Does Systemic Metformin Have a Role in Treating Melasma?

BACKGROUND: Melasma is a common pigmentary condition that affects the patients' quality of life and all the prescribed treatment options till now are not satisfactory, especially in dark-skinned patients. OBJECTIVE: To evaluate the efficacy and safety of systemic metformin (1,000 mg and 500 mg) combined with trichloroacetic acid (TCA) peeling versus TCA alone in the treatment of melasma. PATIENTS AND METHODS: The study included 60 melasma patients divided into 3 groups: Group A received systemic metformin (1000 mg/d), Group B received systemic metformin (500 mg/d) and Group C received placebo. The 3 treatment groups were treated by TCA 25% over the whole face bimonthly for a total of 6 sessions. Melasma area and severity index (MASI), and Melasma impact Quality of life Scale (MELASQOL) were used to assess the outcome. RESULTS: There was a statistically significant decrease in the MASI, and the MELASQOL in the 3 studied groups after treatment with significantly better improvement in Group (A) than Group (C) ( p = .045). CONCLUSION: Systemic metformin is a safe and promising therapeutic option for treating melasma.

Serum pentraxin 3 in systemic lupus erythematosus: A potential indicator of cutaneous disease activity.

BACKGROUND: Although skin manifestations are common in systemic lupus erythematosus (SLE), there is still a lack of a diagnostic marker for cutaneous involvement. Pentraxin3 (PTX3) has been studied in SLE patients; however, it has not been investigated in relation to cutaneous manifestations. OBJECTIVE: To assess the serum PTX3 level in SLE patients, and to investigate its relationship with disease activity as well as with variable skin manifestations. PATIENTS AND METHODS: Thirty-four patients with SLE (17 patients with skin manifestations and 17 without) and 30 healthy subjects were included in the study. Patients were evaluated clinically for systemic and skin manifestations of SLE. Systemic Lupus Erythematosus Disease Activity Index (SLEDAI-2k) and Cutaneous Lupus Erythematosus Activity and Severity Index (CLASI) scores were calculated. Serum level of PTX3 was measured in patients and controls using ELISA. RESULTS: Higher serum PTX3 level was found in SLE patients compared to controls (p < 0.001). Patients with skin manifestations showed higher SLEDAI-2k scores and had higher PTX3 level compared to those without skin manifestations (p = 0.015 and p < 0.001, respectively). PTX3 showed higher levels in association with malar rash (p < 0.001), mucosal ulcers (p < 0.001), alopecia (p < 0.001), and purpuric eruption (p = 0.002). Moreover, PTX3 level positively correlated with CLASI scores (p < 0.001). CONCLUSION: Our results reinforce the important role of Pentraxin3 in SLE patients with skin manifestations, and it may be considered an interesting biomarker for the pattern and extent of cutaneous involvement in SLE.

Which is more effective in atrophic acne scars treatment microneedling alone or platelet rich plasma alone or combined both therapeutic modalities?

Acne scarring usually causes cosmetic and psychological problems. Our aim of the study was to compare the efficacy of microneedling alone, intradermal injection of platelet rich plasma (PRP) alone and combined microneedling with PRP in the treatment of atrophic post-acne scars. Thirty adult patients with facial post-acne scars were randomly recruited and divided into two groups: A and B. Group A: included 15 patients; the left sides of their faces were treated with microneedling by dermapen followed by PRP while on the right side of the faces microneedling alone was performed. Group B: included 15 patients; the left sides of their faces were treated with microneedling by dermapen followed by PRP while the right sides of the faces were treated with intradermal injection of PRP. For both groups, the treatment session was repeated every 3 weeks until clearance of the atrophic acne scars or for four sessions maximally. Patients' evaluation was done pre-treatment and 3 weeks after the last session by photography, Goodman and Baron qualitative grading system and Echelle d'Evaluation Clinique des Cicatrices d'Acné (ECCA) scale. By using all of these evaluation methods, group A showed that there was better improvement on the left side but without statistical significant difference. However, group B showed that there was a significant reduction in the total number of post-acne scars on the left side compared to the right side by using photographic assessment and ECCA grading scale. Skin microneedling, PRP and combined microneedling with PRP are effective therapeutic modalities in atrophic post-acne scars treatment. However, combined microneedling with PRP gives better results and is better tolerated in all types of atrophic acne scars.

A new grading system for female sexual dysfunction based on the female sexual function index in Egyptian women: a cross-sectional study.

