Correlation of anti-γ/ε nicotinic acetylcholine receptor antibody levels with anti-desmoglein 1,3 antibody levels and disease severity in pemphigus vulgaris.

BACKGROUND: A role for nondesmoglein antigens in the pathogenesis of pemphigus vulgaris (PV) has been suggested in several studies. Acetylcholine receptors (AchR), are one of the most important groups of these antigens. However, the exact role of both antimuscarinic (m) and nicotinic (n) AchR antibodies (Abs) is still controversial. AIM: To evaluate anti-desmoglein (Dsg)1, Dsg 3 and anti-γ/ε nAchR Abs values in patients with PV before and 3 months after rituximab (RTX) treatment, and to assess their correlation with disease severity. METHODS: In total, 75 patients with PV (26 men, 49 women) who were planned to receive RTX were enrolled. Disease activity was assessed by using the Pemphigus Disease Area Index (PDAI). Using ELISA, anti-Dsg1,3 and anti-γ/ε nAchR Abs were determined at baseline and 3 months after RTX treatment. RESULTS: At baseline, 53.33% patients had positive values for anti-Dsg1, 89.33% for anti-Dsg3 and 13.33% for anti-γ/ε nAchR Abs. All patients with positive anti-γ/ε nAchR Abs had the mucocutaneous phenotype. PDAI, anti-Dsg1,3 and anti-γ/ε nAchR values were dramatically decreased 3 months after RTX infusion (P < 0.001). There was a significant positive correlation between disease activity and anti-γ/ε nAchR values at baseline (P = 0.04), whereas no significant correlation was observed between anti-Dsg1,3 and anti-γ/ε nAchR values at baseline and 3 months after RTX infusion. CONCLUSION: The reduction in anti-γ/ε nAchR Abs with clinical improvement in this study may suggest a synergic role for anti-γ/ε nAchR Abs with anti-Dsg1,3 Abs, or it could be an epiphenomenon.

Association of Human Herpes Virus 6 Infection with Lichen Planopilaris.

Lichen planopilaris (LPP) is the prototype of cicatricial alopecia and is the follicular form of lichen planus. Some studies showed viral agents such as hepatitis C virus; Epstein Bar virus and human Herpes viruses are associated with classic and oral lichen planus. We conducted this study to find if there is a relationship between LPP and human herpes virus-6 (HHV-6) as this virus is prevalent worldwide. This cross-sectional study was conducted in Razi Hospital, Tehran, during one-year interval. Total of 30 treatment naïve LPP patients and 30 healthy matched controls enrolled the study. Serum anti-HHV-6 antibody and the presence of virus genome examined using ELISA and Nested PCR technique, respectively. HHV-6 genome was also determined three months after treatment in LPP patients. Twenty-nine (96.6%) and 3(10%) of LPP patients were positive for anti-HHV-6 antibody and DNA genome, respectively; while 28(93.3%) and 3(10%) were positive in the control group. The presence of anti-HHV-6 antibody and HHV-6 genome was not statistically different between LPP patients and controls (p value >0.05). The comparison between LPP cases after three months of systemic therapies and the same controls also showed no statistically significant difference (P value >0.05). This study showed there is no association between lichen planopilaris and HHV-6.

Hydrocortisone 1% cream and sertaconazole 2% cream to treat facial seborrheic dermatitis: A double-blind, randomized clinical trial.

BACKGROUND: Seborrheic dermatitis (SD) is a chronic dermatitis with periods of remission and relapse that requires long-term treatment. OBJECTIVE: We compared the efficacy and safety of treatment with sertaconazole with standard corticosteroid medications in adults with facial SD. METHODS: In this double-blind, randomized controlled trial, 60 patients with a diagnosis of SD were enrolled. Patients were instructed to apply either sertaconazole 2% cream (30 patients) or hydrocortisone 1% cream (30 patients) twice daily to the affected area of the face. The severity of facial SD was assessed at 0, 2, and 4 weeks of treatment. Secondary efficacy measures included patient assessment of seborrhea, adverse events, and improvement percentage (IP). RESULTS: SD lesions cleared significantly (p < .05) and similarly in both treatment groups (p > .05). Both treatments resulted in significant improvement of SD lesions and the rate of adverse events was similar in both groups. The IP was higher for treatment with hydrocortisone in Week 2 and similar in both groups at the end of the study. LIMITATIONS: Limitations include the small number of patients who were recruited for this study and the lack of evaluation of time to relapse. CONCLUSION: Treatment with topical sertaconazole may be regarded as a substitute for topical corticosteroid medications due to the fewer adverse events and similar efficacy.

