Complex decongestive therapy in hidradenitis suppurativa-related genital lymphoedema: a case report.

Genital lymphoedema is a rare but debilitating and disfiguring complication of longstanding hidradenitis suppurativa (HS). Despite the existence of medical and surgical methods that offer varying success rates in a limited number of cases, no data exist about the use of complex decongestive therapy (CDT) in HS-related genital lymphoedema. This case report describes the treatment and outcome of a 56-year-old male patient with severe scrotal lymphoedema due to underlying HS (Hurley stage 3). The patient was unresponsive to various topical and systemic antibiotics and biological agents, including adalimumab and certolizumab pegol. When the patient was assessed, ixekizumab treatment for his HS was planned. He had progressive oedema in the genital area for two years with difficulty in wearing trousers and having sexual intercourse, and painful urination. CDT was recommended for three days a week concurrently with ixekizumab treatment. The patient and his wife were also educated about self-drainage techniques and skincare maintenance. After six sessions of CDT over 14 days, the patient demonstrated a significant reduction in scrotal measurements. He achieved a better scrotal contour, the degree of the buried penis was decreased, and urination was easier and painless. The findings of this case report showed that CDT was an easily applicable, practical and promising method that offered a rapid treatment response for HS-related genital lymphoedema.

The Comparative Dermal Stimulation Potential of Constant-Volume and Constant-Amount Diluted Calcium Hydroxylapatite Injections Versus the Concentrated Form.

INTRODUCTION: Biostimulation properties of diluted and hyperdiluted calcium hydroxylapatite (CaHA) injections have become increasingly popular. However, the existing data are insufficient to certify a particular dose-response pattern. OBJECTIVE: To assess and compare the dermal stimulation potentials of different concentrations of CaHA injections. MATERIALS AND METHODS: Two independent experiments (Experiment-1: constant injection volume vs Experiment-2: constant CaHA amount) included 4 study groups each, and these experimental groups were placed consecutively on the abdominal skin of a juvenile Yorkshire pig. Histopathological and immunohistochemical stainings were performed on punch biopsy materials collected 4 months after the injection day. RESULTS: The fibroblast count significantly decreased upon dilution from 1:3 to 1:19 in experiment 1 ( p = .000) but still higher than the control group. In experiment 1, the collagen density of the concentrated form was more elevated than the 1:19 dilution and the negative control groups ( p = .034 and .000, respectively) but similar to the 1:3 dilution ( p = .123). No significant difference was observed between the groups regarding collagen density with a standard amount of CaHA (0.2 mL, 30%) ( p > .05). CONCLUSION: Despite the efficacy being more pronounced till 1:3 dilution, hyperdiluted CaHA at any dilution ratio up to 1:19 can provide a higher fibroblast count than the negative control group.

Increased Prevalence of Bipolar Disorders in Hidradenitis Suppurativa: More Than a Striking Co-existence?

Introduction: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disorder of the hair follicle characterized by intense discharge and pain. Recently, HS intrinsic association with neuropsychiatric disorders has become a focus of attention, and bipolar disorder (BD) emerged as a relevant topic for such an association. Objectives: This study aimed to evaluate BD prevalence among HS patients and present the HS and BD overlap patients demographics, detailed clinical characteristics with a discussion on aggravating factors. Methods: A retrospective chart review of 247 HS outpatients (Group-1) identified nine patients with BD. The frequency of BD in HS patients is compared to psoriasis patients (Group-2) and controls (Group-3) in age- and gender-matched groups. The demographic and clinical features of the 9 patients revealing HS-BD co-existence were analyzed. Results: BD (N = 9) was the 7th most common co-morbidity in the HS cohort. The frequency of BD is detected as 3.6% in group 1, 0.7% (N = 1) in group 2, and 0.6% (N = 1) in group 3, respectively. Group 1 demonstrated an increased prevalence of BD compared to other groups (P = 0.001). Of the 9 patients revealing HS and BD co-existence, 66.6% were active smokers, 66.6% were obese and 44.4 % had metabolic syndrome. Conclusions: This study results reveal that the prevalence of BD in HS patients is higher than psoriasis patients and controls. The pathogenetic mechanisms underlying BD and HS co-existence needs to be investigated further.