OBJECTIVE: To provide a grading system that accurately reflects the grades of female sexual dysfunction (FSD) severity. PATIENTS AND METHODS: A cross-sectional study was conducted in Assiut University Hospital. It included 500 women who answered the Arabic version of the Female Sexual Function Index (FSFI) after getting their consent. A gradient of FSD severity was created, classifying FSD into five grades: severe, moderate, mild to moderate, mild, and no FSD. RESULTS: According to our grading system, FSD was detected in 339 women (67.8 %); Mild FSD in 20.4%, mild to moderate in 41.6%, moderate in 15.3%, and severe in 22.7%. Mean scores of desire show a linear trend of reduction from 3.8 in mild to 3.36 in mild to moderate to 2.25 in moderate and markedly reduced to 2.1 in severe grade. This difference was highly statistically significant (p= 0.002). The same was reported in arousal, orgasm, and satisfaction domains, while in lubrication and pain domains, the difference was not statistically significant. CONCLUSION: In this study, our grading system was complementary to the FSFI. Moreover, it seems to be more practical and useful in grading the severity of FSD.

Botulinum toxin type A versus 5-Fluorouracil in treatment of keloid.

Most therapeutic approaches for keloids remain clinically unsatisfactory. In the last years, intralesional botulinum toxin-A (IL BTX-A) was proposed for treatment of keloids. Our aim of the study was to compare the clinical efficacy of IL BTX-A and IL 5-Fluorouracil (IL 5-FU) in treatment of keloids. A total of 50 patients with keloids were included in the study, 22 patients (with 26 keloids) were treated with IL BTX-A monthly for up to 6 months and other 22 patients (with 27 keloids) were treated with IL 5-FU weekly for up to 6 weeks, while the remaining 6 patients, each having multiple keloids, were treated with both IL BTX-A for some lesions (8 keloids) and IL 5-FU for their remaining lesions (8 keloids). The clinical improvement was assessed according to flattening of the lesions. Side effects were recorded. A significantly better therapeutic response of keloids was detected after IL BTX-A than IL 5-FU (P = 0.041). IL BTX-A achieved excellent and good flattening of the lesions (58.8% and 20.6%) compared to (31.4% and 17.1%) after IL 5-FU, respectively. In BTX-A treated group, there was no statistically significant difference between the clinical response in small lesions compared to medium and large ones (P = 0.476). While in 5-FU treated group, small and medium lesions showed significantly better response than larger ones (P = 0.009). IL BTX-A caused fewer side effects than IL 5-FU, less pain, itching, no hyperpigmentation and less recurrence. Both IL BTX-A and IL 5-FU showed positive results in treatment of keloids. However, IL BTX-A showed higher clinical efficacy even in large size keloids with less side effects.

Effects of different therapeutic modalities for postacne scars on circulating collagen III.

BACKGROUND: Therapies for postacne scarring act through modulation of elastin and collagen, and collagen III might therefore represent a biomarker of treatment effectiveness. PATIENTS AND METHODS: Patients (n = 70) with postacne scars and individuals without scars (n = 56) were included in this case-control study. Patients were treated with Dermaroller microneedling, trichloroacetic acid chemical reconstruction, punch excision, or scar subcision. Scar severity was graded immediately before and after treatment with a photographic quartile scale and the ECCA scale. Serum levels of collagen III were measured in control individuals and in patients, before treatment, 1 month after the first treatment session, and 4 months after the final session. RESULTS: Circulating levels of collagen III were significantly higher in patients with postacne scarring (24.1 ± 12.5) before treatment than in control individuals (2.6 ± 0.8). Circulating levels of collagen in patients were significantly lower 4 months posttreatment (14.3 ± 8.1) than at baseline. The mean percentage change in serum collagen III was positively correlated with both the mean percentage improvement by photographic evaluation (r = .530, P < .000) and the mean percentage change in the ECCA scale (r = .632, P < .000). CONCLUSION: Circulating collagen III is a biomarker for improvement of postacne scarring following different therapies.

Effect of female genital mutilation/cutting; types I and II on sexual function: case-controlled study.

BACKGROUND: The existing literature is contradictory regarding effects of female genital mutilation/cutting (FGM/C) on sexual functions. The aim of this study was to explore the impact of type I and II FGM/C on sexual function of Egyptian women. METHODS: We recruited 197 cut women and 197 control women from those visiting Assiut University hospitals for different reasons. We asked each woman to fill the Arabic female sexual function index (FSFI) (a self reported 19-item questionnaire assessing the main domains of female sexual function). Genital Examination was done to confirm the type of FGM. RESULTS: Female sexual dysfunction (FSD) was found in 83.8% of FGM/C cases in contrast to 64.5% of the control. The total FSFI score in the FGM/C group (19.82 ± 7.1) was significantly lower than in the control group (23.34 ± 8.1). Concerning the types of FGM/C, type 73.6% of cases had type I and 26.4% had type II. Type I FGM/C was performed mainly by physicians (62.1%) while type II was performed mainly by midwives (44.4%). FSD was found in 83.4% of FGM/C I cases and in 84.6% of FGM/C II cases. There was no statistically significant difference between the two types of FGM/C as regards total and individual domain scores except for the pain domain. There were significantly lower total and individual domain scores in both FGM/C types except for the desire domain compared to control. CONCLUSION: In this study, FGM/C was associated with reduced scores of FSFI on all domains scores, and among both types I and II, both were associated with sexual dysfunction.

