy groups during follow-up. In both groups, exclusively one adverse effect was reported. Conclusions: Our results showed that methotrexate therapy with and without corticosteroids had similar efficacy and safety.

Fractional erbium:YAG laser (2940 nm) plus topical hydroquinone compared to intradermal tranexamic acid plus topical hydroquinone for the treatment of refractory melasma: a randomized controlled trial.

OBJECTIVES: Melasma is a chronic acquired condition characterized by grayish-brown macules and patches with a distinct border on the face. Although various treatments methods have been suggested for treating melasma, none has been completely successful. The aim of the study was to compare the efficiency of erbium: yttrium-aluminum-garnet (Er:YAG) laser and 4% hydroquinone (HQ) with the effects of intradermal tranexamic acid (TA) and 4% HQ for the treatment of refractory melasma. METHODS: The study included 31 female patients with refractory melasma. The left or right side of the patient's face was chosen randomly to receive laser therapy with topical HQ on the one side (i.e. the laser side) and intradermal injection of TA plus topical HQ on the other side (i.e. the mesotherapy side). Digital photography was performed at baseline, at the end of the treatment, and three months after the treatment as follow-up. Two independent dermatologists evaluated the modified Melasma Area and Severity Index (mMASI) score according to the pictures. Overall, 27 patients completed the study and went through the clinical evaluation. RESULTS: Treatment using HQ in combination with either Er:YAG laser therapy or intradermal injection of TA significantly improved the hemi-mMASI and resulted in higher patient satisfaction. While the improvement was not significantly different between the two regiments after the treatment and upon follow up and both were equally efficient in the treatment of refractory melasma (p = 1.308), recurrence rate was higher after treatment with Er:YAG laser than TA (12% vs 34%). CONCLUSION: This study confirmed the comparable efficacy of TA plus topical HQ versus Er:YAG laser plus topical HQ for the treatment of refractory melasma. Both groups improved significantly and no subject left the treatment because of adverse effects. TRIAL REGISTRATION NUMBER: IRCT20191011045057N1.

Interventions for bullous pemphigoid: An updated systematic review of randomized clinical trials.

Background: Bullous pemphigoid (BP) is a widely recognized autoimmune blistering disease (AIBD) linked with a high incidence of morbidity and mortality. The aim of this study was to evaluate the available findings of randomized clinical trial studies to update interventions for Bullous pemphigoid. Methods: This article provides an updated overview of interventions for BP. A literature search was performed using Cochrane Central Register of Clinical Trials, MEDLINE, Scopus, and Web of Science from August 2010 to December 2020. All randomized clinical trials (RCTs) were done on adults and investigated the effectiveness of administered topical or systemic medications versus placebos or controls included in the current systematic review. Three RCTs comprising 363 patients were included in the systematic review. One of the eligible studies was placebo-controlled. All of the included studies used various interventions including, methylprednisolone plus azathioprine versus methylprednisolone plus dapsone, doxycycline versus prednisolone, and intravenous immunoglobulin (IVIG). Results: Following their potentials in disease control, no difference was observed between dapsone and azathioprine; although, dapsone had a higher corticosteroid-sparing potential. The evaluation of the effect of doxycycline in short-term blister control in comparison to corticosteroids showed that the medication was not inferior to prednisolone, although it had a higher long-term safety. Conclusion: Therapeutic outcome of IVIG for steroid-resistant patients was satisfactory. Moreover, the effectiveness and reliability of various immunosuppressive drugs and tetracyclines are investigated by blinded RCTs for the treatment of BP.

Microneedling in Combination with Topical Pimecrolimus 1% versus Topical Pimecrolimus 1% for the Treatment of Refractory Stable Vitiligo: A Randomized Clinical Trial.

OBJECTIVE: Vitiligo is a common, autoimmune disease that results in the destruction of the melanocytes and manifests as depigmented macules on various areas of the skin. Numerous treatment options have been proposed for vitiligo. The purpose of this study was to compare the efficacy of microneedling plus topical pimecrolimus 1% versus the sole use of topical pimecrolimus 1% for the treatment of vitiligo. METHODS: This clinical trial was conducted on 30 skin lesions on 15 Al-Zahra hospital patients. Each patient had two similar lesions in the limb area, and each lesion was considered a separate treatment group. The left or right side of the patient's lesion was randomly assigned to receive microneedling plus topical pimecrolimus for three months, while the other side received only topical pimecrolimus 1%. As part of the follow-up, digital photography was taken at the baseline and biweekly for three months after treatment and six months' follow-up. The following methods were used to evaluate the results: DLQI questionnaires, patient satisfaction questionnaires, and two independent dermatologists comparing the improvement rate for each group. RESULTS: Topical pimecrolimus 1% treatment led to unsatisfactory results, whereas the combination of microneedling and topical pimecrolimus1% treatment produced a more favorable overall outcome (P < 0.001). CONCLUSION: This study established that combination therapy results in more significant patient improvement. Additionally, one patient experienced mild skin irritation as a side effect of topical pimecrolimus.

Traumatic tattoos induced by IPL hair removal: A rare case report.

Using blue marker on the patient skin before IPL can lead to tattoos on the marked areas that must be avoided.

Generalized granuloma annulare in a case of breast cancer: A case report and review of the literature.

Generalized granuloma annulare can be associated with breast cancer. Atypical granuloma annulare especially in older patients should alert physicians to the possibility of an occult malignancy.

Oral Pulse Betamethasone, Methotrexate, and Combination Therapy to Treat Severe Alopecia Areata: A Randomized, Double-blind, Placebo-controlled, Clinical Trial.

