Clinical and dermoscopic assessment of ablative carbon dioxide laser versus intradermal heparin sodium in xanthelasma.

BACKGROUND: Ablative carbon dioxide (CO2 ) laser is still a cornerstone in the management of xanthelasma. However, post-laser complications such as post-inflammatory hyperpigmentation or scarring have to be considered. Heparin sodium was recently suggested as an effective therapeutic modality for xanthelasma. OBJECTIVE: The aim of this work was to compare the therapeutic value of ablative CO2 laser versus intradermal heparin sodium in xanthelasma. METHODS: This study was piloted on 30 xanthelasma patients, whose lesions were randomly categorized into two groups. Group A was managed with CO2 laser ablation (2 sessions scheduled every 4 weeks), whereas Group B was managed with intradermal heparin sodium injections (10 sessions scheduled every week). Pre- and post-treatments evaluations were done both clinically and dermoscopically. RESULTS: Significant reduction of xanthelasma lesions was reported in response to both therapeutic interventions. However, the ablative CO2 laser was more significantly effective than intradermal heparin sodium. Interestingly, intradermal injection of heparin sodium was nearly as effective as ablative CO2 laser in early (<2 years duration) grade I and II xanthelasma, with a lower incidence of post-therapy side effects. CONCLUSIONS: Intradermal injection of heparin sodium could be suggested as a safe and cost-effective therapeutic technique for early mild grade I and II xanthelasma. Moreover, it could be recommended as a pre-operative management of grade III and IV xanthelasma to reduce the lesions to be easily ablated with CO2 laser.

Efficacy of prostaglandin E2 versus prostaglandin F2 alpha assisted with narrowband-UVB in stable vitiligo.

In the recent decades, prostaglandins were recommended as a new therapeutic modality of stable vitiligo with promising efficacy. Therefore, we designed the current work to compare the significance of two different subtypes of prostaglandins [prostaglandin E2 (PGE2) versus prostaglandin F2 alpha (PGF2α)], assisted with NB-UVB phototherapy, in treatment of stable vitiligo. This study was conducted on 30 patients with stable non-segmental vitiligo. Three approximately similar vitiliginous areas were chosen in each patient and assigned into 3 groups. Each group treated with intradermal injection of either PGE2 (group I), PGF2α (group II), or saline as placebo (group III) at frequency once/week for 12 weeks. Concomitantly, all groups received NB-UVB phototherapy twice weekly for 3 months. The outcomes of this study discovered that the therapeutic efficacy of intradermal injection of either PGE2 or PGF2α assisted with NB-UVB phototherapy was comparable with non-significant difference between them in spite of being significantly higher than NB-UVB alone. However, there were a significantly earlier onset of repigmentation and higher degree of satisfaction regarding areas treated with PGE2 than those treated with PGF2α. In conclusion, both PGF2α and PGE2 intradermal injection could be considered as quite simple and affordable techniques in the treatment of stable vitiligo with no reported side effects and good patient satisfaction.

YKL-40 immunoexpression as a prognosticator of mycosis fungoides.

BACKGROUND: YKL-40 is a 40 kDa chitinase-like glycoprotein that is predicted to contribute to the pathogenesis of several inflammatory and neoplastic conditions. OBJECTIVES: To assess YKL-40 immunoexpression in different stages of mycosis fungoides (MF) to find out if YKL-40 is playing a possible role in disease pathophysiology and progression. METHODS: This work included 50 patients with different stages of MF diagnosed on the basis of clinical, histopathological, and both CD4 and CD8 immunophenotyping, in addition to 25 normal control skin. The Immune Reactive Score (IRS) of YKL-40 expression was determined in all specimens and statistically analyzed. RESULTS: YKL-40 expression reported a significant rise in MF lesions compared to control skin. Among MF specimens, the mildest expression was observed in the early patch stage followed by the plaque stage, while the strongest was in tumor stages. Positive correlations were discovered between IRS of YKL-40 expression in MF specimens and patients' age, disease chronicity, clinical staging, and TNMB classification. CONCLUSION: YKL-40 might participate in MF pathophysiology, and the highest expression is associated with advanced stages of the disease and poor outcomes. Therefore, it might be of value as a prognosticator for monitoring high-risk MF patients and follow-up assessment of treatment success.