Suppression of transforming growth factor-beta1 expression in keloids after cryosurgery.

The biological mechanism underlying cryosurgical treatment of keloids remains unclear. Transforming growth factor-beta1 (TGF-ß1) has been implicated in the pathogenesis of keloids and was reported to be the target of several therapeutic modalities. However, the effect of cryosurgery on its expression in keloid tissue has not been yet investigated. In this study, 26 consecutive keloid patients were treated with cryosurgery for 2-6 sessions. Keloids were biopsied before starting cryosurgery and after two treatment sessions for the immunohistochemical evaluation of TGF-ß1 expression. The average volume reduction, after two treatment sessions (in 22 patients completing the study) was 68.77 ± 15.82%. Dermal overexpression of TGF-ß1 was demonstrated in all keloid specimens before treatment. Following therapy, significant reduction of that expression was detected in all keloid specimens (P = 0.016). In addition to attesting the clinical efficacy of cryosurgery, our findings indicate that cryosurgery effectively suppressed TGF-ß1 expression, possibly contributing to keloid regression.

Combined Jessner Solution and Trichloroacetic Acid Versus Trichloroacetic Acid Alone in the Treatment of Melasma in Dark-Skinned Patients.

BACKGROUND: Melasma is a common challenging pigmentary skin disorder especially in dark-skinned females urging them to seek medical help. Many modalities of treatment are available, but none is satisfactory. OBJECTIVE: To compare safety and efficacy of combined trichloroacetic acid (TCA) (20%-25%) and Jessner's solution versus TCA (20%-25%) alone in dark patients with melasma. MATERIALS AND METHODS: The study design was a split face, right-left, assessor-blinded, randomized controlled study. Twenty-four adult female patients (skin phototypes IV-V) with bilateral melasma were treated for 6 sessions at 2 weeks intervals. Clinical assessment of the 2 sides of the face with Melasma Area and Severity Index (MASI) score was performed, and photographs were taken before and after the peeling course. RESULTS: Both therapeutic modalities showed significant decrease in MASI score, which was significantly lower on the side treated with both Jessner solution and TCA. There were significant negative correlations between the percentage of improvement of MASI score and both age of the patients and duration of the melasma. CONCLUSION: Dark skin melasma can be treated with both regimens safely and effectively; however, combined Jessner solution and TCA is more effective.

Vitiligo management strategy in Jeddah, Saudi Arabia as reported by dermatologists and experienced by patients.

BACKGROUND: Vitiligo patients repeatedly experience disinterest from the medical world regarding their disease as it does not cause physical impairment. Several therapeutic options are available for vitiligo management. OBJECTIVES: The aim is to study vitiligo management strategy in Jeddah, Saudi Arabia (KSA) as indicated by dermatologists and as experienced by patients. METHODS: A written questionnaire was distributed to 132 dermatologists practicing in Jeddah, KSA. Another questionnaire was filled by 186 vitiligo patients attending dermatology outpatient clinic Al-Jedaani Hospital. RESULTS: For 76% of the participating dermatologists in Jeddah, KSA, vitiligo is not a pure cosmetic problem and 69% of the participating dermatologists encourage vitiligo treatment (acknowledged by 65% of patients). The main therapy was topical steroids and narrowband ultraviolet-B (NB-UVB) therapy in vitiligo focalis and vulgaris, respectively, for both children and adults. Of the participating patients, 51%, 57%, and 21% of patients reported getting adequate information from their first dermatologists about the disease name, treatment options, and prognosis, respectively. There is a significant correlation between ever receiving treatment and awareness of the exact diagnosis (p < 0.01), awareness of treatment options (p < 0.05) and treatment encouragement (p < 0.01). CONCLUSION: Dermatologists in Jeddah, KSA, are enthusiastic about vitiligo management; however, still some patients feel discouraged and misinformed. The study demonstrates the need for national evidence-based guidelines reflecting unique features of patients in this community.

Propolis as an alternative treatment for cutaneous warts.

Warts are common problems affecting adults and children. Multiple treatment options are available, but no single therapy stands out as uniformly effective. Propolis and Echinacea are relatively safe immunomodulators with antiviral properties. The purpose of this study was to assess the efficacy of Propolis and Echinacea in treating different types of warts. In a single-blind, randomized, 3-months trial, 135 patients with different types of warts received oral Propolis, Echinacea, or placebo. In patients with plane and common warts treated with Propolis, cure was achieved in 75% and 73% of patients, respectively. These results were significantly better than those associated with Echinacea treatment or placebo. We conclude that Propolis is an effective and safe immunomodulating therapy for plane and common warts.