Evaluation of Hepatitis B Vaccination among Lichen Planus Patients.

Lichen planus (LP) is an idiopathic chronic inflammatory mucocutaneous disease. Many reports in the literature have described hepatitis B vaccine as a predisposing factor for LP. This study was performed to determine the rate of previous vaccination against hepatitis B in LP patients. This was a cross sectional study on LP patients. Diagnosis of LP was confirmed by histological examination. Data were gathered by dermatology residents based on a checklist designed to guide their interview. Blood samples were tested for HBsAB titer, HBsAg, HCV Ab and liver function tests. One hundred & twenty four (124) patients entered the study. Females were 2.72 times more affected. The mean age of patients was 45.63 years (age range; 18-88). Forty-four (35.5%) patients had been vaccinated against hepatitis B. Lichen planus during the first six months of vaccination occurred in only one patient. Our findings bring into question the causative role of HBV vaccine in LP incidence in our population.

Comparison of desmoglein 1 and 3 enzyme-linked immunosorbent assay and direct immunofluorescence for evaluation of immunological remission in pemphigus vulgaris.

BACKGROUND: Drug withdrawal is the ultimate goal in the management of patients with pemphigus. Direct immunofluorescence (DIF) has long been considered the gold-standard test to predict immunological remission in pemphigus vulgaris (PV); however, there have been no comparisons between DIF and antidesmoglein (anti-Dsg) ELISA. AIM: To compare anti-Dsg ELISA with DIF in patients with PV for evaluation of immunological remission. METHODS: The study enrolled 46 patients with PV who had absence of any lesion, and had a daily prednisolone dosage of ≤ 10 mg without adjuvant drug treatment in the preceding 6 months. Biopsy specimens were taken from patients and processed for DIF. Intercellular deposition of IgG and/or C3 was considered positive. Serum samples were also collected for anti-Dsg1 and anti-Dsg3 ELISA, and an ELISA index value of > 20.0 was considered positive. RESULTS: DIF and anti-Dsg ELISA were positive for 11 (23.9%) and 18 patients (39.1%), respectively. Anti-Dsg ELISA had a sensitivity of 100%, a specificity of 80%, a positive predictive value of 61.1% and a negative predictive value of 100%. CONCLUSIONS: The high sensitivity of anti-Dsg ELISA proves that this simple serological test is a good substitute for DIF for evaluation of immunological remission in PV. As none of the DIF-positive patients was anti-Dsg-negative, it is possible that during the course of immunological remission, results for DIF may become negative before the results for Dsg ELISA do so.

Pemphigus vulgaris-associated Kaposi's sarcoma: response to paclitaxel and review of the literature.

Systemic corticosteroids have long been the mainstay of treatment for pemphigus patients. However, the necessity of their high-dose and long-term administration has brought about a number of complications, sometimes causing significant morbidities. Maintaining a balance between therapeutic and undesirable effects of medications is not always easily achievable. Therefore, additional treatment modalities are frequently needed to control side-effects. Kaposi's sarcoma (KS) is a rare, potentially life-threatening complication in this setting. Due to the rarity of data on pemphigus-associated KS treatment, the best therapeutic approach is still undecided. Here, we report two cases of pemphigus patients who had developed extensive KS as a result of severe immunosuppressive therapy and were successfully treated with paclitaxel. In addition, we performed a review of literature to assess the results of the previously employed treatment modalities in this setting.