Cell adhesion molecule 1 expression in mycosis fungoides versus parapsoriasis versus inflammatory dermatosis: an immunohistochemical comparative study.

Cell adhesion molecule 1 (CADM1) is one of the immunoglobulin super family adhesion molecules, that is proposed to contribute in the pathogenesis of various types of cutaneous T-cell lymphoma, including mycosis fungoides (MF). In this work, we decided to examine the immunohistochemical expression of CADM1 in MF specimens compared to premycotic parapsoriasis, benign inflammatory dermatosis and normal control skin specimens. 125 participants were enrolled (50 MF, 25 parapsoriasis, 25 inflammatory dermatosis, and 25 healthy controls). Patients were selected from the Outpatient Clinic of Dermatology and Venereology Department, Tanta University Hospitals. From all, 4 mm punch skin biopsies were taken and examined for CADM1 immunohistochemical expression. The current study revealed statistically significant upregulation of CADM1 expression in MF specimens in comparison to parapsoriasis, inflammatory dermatosis, and normal control specimens. Additionally, there was statistically significant positive correlation between CADM1 expression and progression of TNMB staging of MF disease. Therefore, it is possible to recommend CADM1 as a beneficial diagnostic immunohistochemical marker for differentiation between early stages of MF and both the premycotic parapsoriasis and benign inflammatory dermatosis. Moreover, it may be of value in early detection of neoplastic transformation of parapsoriasis as well as in assessment of MF progression.

Impact of NB-UVB phototherapy on Caveolin-1 expression in chronic plaque psoriasis.

BACKGROUND: Caveolin-1 (Cav-1) is a significant structural and regulatory constituent of cell membranes that has been implicated in cell kinetics and inflammation. OBJECTIVE: To assess Cav-1 expression in psoriasis before and after phototherapy. PATIENTS AND METHODS: Thirty psoriasis cases and 30 healthy controls were recruited. Cases were managed with narrow band-ultraviolet B (NB-UVB) phototherapy at frequency three times per week for 12 weeks. From every case, two biopsy specimens were gained from psoriatic lesions (pre and post phototherapy), in addition to one from apparently normal skin of psoriasis cases. Regarding the control group, one biopsy was taken from a matched site. All were studied for Cav-1 antibody immuno-expression. RESULTS: There was a significant decrease in Cav-1 expression in psoriatic lesions compared to both the apparently normal skin of psoriasis patients and standard control skin of healthy individuals. After NB-UVB phototherapy, significant upregulation of Cav-1 immunostaining score was observed in previously psoriatic skin when compared to that before treatment. In addition, there were significant negative correlations between Cav-1 immunostaining score and the clinical scores of psoriasis severity including; the erythema, scaling, and induration (ESI) score and the patient psoriasis area and severity index (PASI) score. CONCLUSION: Induction of Cav-1 expression may be a likely pathway for the effectiveness of NB-UVB in psoriasis. Cav-1 may be a useful marker for evaluation of psoriasis severity, disease progression, and therapeutic efficacy.

YAP1 Expression in Lichen Planus and Squamous Cell Carcinoma: Role in Disease Pathogenesis and Potential Therapeutic Target.

BACKGROUND: Lichen planus (LP), especially oral type, reported a potential risk of malignant transformation to squamous cell carcinoma (SCC). Yes-Associated Protein (YAP1), a key component of the Hippo pathway, acts as a transcription cofactor regulating expression of genes involved in cell proliferation, apoptosis, and migration. Therefore, it has been implicated in carcinogenesis of a wide variety of human cancers. OBJECTIVES: To study YAP1 expression in LP and SCC in comparison to normal control (NC) specimens. PATIENTS AND METHODS: This study was conducted on 50 NC specimens, 50 LP specimens, and 50 SCC specimens. They were categorized into 2 main groups; cutaneous (25 NC, 25 LP, 25 SCC), and oral (25 NC, 25 LP, 25 SCC). All specimens were examined for YAP1 antibody expression by immunohistochemistry and YAP1 mRNA expression by reverse transcription-polymerase chain reaction (RT-PCR). RESULTS: In both cutaneous and oral groups; significant upregulation of YAP1 expressions was observed in SCC specimens followed by LP and then NC specimens in the same sequence. Its expression in SCC was found to be significantly higher in poorly and moderately differentiated types than well differentiated types. CONCLUSION: YAP1 may have a potential role in the pathogenesis of LP and oncogenesis and progression of SCC. Moreover, it could be considered as a novel therapeutic target for such cases.