An Anti-Interleukin-17A Monoclonal Antibody, Ixekizumab, in the Treatment of Resistant Hidradenitis Suppurativa: A Case Series.

Introduction: Although adalimumab is the only approved biologic for the treatment of hidradenitis suppurativa (HS), the treatment response may not be satisfactory in all patients. Recently, many other biological agents, including interleukin 17 inhibitors such as ixekizumab, have shown promise. Case Presentations: Five severe HS (Hurley stage III) patients resistant to conventional treatments and adalimumab for at least 3 months were recruited. Patients were prescribed ixekizumab with a scheme approved for psoriasis (160 mg once, followed by 80 mg at weeks 2, 4, 6, 8, 10, and 12.) The primary outcome measure was achieving the Hidradenitis Suppurativa Clinical Response (HiSCR) score following 12 weeks. Secondary outcome measures included the patient-reported Dermatology Life Quality Index (DLQI) and visual analog scale (VAS). Four of 5 patients (80%) achieved HiSCR. While improvement was observed in the VAS and DLQI scores of 4 patients, the decline was limited in 1 patient. No adverse event was recorded related to ixekizumab. Conclusion: The result of our observation suggests that ixekizumab may be effective for HS, especially in challenging cases.

Certolizumab pegol in the treatment of severe hidradenitis suppurativa after adalimumab failure: A real-life experience.

There exists an unmet need to treat hidradenitis suppurativa (HS) despite several approved therapeutic agents for its treatment. We sought to investigate the role of certolizumab pegol in severe, recalcitrant HS patients unresponsive to adalimumab. This retrospective cohort includes HS patients over 18 years of age who had a history of unresponsiveness to adalimumab and whose treatments were switched to certolizumab pegol with dosing similar to psoriasis (400 mg every 2 weeks). For subjects who achieved a hidradenitis suppurativa clinical response (HiSCR) following 12 and 24 weeks of treatment, dermatological life quality index (DLQI), abscess, inflammatory nodule count (AN count), and International Hidradenitis Suppurativa Severity Score System (IHS4) were evaluated as outcome measures. Eleven severe, recalcitrant HS patients with Hurley stage III HS were enrolled for this study. All patients were male and had a history of prior adalimumab exposure. Only three (27.2%) patients also had a history of using biologic agents other than adalimumab for HS. Six of 11 patients (54.5%) achieved HiSCR at week 12. However, two among these six responders lost response at week 24 despite continued therapy (HiSCR at week 24: 33.3%). The decrease in DLQI (p: 0.017 and 0.021) and IHS4 (p: 0.008 and 0.007) scores of the patients at weeks 12 and 24 showed a significant difference compared to the baseline. Certolizumab pegol is a promising treatment option for severe, recalcitrant HS patients who are unresponsive to adalimumab.

Comparison of fractional erbium:YAG laser-assisted tranexamic acid delivery alone and in combination with oral tranexamic acid in melasma.

Tranexamic acid (TA) emerged as a promising agent for melasma. However, due to its hydrophilic structure, topical TA should be combined with a penetration-enhancing strategy to augment efficacy. To evaluate the efficacy of fractional erbium:YAG laser-assisted delivery (LAD) of topical TA 5% either with or without oral TA treatment in recalcitrant melasma patients. The authors retrospectively assessed the treatment outcomes of melasma patients treated by fractional erbium:YAG LAD of topical TA 5%. Patients receiving a standard protocol including four biweekly laser sessions were eligible. The study included two groups: group 1 patients received oral TA and LAD of topical TA 5%, and group 2 patients received only LAD of topical TA 5%. Two blinded dermatologists reported pre-treatment and post-treatment modified MASI (mMASI) scores. Mean mMASI scores in both group 1 (n = 15) and group 2 (n = 19) were significantly lower at the end of the treatment than baseline values (p = 0.001; p = 0.022, respectively). The decrease of mMASI scores were higher in group 1 (median = 2.1) (64.7%) than in group 2 (median = 1.2) (41.8%) (p = 0.027). Fractional erbium:YAG LAD of topical TA 5% is an efficient treatment regimen for melasma patients recalcitrant to conventional treatment approaches. The implementation of oral TA to this regimen improves the therapeutic outcomes.