Randomized double blind trial of prednisolone and azathioprine, vs. prednisolone and placebo, in the treatment of pemphigus vulgaris.

BACKGROUND: The classic treatment for pemphigus vulgaris is prednisolone. Immunosuppressive drugs can be used in association. OBJECTIVE: To compare the efficacy of Azathioprine in reducing the Disease Activity Index (DAI). PATIENTS AND METHODS: A double blind randomized controlled study was conducted on 56 new patients, assigned to two therapeutic groups: (i) prednisolone plus placebo; (ii) prednisolone plus Azathioprine. Patients were checked regularly for 1 year. 'Complete remission' was defined as healing of all lesions after 12 months, and prednisolone <7.5 mg daily, (DAI ≤ 1). Analysis was done by 'Intention To Treat' (ITT) and 'Treatment Completed Analysis' (TCA). RESULTS: Both groups were similar in age, gender, disease duration, and DAI. Primary endpoint: By ITT and TCA, the mean DAI improved in both groups with no significant difference between them. The difference became significant for the last trimester (3 months; ITT: P = 0.033, TCA: P = 0.045). Secondary endpoint: The total steroid dose decreased significantly in both groups, with no significant difference between them, except for the last trimester (ITT: P = 0.011, TCA: P = 0.035). The mean daily steroid dose decreased gradually in both groups becoming statistically significant in favour of azathioprine, in the last trimester, especially at 12th months (ITT: P = 0.002, TCA: P = 0.005). Complete remission was significant at 12 months only for TCA (AZA/Control: 53.6%/39.9%, P = 0.043). LIMITATIONS: Sample size was rather small to demonstrate all differences. Other limitations include the choice of primary and secondary endpoints and the unavailability to measure thiopurine methyltransferase activity. CONCLUSION: Azathioprine helps to reduce prednisolone dose in long-run.

Subcision-suction method: a new successful combination therapy in treatment of atrophic acne scars and other depressed scars.

BACKGROUND: Among therapeutic modalities of acne scars, subcision is a simple, safe procedure with a different and basic mechanism for correcting atrophic and depressed scars. Subcision releases scar surfaces from underlying attachments and induces connective tissue formation beneath the scar directly, without injury to the skin surface. Therefore, subcision is a valuable method, but due to high recurrence rate, its efficacy is mild to moderate. OBJECTIVES: To increase the efficacy of subcision, a new complementary treatment of repeated suction sessions was added at the recurrence period of subcised scars. METHODS: In this before and after trail, 58 patients with mild to severe acne scars of various types (rolling, superficial and deep boxcar, pitted), chicken pox, traumatic and surgical depressed scars were treated by superficial dermal undermining, with mainly 23-guage needles. The protocol for suctioning was: start of suction on third day after subcision for flat and depressing subcised scars and its continuation at least every other day for 2 weeks. RESULTS: Forty-six patients followed the protocol completely, had 60-90% improvement in depth and size of scars (significant improvement) with mean: 71.73%. 28.2% of them had '80% improvement or more' (excellent improvement). Twelve patients started suction late and/or had long interval suction-sessions, had 30-60% improvement (moderate improvement) with mean: 43.75%. CONCLUSION: Frequent suctioning at the recurrence period of subcision increases subcision efficacy remarkably and causes significant and persistent improvement in short time, without considerable complication, in depressed scars of the face. Therefore, subcision-suction method is introduced as a new effective treatment.

A study on plucked hair as a substrate for direct immunofluorescence in pemphigus vulgaris.