Efficacy of platelet-poor plasma gel in combination with fractional CO2 laser in striae distensae: A clinical, histological, and immunohistochemical study.

BACKGROUND: Platelet-poor plasma gel is a semi-solid plasma formulation that recently recommended as autologous bio-filler for treatment of atrophic dermal scars. AIM: To compare the therapeutic efficacy and safety of intradermal injection of plasma gel in combination with fractional CO2 laser versus fractional CO2 laser alone in striae distensae (SD). PATIENTS AND METHODS: This study included 36 SD patients treated by three sessions (one session/1.5 months) of fractional CO2 laser on all SD lesions following intradermal injection of plasma gel on one side and saline (as placebo) on the other side. RESULTS: Significant clinical improvements associated with remarkable narrowing of SD lesions and prominent enhancement of skin texture were observed on both treatment sides. Obviously, higher degrees of clinical improvements of SD lesions were reported following combined therapy with fractional CO2 laser and plasma gel rather than fractional CO2 laser monotherapy. However, post-inflammatory hyperpigmentation (PIH) was reported more frequently with fractional CO2 laser monotherapy. Histopathological and immunohistochemical examinations revealed significant epidermal improvement, and homogenization, and orientation of dermal collagen bundles as a result of both therapeutic procedures. CONCLUSION: Plasma gel in combination with fractional CO2 laser could be considered a promising novel treatment modality for SD. Plasma gel not only improves the efficacy of fractional CO2 laser but also decreases the frequency of PIH.

Botulinum toxin and platelet rich plasma as innovative therapeutic modalities for keloids.

Keloids characterize a definitely challenging type of cutaneous scars for which a diversity of therapeutic modalities has been suggested. The aim of this work was to compare the therapeutic efficacy of intralesional injection of botulinum toxin type-A (BTX-A), platelet rich plasma (PRP), and triamcinolone acetonide (TAC) in keloids. A total of 60 keloids patients were enrolled and divided randomly into three equal groups. Group I treated by intralesional BTX-A injection, group II treated by intralesional PRP injection, and group III treated by intralesional TAC injection. Clinical assessment was done by Vancouver Scar Scale (VSS), Verbal Rating Scale (VRS), and dermoscopic examination. Additionally, histopathology and immunohistochemistry of connective tissue growth factor (CTGF) expression were evaluated. The results of this study revealed significant improvement of both VSS and VRS in response to all treatment modalities. There was significant improvement of VSS in BTX-A and PRP groups more than TAC group. However, no significant difference observed between BTX-A and PRP groups. Immunohistochemical examination showed significant decrease of CTGF expression after treatment in BTX-A and PRP groups more than TAC group. In conclusion, both BTX-A and PRP could yield a chance for cosmetically better outcomes in keloids treatment than conventional TAC injection.

A comparative study of combined microneedling and narrowband ultraviolet B phototherapy versus their combination with topical latanoprost in the treatment of vitiligo.

Regardless of the continuous discovery of innovative modalities for the treatment of vitiligo, none of them ensure excellent therapeutic outcome. Microneedling had been suggested either singly or concomitantly with other therapeutic modalities for vitiligo with encouraging results. Latanoprost, a prostaglandin F2-alpha (PGF2α), and their analogues are recently recommended for vitiligo treatment. This study was designed to assess the therapeutic efficacy of microneedling in combination with NB-UVB phototherapy versus their combination with latanoprost in vitiligo. It was conducted on 50 patients presented with stable bilateral localized nonsegmental vitiligo. In every patient; two bilateral, nearly symmetrical lesions were selected and treated by microneedling (12 sessions at 2-week interval) followed by topical application of latanoprost 0.005% solution on one side, and topical saline (as placebo) on the other side. In addition, all patients received concomitant NB-UVB phototherapy (three sessions/week) for 6 months. Significant clinical improvement of vitiligo lesions with significant increase in the degree of repigmentation were reported in response to both treatment regimens. Latanoprost in combination with microneedling and NB-UVB provides more significant therapeutic outcomes than combined microneedling and NB-UVB. In conclusion, topical latanoprost 0.005% enhances the therapeutic efficacy of combined microneedling and NB-UVB phototherapy in localized stable nonsegmental vitiligo.