The role of online consultation requests to personal social media accounts and instant messaging services of dermatologists in occupational burnout: An emerging problem.

BACKGROUND: Burnout affects all physicians, including dermatologists. Long working hours, high workload, and work-related activities outside working hours are common risk factors for burnout that disrupt the work-life balance. This study aimed to evaluate dermatologists' approach to online consultation requests via social media (SM) and instant messaging services (IMS), the psychological effects of these consultations on dermatologists, and their relationship with burnout syndrome. MATERIALS AND METHODS: A cross-sectional, descriptive research was conducted as an online survey using Google Forms. The survey consisted of 55 items and was sent to dermatologists through a closed Facebook group of the Turkish Society of Dermatology. The burnout levels of dermatologists were evaluated using three subscales of the Maslach Burnout Inventory (MBI): emotional exhaustion (EE), depersonalization (DP), and personal achievement (PA). RESULTS: Out of the total 270 participants, 268 (99.3%) participants reported using SM and IMS, whereas 263 (98.1%) received personal consultation requests on these applications. Among all IMS, WhatsApp (n=258, 98.1%) was the most common IMS for online consultation requests. Median (IQR) scores for EE, DP, and PA subscales were 18 (11), 6 (5), and 21 (6), respectively. A positive correlation was observed between the frequency of online consultation requests and MBI-EE subscale scores (r = 0.136; 95% CI, 0.013-0.254; p = 0.026). Fatigue (95.1%), anger (66.6%), and unhappiness (45.2%) were among the most common adverse effects of online consultations on dermatologists. CONCLUSION: Online consultation requests to dermatologists' personal IMS and SM accounts can lead to burnout. The current study findings raise the awareness of the risks of burnout among dermatologists. There is an implicit need for further research, mobile apps other than frequently used IMS and SM apps, and regulations to avoid problems related to the consequences of online dermatology consultations through IMS and SM.

Patients With Hidradenitis Suppurativa Negatively Perceive Both Medical and Euphemistic Appellations of Their Disease: A Study From Turkey.

BACKGROUND: The use of medical terms and folk names (euphemisms) affect a patient's understanding of diseases and perceptions of severity. OBJECTIVES: We determine the psychological effects on patients with hidradenitis suppurativa of medical and folk names of their disease. METHODS: This was a cross-sectional and exploratory study conducted at a tertiary referral university hospital in Turkey. A questionnaire on the medical and folk names of hidradenitis suppurativa was administered to 31 males and 25 females. RESULTS: The patients expressed that they found the medical term hidradenitis suppurativa to be incomprehensible because it is a foreign term. When hearing it for the first time, it evoked negative responses such as confusion and worry about their health. Half of the patients preferred their doctors to use a more understandable and pronounceable name. More than 80% of patients expressed feeling depressed and stigmatized by the folk name of their disease. They preferred the terms boils, abscesses, or hidradenitis when referring to their disease. CONCLUSION: Both medical and folk names for hidradenitis suppurativa have negative effects on patients, and most patients feel stigmatized by either term.

A case of psoriasis successfully treated by extracorporeal photopheresis during COVID-19 pandemic.

Psoriasis is a chronic inflammatory skin disease that is characterized by well-demarcated erythematous plaques with a silver scale. Although many new and emerging therapeutic agents are often sufficient to control the disease, there is still a need for alternative treatment options in challenging cases. Extracorporeal photopheresis (ECP) has been applied to many T-cell-mediated diseases to restore immune homeostasis and treat psoriasis effectively. In this paper, we present a psoriasis patient who did not respond to methotrexate, narrowband ultraviolet B, or acitretin. Because of a diagnosis of non-Hodgkin lymphoma, the patient had contraindications for cyclosporine, fumaric acid esters, and biologics but achieved remission with a total of 12 sessions of ECP in two and a half months. Although exacerbation was recorded after polymerase chain reaction (PCR) confirmed coronavirus 2019 (COVID-19) disease infection at the end of the first month, scores from the psoriasis area severity index (PASI) and dermatological life quality index (DLQI) were regressed significantly within two and a half months. ECP seems to provide an effective and rapid response for psoriasis and should be considered for psoriasis patients who fail to respond or have contraindications to existing treatments.