Immunohistochemical staining for CD45R isoforms in paraffin sections to diagnose mycosis fungoides-type cutaneous T-cell lymphoma.

The definitive diagnosis of mycosis fungoides (MF)-type cutaneous T-cell lymphoma (CTCL) is difficult because a cumulative set of information is typically required: clinical features, histopathology, and special diagnostic tests (typically immunophenotyping and T-cell receptor gamma [TCRgamma] gene rearrangement). Fresh tissue is not always available for the special tests. We report a simple and readily available procedure evaluating the staining pattern on formalin-fixed, paraffin-embedded skin that can help with the diagnosis of patch/plaque stage MF. We reviewed 92 cases of MF or probable MF that had clinical information, immunophenotyping and TCRgamma gene rearrangement studies and that had been evaluated in our multidisciplinary lymphoma conference. We used antibodies to the isoforms of CD45, CD45RO for mature T cells and CD45RB for subsets of T cells. When atypical CD45RB-positive/CD45RO-negative cells were seen in nonspongiotic epidermis, the individuals had a high cumulative clinical and histologic score for MF. In contrast, 15 cases of known contact dermatitis showed a reactive pattern of both CD45RB- and CD45RO-positive cells in spongiotic epidermis. We compared the epidermal CD45RB-positive/CD45RO-negative staining pattern with CD7 deficiency by immunophenotyping and TCRgamma gene rearrangement, two commonly used methods in the diagnosis of MF. The epidermal CD45RB-positive/CD45RO-negative staining pattern is comparable and may be better in equivocal cases of possible MF. Therefore immunostaining for CD45RB and CD45RO on paraffin sections is a simple, reliable, and convenient modality in the diagnosis of MF.

Transduced monocyte/macrophages targeted to murine skin by UV light.

We have selectively targeted monocyte/macrophages overexpressing an immunomodulatory molecule, latency-associated peptide (LAP), a naturally occurring antagonist for transforming growth factor-beta1, to murine skin utilizing UV light to produce a cutaneous influx of transduced monocyte/macrophages. Bone marrow (BM) cells from BALB/c mice were transduced in vitro with a retroviral construct containing green fluorescent protein (GFP) for detection and human LAP (hLAP) as a test molecule. The transduced BM cells were then cultured in vitro with granulocyte-macrophage colony-stimulating factor (GM-CSF) to produce differentiation to monocyte/macrophages. More than 80% of transduced BM cells were CD11b-positive and MOMA-positive by fluorescence-activated cell-sorter analysis and secreted LAP by ELISA after 10 days of culture in granulocyte-macrophage colony-stimulating factor (GM-CSF). Transduced monocyte/macrophages containing either GFP or hLAP-GFP were then injected intravenously into BALB/c mice. One-half of recipients in each group were exposed to UVB (72 mJ) to induce monocyte/macrophage infiltration into skin. Recipients were sacrificed 60 h after UV irradiation. We found transduced cutaneous macrophages expressing GFP by examining with fluorescence microscopy frozen skin sections of recipient mice immunostained with antibodies to GFP and to macrophage marker F4/80. We identified hLAP sequences by polymerase chain reaction (PCR) of total DNA in recipient blood and UV-irradiated skin but not in unirradiated skin. LAP sequences were also detected at much lower levels in other organs (lung, spleen, and liver) by PCR. Therefore, we have shown that genetically altered monocytic cells can be injected intravenously and targeted to mouse skin by UV exposure. This macrophage-based gene-transfer method may be a potentially useful immunotherapeutic approach for delivering monocyte/macrophage-derived products to skin.

Evaluating invasive cutaneous melanoma: is the initial biopsy representative of the final depth?

BACKGROUND: An accurate initial biopsy of the deepest portion of the melanoma is vital to the management of patients with melanomas. OBJECTIVE: Our goal was to evaluate the accuracy of preliminary biopsies performed by a group of predominantly experienced dermatologists (n = 46/72). METHODS: A total of 145 cases of cutaneous melanoma were examined retrospectively. We compared Breslow depth on preliminary biopsy with Breslow depth on subsequent excision. Was the initial diagnostic biopsy performed on the deepest part of the melanoma? RESULTS: Of nonexcisional initial shave and punch biopsies, 88% were accurate, with Breslow depth greater than or equal to subsequent excision Breslow depth. Both superficial and deep shave biopsies were more accurate than punch biopsy for melanomas less than 1 mm. Excisional biopsy was found to be the most accurate method of biopsy. CONCLUSIONS: Deep shave biopsy is preferable to superficial shave or punch biopsy for thin and intermediate depth (<2 mm) melanomas when an initial sample is taken for diagnosis instead of complete excision. We found that a group of predominantly experienced dermatologists accurately assessed the depth of invasive melanoma by use of a variety of initial biopsy types.