Synergistic effect of platelet-rich plasma in combination with fractional carbon dioxide laser versus its combination with pulsed dye laser in striae distensae: A comparative study.

BACKGROUND: Striae distensae (SD) are very common atrophic cutaneous scarring that are therapeutically challenging. Various kinds of laser had been suggested as effective treatment modalities for SD. In addition, platelet-rich plasma (PRP) was recently recommended for its therapy. OBJECTIVE: To evaluate the synergistic role of PRP injection as a combined modality to fractional CO2 laser (Fr CO2 ) versus its combination with pulsed dye laser (PDL) in SD. PATIENTS AND METHODS: Thirty SD patients were included in this study and treated by intradermal injection of autologous PRP on both sides, followed by laser therapy (Fr CO2 laser on right side and PDL on left side). They received 3 treatment sessions at 6 weeks interval. RESULTS: Both treatment sides reported significant clinical improvements of SD lesions, evidenced by significant reduction of width of striae lesions and significant improvement of skin texture. Furthermore, significantly higher degree of clinical improvements were observed in response to treatment sessions by combined PRP with Fr CO2 laser rather than combined PRP with PDL. Generally, post-inflammatory hyperpigmentation (PIH) were mild in all patients. Histopathologically, SD lesions showed improvement of epidermal thickness, and more homogenization and regular orientation of dermal collagen fibers in both treatment sides, with more significant improvement on the side treated by combined PRP with Fr CO2 laser sessions rather than the other side. CONCLUSIONS: PRP injection in combination with Fr CO2 laser or PDL is considered safe and effective therapeutic regimens for SD. However, its combination with Fr CO2 laser is more promising with better outcome and fewer side effects.

Fractional carbon dioxide laser-assisted delivery of lyophilized-growth factors is a promising treatment modality of post-acne scars.

Lyophilized-growth factors (L-GFs), is a new platelet rich plasma (PRP) preparation that is standardized in growth factors concentrations. The aim of this study was to compare the therapeutic efficacy of ablative fractional CO2 laser in combination with L-GFs vs PRP in post-acne scars. This study was conducted on 45 patients presented with facial post-acne scars. Each patient received three sessions of fractional CO2 laser on both sides of the face followed by topical application of L-GFs on one side and conventional PRP on the other side. Assessment was done before and after treatment semiquantitatively by Echella d'Èvaluation Clinique des Cicatrices d'Acné (ECCA) score and qualitatively by Goodman and Baron's qualitative scar (GBQS) scale, in addition to dermoscopic evaluation. The current study reported significant clinical improvement of post-acne scars on both sides of the face evidenced by significant reduction of both ECCA score and GBQS scale with minimal side effects. The degree of clinical improvement and patients' satisfaction were significantly higher with shorter downtime in response to fractional CO2 laser combined with L-GFs rather than its combination with PRP. In conclusion, laser assisted delivery of L-GFs via fractional CO2 laser could be considered a novel successful therapeutic modality for post-acne scars.

Platelet-poor plasma gel vs platelet-rich plasma for infraorbital rejuvenation: A clinical and dermoscopic comparative study.

Infraorbital dark circles and tear trough deformity are considered common aesthetic problems. Numerous therapeutic modalities have been suggested with variable outcomes. The aim of this study was to compare the efficacy of platelet-poor plasma (PPP) gel vs platelet-rich plasma (PRP) in infraorbital rejuvenation. A total of 68 females presented with dark circles and/or tear trough deformity were recruited and treated by PPP gel injection in the right infraorbital region (Group A) and PRP injection in the left infraorbital region (Group B). They received three treatment sessions at 2-week interval, and followed up monthly for 3 months. They were evaluated clinically and dermoscopically before treatment and at the end of follow-up period. Both groups showed significant clinical improvements proved by significant reduction of degree of hyperpigmentation and tear trough rating scale. Obviously, more significant clinical and dermoscopic improvements were observed in Group A than Group B. Therefore, it could be concluded that both PPP gel and PRP were clinically effective procedures for aesthetic improvement of infraorbital region. Moreover, PPP gel seems to be significantly more effective than PRP as a therapeutic modality.