Family physicians' awareness and general knowledge of hidradenitis suppurativa: A survey research.

RATIONALE, AIMS, AND OBJECTIVE: Medical consultations of family physicians play a key role in early diagnosis and proper management of hidradenitis suppurativa (HS). This study aimed to investigate family physicians' disease awareness, general attitudes, and knowledge of HS. MATERIAL-METHODS: This cross-sectional descriptive study was conducted with 211 family physicians and residents through a web-based survey. The questionnaire consisted of 25 questions about the demographic characteristics of the participants as well as their awareness and general knowledge of HS. RESULTS: While 90% of physicians know that the diagnosis of HS is made clinically without any need for a laboratory examination, only 23.7% of them felt confident performing such a diagnosis. About 63% of participants defined HS as an infectious disease of the apocrine glands, contradictive to the real pathophysiology. About 21% of them had not been medically trained in HS, and 3% of them even had never heard the name of HS. Only 33% were aware of the role of biological agents. Most of the family physicians (57.4%) were willing to participate in postgraduate education programmes about HS. CONCLUSION: The family physicians' awareness of HS is limited. Increased practice in medical education and postgraduate education programmes may help increase the knowledge of family physicians.

Disease severity and poor mental health are the main predictors of stigmatization in patients with hidradenitis suppurativa.

Hidradenitis suppurativa (HS) causes significant psychological distress in patients. We aimed to investigate the stigmatization level of HS patients and to determine the related physical, social, and psychological factors. A questionnaire with 22 questions about the physical and psychosocial problems related to HS was administered to 29 male and 34 female patients between the ages of 18 and 66 to evaluate the thoughts, emotions, attitudes, and behaviors of patients. Each patient filled Dermatology Life Quality Index, Beck Depression Inventory, Liebowitz Social Anxiety Scale, Body Image Scale, and 6-item Stigmatization Scale. Hurley classification was used to assess severity of disease. Patients with HS feel stigmatized depending on physical and psychosocial problems caused by the disease. Higher stigmatization scores correlated with higher scores of depression (r: .437, P < .001), social anxiety (r: .263, P: .03), and worse life quality (r: .522, P < .001), and body image perception (r: .696, P < .001). The degree of stigmatization was closely associated with the presence of painful lesions and disruption of socializing (P: .021 and .033, respectively). Disease severity (ß: 5.12, P: .003 for moderate disease) and reporting feeling psychologically negatively affected due to HS (ß: 4.26 P: .007) were the two main predictors of stigmatization in patients with HS. Cross-sectional nature of the study is the limitation. In conclusion, the stigmatization level of patients with HS is strongly related to disease severity and poor mental health.

Rapid Response to Certolizumab Pegol in Hidradenitis Suppurativa: A Case Report.

INTRODUCTION: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease of hair follicles which usually affects patients' quality of life negatively. Although there are various therapeutic approaches including topical and systemic antibiotics, retinoids, biological agents, and also surgical modalities, there is no curative treatment option and clinical management of HS is still challenging. CASE PRESENTATION: Herein, we present a 43 year-old man with HS who had used different treatments in 15 years. The patient showed improvement initially with adalimumab, then exhibited secondary unresponsiveness after 18 months. While worsening of HS was recorded due to increased discharge under secukinumab, no additional benefit was observed with methotrexate. He was not willing to undergo surgical procedures due to previous surgical experience. Finally, certolizumab pegol has been started to patient with similar dosing to psoriasis patients. Sartorius, 10-point visual analogue scale (VAS), and dermatological life quality index (DLQI) scores regressed from 171 to 105, 9/10 to 3/10, and 27 to 19 after 3 months with certolizumab pegol treatment. DISCUSSION/CONCLUSION: Certolizumab pegol is a humanized antigen-binding fragment of a monoclonal antibody which binds to TNF-alpha. However, certolizumab pegol is only approved for plaque psoriasis in dermatology; it is likely to be a promising effective agent for HS, especially in challenging cases.