BACKGROUND: It has recently been demonstrated in a study on 15 patients that plucked hair can be used as a substrate for direct immunofluorescence (DIF) in pemphigus. OBJECTIVE: Our aim was to assess the sensitivity of DIF on plucked hairs in pemphigus vulgaris (PV) patients with positive DIF of oral mucosa. METHODS: One hundred and ten new PV patients were enrolled in the study. They all showed the typical clinical and histological findings as well as positive DIF of the oral mucosa, diagnostic for PV. Approximately 30 hairs were obtained in the same way as for the trichogram. The hairs with their outer root sheaths (ORS) were processed for DIF in order to detect immunoglobulin G and C3. RESULTS: Immunodeposits favouring PV were demonstrated in the ORS of 100 cases showing a sensitivity of 91%. CONCLUSION: Regarding the relatively high sensitivity of DIF on plucked hair in PV patients with positive oral mucosal DIF in our study, it seems that hair plucking is a suitable alternative to the more invasive techniques of skin or mucosal biopsy for obtaining specimens for DIF in PV.

Subcision in acne scar with and without subdermal implant: a clinical trial.

BACKGROUND: Subcision is a procedure that has been reported to be beneficial in treatment of acne scars. OBJECTIVE: This stady aims to assess the efficacy of subcision in the treatment of rolling acne scars and evaluate a novel subdermal filler 'absorbable plain catgut suture' with subcision. METHODS: Twenty-two patients with rolling acne scars underwent subcision, 20 of whom completed treatment and follow-up period. One side of the face underwent subcision and another side subcision with subdermal implant. The patients and investigators' assessment of improvement were both recorded. RESULTS: Subcision showed mild improvement in about 60% of patient and moderate improvement in about 40% of them. The rate of response showed no significant difference with the use of subdermal implant. The side-effects of local oedema, bruising and infection were all transient. CONCLUSIONS: Subcision seems to be a safe method to correct the rolling acne scars with long-term improvement. However, the subdermal implant led to no significant superior results.

Efficacy and safety of cryotherapy vs. trichloroacetic acid in the treatment of solar lentigo.

BACKGROUND: Solar lentigines are common sun-induced benign melanocytic proliferation that presents a significant cosmetic worrying for many middle-aged and elderly patients. Although the newer photoselective lasers have become the mainstay of treatment, cryotherapy and trichloroacetic acid (TCA) solution are inexpensive alternatives in the treatment of solar lentigines. The purpose of this study was to assess the efficacy of cryotherapy compared with TCA 33% on solar lentigines of the back of the hands (SLBH) in patients presenting to dermatologic clinic of our hospital. METHODS: Each hand of 25 women with SLBH was treated randomly with either cryotherapy or TCA 33% solution. Photographs of the hands were taken prior to and 2 months following the treatment. The response and side- effect rate were compared. RESULTS: Cryotherapy was more likely to produce substantial lightening of the solar lentigines than TCA 33% solution (P = 0.025) but more painful and took more time to heal. Post-inflammatory hyperpigmentation (PIH) was almost equal in two types of treatment (P > 0.05). Statistically, the better results were seen in fairer Fitzpatrick's skin types (P = 0.00). CONCLUSION: Cryotherapy shows better results than TCA 33% solution in the treatment of SLBH particularly in lower Fitzpatrick skin types. PIH is the major complication of each type of treatments particularly in darker Fitzpatrick skin types. Generally, the major criterion for treatment of SLBH with cryotherapy or TCA is Fitzpatrick's skin type of patients.

Narrow-band UVB in the treatment of early stage mycosis fungoides: report of 16 patients.

Although early stage mycosis fungoides (MF) has a generally good prognosis, and long-term survival rates with current therapies (UVB, photochemotherapy, topical nitrogen mustard, electron beam radiotherapy) are similar, there is concern regarding their potential side effects. It has been reported that the same effective UVB dose is safer than PUVA in terms of carcinogenicity, and that it produces fewer side effects. Our aim was to evaluate the effect of narrow-band UVB in the treatment of early stage MF. Sixteen patients (seven males, nine females; mean age, 40 years) with early stage MF received TL-01 phototherapy three times per week using a standard protocol. Twelve patients (75%) had complete response in a mean of 27.9 treatments, three had partial response, and one no response. Upon discontinuation of treatment, six patients with complete response relapsed in a mean time to relapse of 4.5 months. The present study indicates that narrow-band-UVB is an effective treatment modality for early stage MF.