Significance of SOX18 expression in nonmelanoma skin cancers for prediction of high-risk patients: a preliminary study.

BACKGROUND: SOX18 is an integral transcription factor that is involved in endothelial cells differentiation during both angiogenesis and lymphangiogenesis. Therefore, it has been implicated in tumor progression and metastasis. OBJECTIVE: To study SOX18 expression in nonmelanoma skin cancers (NMSCs) in comparison to seborrheic keratosis (SK) and normal control skin, and to assess its probable role in tumor evolution and progression. PATIENTS AND METHODS: This study was conducted on 60 specimens of NMSCs: 30 basal cell carcinomas (BCC) and 30 squamous cell carcinomas (SCC), 30 specimens of SK, and 30 normal skin specimens. All were examined for immunohistochemical expression of SOX18 antibody. Additionally, morphometric assessment of vessel density (blood & lymphatic) in each specimen was estimated. RESULTS: Significant SOX18 overexpression was observed in all studied cutaneous tumors in comparison to control skin. The highest score of SOX18 expression was detected in SCC, then BCC, and the least expression was reported in SK with significant difference between them. Furthermore, significant upregulation of SOX18 expression was observed in high-risk types of both BCC and SCC compared to low-risk types. Stromal vessel density showed significant differences between the studied tumors with the highest mean value in SCC, followed by BCC and then SK. Positive correlation between SOX18 expression in the studied tumors and their vessel density was detected. CONCLUSIONS: SOX18 may have a potential role in the evolution as well as progression of NMSCs, possibly through induction of both angiogenesis and lymphangiogenesis. Furthermore, it could be beneficial for prediction of NMSC patients with poor prognosis.

The Prognostic Value of Podoplanin Expression in Nonmelanoma Skin Cancers: Correlation With Lymphatic Vessel Density.

BACKGROUND: Podoplanin is one of the integral molecules controlling cellular motility and migration that is considered crucial in initiating tumor invasiveness and metastasis. OBJECTIVE: This work aimed at studying the immunohistochemical expression of podoplanin in nonmelanoma skin cancers (NMSCs) and seborrheic keratosis (SK) in comparison to normal control skin and to evaluate its possible role in their pathogenesis. PATIENTS AND METHODS: This study included 120 patients and paraffin blocks of epidermal tumors [30 SK, 30 basal cell carcinoma (BCC), 30 basosquamous carcinoma (BSC) and 30 squamous cell carcinoma (SCC)], in addition to 30 normal control skin specimens from age- and sex-matched healthy volunteers. All were examined for intratumoral and peritumoral immunohistochemical expression of podoplanin antibody (D2-40). In addition, morphometric measurement of lymphatic vessel density was evaluated in all studied specimens. RESULTS: Podoplanin expression was significantly upregulated in all the studied epidermal tumor specimens in comparison to normal control skin specimens. The highest mean value of podoplanin expression (both intratumoral and peritumoral cells) was observed in SCC followed by BSC, then BCC, SK, and control skin in the same sequence. Positive correlations were detected between its expression in both BSC and SCC with the mean of lymphatic vessel density in the studied specimens and the presence of lymph node metastasis. CONCLUSIONS: Podoplanin plays an evident role in the development and progression of both benign and malignant skin neoplasms and may serve as a potential predictor of their clinical course and prognosis.

Immunohistochemical Expression of Calmodulin in Cutaneous Lichen Planus: A Case-Control Study.