The purpose of this study is to compare oral betamethasone pulse therapy, methotrexate therapy and a combination of the two for patients with Alopecia Areata (AA) as an autoimmune disorder. In this study, 36 patients with severe AA were selected and classified into three groups of 12: 1- Oral betamethasone therapy (3 mg, once a week) with placebo; 2- Oral methotrexate (15 mg, once a week) with placebo; and 3- A combination of methotrexate (15 mg, once a week) and betamethasone (3 mg, once a week). The Severity Alopecia Tool (SALT) was used to measure improvements in the lesions through photographs, and the patients also rated their condition on the Visual Analogue Scale (VAS). Assessments were performed, and the results were compared at baseline and then at intervals of three months for nine months. The demographics and SALT score were similar in the three groups (P > 0.05). All the groups showed improvements in SALT, VAS and photographic scores three months after beginning the treatment (P < 0.001). Betamethasone therapy (P = 0.006) and combination therapy (P < 0.001) provided greater SALT improvement than methotrexate, and combination therapy led to a greater improvement in VAS and photographic findings compared to the two other groups (P < 0.05). Oral steroid, methotrexate and combination pulse therapy were effective treatments for AA, while oral steroid pulse therapy and combination therapy were superior to methotrexate.

Giant cerebriform melanocytic nevus of the scalp: A case report.

Giant melanocytic nevus is a rare condition caused by benign proliferation of melanocytes. There is a slight risk of malignancy in these lesions which should be noticed especially when they become larger. GCMN can be removed by plastic surgery.

Platelet-rich plasma versus carboxytherapy for the treatment of periocular hyperpigmentation; which approach is superior?

Periorbital hyperpigmentation (POH) is a common aesthetic condition causing people referring to dermatology clinics. Although the therapeutic approach is steeply dependent to the etiology of POH, the gold standard approach of treatment is still a question. The current study is designed to compare the use of carboxytherapy versus platelet-rich plasma (PRP) for the treatment of POH. In the current clinical trial, number of 21 patients with POH underwent carboxytherapy in one side of the face and PRP therapy on the other side. SPSS software version 22 was used with independent T-test, Chi-square, and ANOVA for analytics. Carboxytherapy was performed by intradermal injection of 5 cc carbon-dioxide gas once weekly for 6 weeks. The PRP treatment was performed by intradermal injection of PRP in periorbital space using an insulin syringe every 2 weeks for three times. The periorbital darkness was assessed using visual analogue scale preoperatively and within 8 weeks postoperatively by the patients and the dermatologists. Automatic assessments of skin vascularity and pigmentation were assessed using a digital camera. The patients represented significant darkness improvement postoperatively for both of the approaches (p value: 0.84, p value: 0.87), while the comparison of the two groups revealed insignificant postoperative changes by dermatologists assessments (p value = 0.59, p value: 0.61), the patients' assessments (p value = 0.85), the digital camera skin vascularity and pigmentation assessments (p value > 0.05). Conclusion: Although insignificant changes following both of the approaches were found, it may have occurred due to the technique, quality of material, or inadequate treatment sessions due to the type of Iranian skin; therefore, more evaluations considering particular entities such as vascularity for longer duration of follow-up and new design are strongly recommended.

Effectiveness of dermabrasion plus 5-fluorouracil vs suction blister in treating vitiligo: A comparative study.

Vitiligo is a prevalent destructive melanocyte skin disease that negatively affects the patients' life in terms of self-esteem. Suction blister and dermabrasion plus 5-fluorouracil are effective treatments for vitiligo. The present study was conducted to compare the outcomes of these two techniques. The present clinical trial was conducted on 36 patients with persistent refractory vitiligo which defined as the lack of any new or progressed lesion during the previous year as well as no responding to conventional therapies of vitiligo including topical treatments and phototherapy. Individuals with two vitiligo patches, with similar baseline Vitiligo Area Severity Index (VASI) scores were randomly allocated to dermabrasion plus 5-fluorouracil or suction blister treatments. VASI and repigmentation scores were measured and compared at the baseline, four, and 12 weeks after performing the procedures. Both of the approaches accompanied with significant improvement in both entities of VASI and repigmentation scores (P value < .05) at the end of the study, besides the trend of VASI and repigmentation scores between the two groups revealed insignificant difference (P > .05). The short-term follow-up of the patients was the limitation of this study. The present findings suggested that both surgical techniques of dermabrasion plus 5-fluorouracil and suction blister posed acceptable outcomes within 12-week follow-up.

Cyclosporine or methotrexate, which one is more promising in the treatment of lichen planopilaris?; A comparative clinical trial.

BACKGROUND: Lichen Planopilaris (LPP) is a primary scarring alopecia with unknown etiology and its management is a challenge for dermatologists. We aimed to compare the safety and efficacy of methotrexate and cyclosporine in LPP patients. METHODS: In a randomized clinical trials, 33 patients were randomly allocated to receive either 15-mg oral methotrexate per week or 3-5-mg/kg/day cyclosporine for six months. During the treatment course, side effects, signs/symptoms and laboratory test were assessed periodically. Lichen planopilaris activity index (LPPAI) was measured at baseline and 2, 4, and 6 months after the intervention. Score of both photography and patient's opinion were also obtained. The collected data were analyzed in SPSS software (Ver.25.0. Armonk, NY: IBM Corp). RESULTS: Both medications had positive effects on the signs and symptoms of LPP with a significant difference between the variables (p < 0.05), and the results showed similar efficacy at the end of 6th months of the therapy with both cyclosporine and methotrexate (p > 0.05). CONCLUSIONS: Regarding the results of the present study, both cyclosporine and methotrexate are effective in treating refractory lichen planopilaris and we propose methotrexate as a possible earlier choice over cyclosporine. This study was registered in Iranian Registry of Clinical Trials (IRCT20190717044256N1).