Nicolau syndrome following subcutaneous glatiramer acetate injection: A case report and review of the literature.

Nicolau syndrome is a rare serious drug reaction associated with the administering various injectable medications. It is often characterized by an acute and severe pain accompanying erythema that tends to rapidly evolve into the livedoid reticular or hemorrhagic patches and less commonly to ulcers and skin necrosis. Herein, we report a 34-year-old woman who presented with painful, tender discoloration over her abdominal skin following subcutaneous glatiramer acetate injection. Since the patient was diagnosed with multiple sclerosis 18 months ago, she had been on treatment with subcutaneous glatiramer acetate injections thrice weekly. The patient was diagnosed with Nicolau syndrome clinically and histopathologically. After 15-day treatment with topical betamethasone valerate and mucopolysaccharide polysulfate cream twice daily, the lesion completely regressed with only minimal hypopigmented irregular scarring. Nicolau syndrome should be considered in patients with severe pain, tenderness, and redness localized at the injection site following glatiramer subacetate.

Bioactivity of abobotulinum toxin is preserved till 2 weeks upon storage at room temperature: Half body comparative study on rabbit model.

BACKGROUND: Breakages of the cold chain of botulinum neurotoxin A (BONT-A) preparations is not a rare event and occurs due to several unexpected and unintentional reasons during daily practice and intervention schedules could not be proposed due to the lack of data. OBJECTIVE: To investigate the heat stability of abobotulinum toxin A (AboBONT-A) in terms of efficacy and duration of action upon storage at room temperature (25°C) for 2, 4, and 8 weeks. METHODS AND MATERIALS: Twenty rabbits were divided into four groups and received an injection of ideally stored AboBONT-A (Group 1) and stored AboBONT-A for 2 (Group 2), 4 (Group 3), and 8 weeks (Group 4) at room temperature into the anterior auricular muscle. All rabbits were followed up and photographed by weekly for 16 weeks. Grade of paralysis was evaluated by using a modified visual scoring system. RESULTS: No significant alteration was found in initial potency of stored AboBONT-A at room temperature for up to 4 weeks. Storage at room temperature for 2 weeks did not affect the duration of action (group 2; P = .69), and faster recovery was observed in group 3 and group 4. CONCLUSION: The bioactivity of AboBONT-A is not altered till 2 weeks upon storage at room temperature.

Medical and socioeconomic challenges of private dermatocosmetology clinics during COVID-19 pandemic: A survey from Turkey.

BACKGROUND: Coronavirus 2019 (COVID-19) disease has rapidly spread worldwide with a multitude effects on daily life. Since the transmission risk increases with close contact, some cosmetic procedures are considered high risk and majority of them had to be postponed or canceled in private dermatocosmetology clinics especially during the heavy period of the outbreak. AIMS: We aimed to document the medical and socioeconomic problems emerged in dermatocosmetology clinics in Turkey caused by COVID-19 pandemic and to discuss the management strategies taken by dermatologists. PATIENTS/METHODS: This survey research was conducted with 100 dermatologists who work in private dermatocosmetology clinics. The survey included 38 questions about office re-arrangements including patient admission and office environment, safety precautions taken for cosmetic procedures, management of clinic staff, and financial impact of the pandemic. RESULTS: A remarkable decrease in major cosmetic interest was reported in private clinics; meanwhile, there was an increase in applicants for noncosmetic dermatological complaints. The most avoided cosmetic procedures were application of skin care devices, lasers, chemical peeling, and thread lifting, while botulinum toxin injection was the most performed procedure. Nearly half of the participants had severe financial damage. Of the participants, 55% reported that they worked anxiously during this period and 60% believed that they managed the early period of the pandemic successfully. CONCLUSION: Private dermatocosmetology clinics have to work in a totally different period that they have never experienced before. The pandemic has had serious impacts on both medical and socioeconomic issues which had to be managed carefully.