BACKGROUND: Calmodulin (CaM) is a multifunctional intermediate messenger protein that plays important role in cell motility, proliferation, and apoptosis. Therefore, it is thought to be involved in various ways in the apoptotic processes which are implicated in the pathogenesis of lichen planus. OBJECTIVE: The aim of this study was to evaluate the immunohistochemical expression of CaM in lichen planus lesions in comparison to normal control skin to throw light on its possible role in disease pathogenesis. PATIENTS AND METHODS: This case-control study was conducted on 50 patients with lichen planus, in addition to 20 age- and sex-matched healthy individuals. Skin biopsy specimens were taken from lesional skin of lichen planus patients as well as normal skin of controls. All were examined for immunohistochemical expression of CaM antibody. RESULTS: There was statistically significant increase of the immunohistochemical expression of CaM in lesional skin of lichen planus patients compared with normal skin of controls (Chi-square test, P < 0.001). No significant correlation could be detected between CaM expression in lesional skin and the studied clinical parameters of lichen planus patients. LIMITATIONS: Tha main limitation of this study is its small sample size. CONCLUSION: CaM is upregulated in cutaneous lichen planus lesions suggesting a possible role in disease pathogenesis. Targeting CaM is expected to be a novel strategy for treatment of lichen planus.

Assessment of the efficacy and safety of platelet poor plasma gel as autologous dermal filler for facial rejuvenation.

BACKGROUND: The popularity of dermal fillers has grown rapidly in the last few years for facial rejuvenation. Plasma gel is an autologous gelatinous material that is prepared from the patient's own platelet poor plasma. OBJECTIVE: To evaluate the clinical efficacy and safety of plasma gel injection as a dermal filler for facial rejuvenation. PATIENTS AND METHODS: The current study was carried out on 52 females presented with facial aging divided into two groups: Group A included 34 females with facial wrinkles, and Group B included 18 females with tear trough deformity. After taking written informed consent, they received two sessions of plasma gel injections at 2-week interval and followed up monthly for 3 months. They were assessed clinically before treatment sessions and at the end of follow-up period. RESULTS: Both studied groups showed immediate significant clinical improvement after plasma gel injection that maintained till the end of follow-up period. This finding was confirmed by significant reduction in the mean values of Wrinkle Severity Rating Scale (WSRS) in Group A and Tear Trough Rating Scale (TTRS) in group B, and significant improvement of skin homogeneity and texture in both groups. In general, the reported side effects were minimal and transient. CONCLUSION: Autologous platelet poor plasma gel injection seems to be a cost-effective, safe, well-tolerated, and minimally invasive technique producing significant aesthetic correction of facial wrinkles and tear trough deformity.

Study of the efficacy of carboxytherapy in alopecia.

BACKGROUND: Management of alopecia areata (AA) and androgenetic alopecia (AGA) is often challenging. The use of carboxytherapy may be a novel therapeutic option for such cases. OBJECTIVE: To evaluate the clinical efficacy and safety of carboxytherapy in alopecia areata and androgenetic alopecia. PATIENTS AND METHODS: This study was conducted on 80 patients with alopecia divided into two groups; Group I included 40 AA patients (Group IA received carboxytherapy and Group IB control received placebo), and Group II included 40 AGA patients (Group IIA received carboxytherapy and Group IIB control received placebo), and followed up monthly for 3 months. They were evaluated clinically (by assessment of Severity of Alopecia Tool (SALT) score in group I, and Sinclair scale and Norwood-Hamilton scale in group II), by dermoscopy and digital dermoscopy at each visit. RESULTS: Group IA patients showed significant clinical improvement in SALT score and dermoscopic improvement after carboxytherapy and at the end of follow-up period with significant reduction in dystrophic hair, black dots, yellow dots, and tapered hair coinciding with significant emergence of regrowing hair. Group IIA patients showed significant clinical and dermoscopic improvement after carboxytherapy with significant increase in hair density measured by digital dermoscopy. However, regression of these results was observed during the follow-up period but was still significantly better than before treatment. There were statistically significant improvements in clinical score, global assessments, dermoscopic, and digital dermoscopic findings in both group IA and group IIA received carboxytherapy in comparison with group IB and group IIB received placebo injections, respectively. CONCLUSION: Carboxytherapy seems to be a promising therapeutic option for patchy AA and could be helpful as an adjuvant therapy of AGA but more than 6 sessions are required and adjuvants are recommended for maintenance of the results.