Successful treatment of severe refractory post-cesarean pyoderma gangrenosum with intravenous immunoglobulin.

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by rapidly progressing necrolytic ulceration of the skin. Proper treatment is crucial since it can result in devastating consequences. First-line treatments include systemic corticosteroids or cyclosporine. However, no standardized treatment regimens for refractory cases exist and treatment outcomes are affected by underlying conditions. PG after cesarean section, which is believed to occur in association with underlying pregnancy- and parturition-related immune changes, is extremely rare, and all reported cases in the literature have been successfully treated with systemic or topical corticosteroids. We report a case of a 32-year-old patient with severe PG occurring on her cesarean scar 3 days after the cesarean delivery. Treatment with systemic corticosteroids and first-line immunomodulatory agents resulted in insufficient response and serious complications. Intravenous immunoglobulin (IVIG) was then initiated, and a rapid clinical response was seen. Corticosteroid dose was gradually decreased and ceased. IVIG infusion was continued for 3 months until complete recovery. Reactivation was not observed in a 1-year follow-up period. Due to its cost, IVIG infusion is less suitable as a first-line agent. However, IVIG may be an important therapeutic option in resistant postpartum PG, in which first-line agents have failed or led to complications.

Evaluation of sequential effect of isotretinoin on the haematological parameters in patients with acne vulgaris.

PURPOSE: Isotretinoin is the most effective drug for acne with some side effects. Few studies exist regarding the effects of isotretinoin on haematological parameters with different results. Mostly, baseline values with a single value during or at the end of the treatment were compared. In this study, we aimed to determine the differences in haematological parameters during isotretinoin treatment until reaching the cumulative dose of 120 mg/kg. MATERIALS AND METHODS: The study included 118 patients with moderate-to-severe acne vulgaris. Patients with preexisting liver disease, anaemia, iron deficiency, abnormal liver function tests, thrombocytopenia/thrombocytosis or hyperlipidaemia were excluded. Laboratory monitoring for haematological parameters was performed at baseline and monthly during treatment. Parameters at the baseline, at the first and second months and at the end of the therapy were taken into account. RESULTS: According to general linear model analysis, platelets and plateletcrit increased at the first month of the treatment and then decreased to baseline. White blood cells and neutrophils decreased at the first month, then increased to baseline value at the second month, and were found to be decreased again at the end of the treatment. Mean corpuscle volume was found to be increased at the end of the treatment. Other parameters in CBC did not show statistically significant differences. CONCLUSIONS: Although some changes occur in haematological parameters during isotretinoin therapy, all of these changes remain within the normal range. Evaluating the spot values at any time during treatment may cause misinterpretations.

Hyperbaric oxygen therapy for the management of chronic wounds.

Wound healing is actually a complex, precisely coordinated interaction between inflammatory cells and mediators, establishing significant overlap between the phases of wound healing. Chronic wounds are defined as wounds that do not follow the well-defined stepwise process of physiologic healing. The true incidence and economic impact of chronic wounds are difficult to assess because of the wide range of causative diseases and available treatment options. Despite multiple simultaneous and sequential therapeutic approaches, chronic wounds are highly resistant to treatment and are often indolent or even slowly progressive. Hyperbaric oxygen therapy (HBOT) has been explored as a treatment modality for chronic wounds because of its potential to promote healing and reduce bioburden in the wound bed. Multiple potential beneficial effects for wound healing have been demonstrated in various laboratory studies and experimental animal models. In this manuscript, HBOT, its mechanism of action, adverse effects and usage in diabetic and nondiabetic chronic wounds have been reviewed.

Autochthonous transmission of Leishmania donovani and Leishmania major with all the components of infection cycle at Europe's doorstep.

OBJECTIVES: Leishmaniasis is a vector-borne disease and dogs may act as urban reservoirs. Turkey and most of the Mediterranean basin countries are endemic for leishmaniasis. In this study, it is aimed to report the autochthonous leishmaniasis cases, with all the components of the infection cycle (reservoir, vector, and the host) in a region close to Europe. METHODS: Nine human and four canine autochthonous leishmaniasis cases were included in the study. Direct microscopy, culture methods, serological, and molecular tests were applied to the samples obtained from the cases. RESULTS: VL and CL patients consisted of 2 L.infantum, 1 L. donovani, 2 L. tropica, and 2 L. tropica,1 L. major,1 L. infantum infected patients respectively. CanL cases were infected with L. infantum, L. donovani, L. tropica, and L. major. CONCLUSIONS: All the cases were autochthonous cases located in Manisa province. As Greece and all the Mediterranean basin countries in Europe share competent vectors, it is concluded that the detection of all 4 species of Leishmania parasites in such proximity to Europe poses an important public health threat for Europe. This study reports all four species of Leishmania spp., including L. major and L.donovani in close proximity to continental Europe.

Primary cutaneous anaplastic CD30 + large-cell lymphoma that completely regressed after incisional skin biopsy.

We describe a 48-year-old woman with three erythematous nodules localized on the left forearm, with 2 months evolution. Histological and immunohistochemical examination revealed a CD30(+) large-cell lymphoma. Systemic involvement was not detected. The tumor regressed spontaneously within a week, after the incisional skin biopsy. In control skin biopsy, there was not any histological feature of lymphoma. No reactivation or any symptom of systemic disease was observed during the 10-month follow-up period.

Oxidative stress impairs endothelial nitric oxide levels in Behçets' disease.

BACKGROUND: Behçet's disease (BD) is an inflammatory vasculitis. Endogenous nitric oxide (NO), produced by endothelial cells, has pleiotropic effects such as vasodilatator, antiplatelet, antiproliferative. Reactive oxygen species (ROS) are produced at sites of endothelial inflammation. ROS target polyunsaturated lipids, which results in malondialdehyde (MDA) production. OBJECTIVE: The aim was to investigate the oxidative stress in BD patients by measuring MDA and total antioxidant status (TAS) levels and to establish a possible relationship with respect to NO levels regarding disease activity. MATERIALS AND METHODS: 55 BD patients (30 active/25 inactive) and 20 healthy volunteers were included in the study. Blood samples were drawn following an overnight fasting. TAS and MDA levels were determined spectrophotometrically. Serum nitrite (NO(2-)) and nitrate (NO(3-)) levels were measured to estimate NO production. Data were expressed as mean ± SD. RESULTS: TAS levels were significantly lower in BD patients than the controls (1.19 ± 0.34 vs. 3.29 ± 0.89 mmol/L). In the active BD group, MDA levels (0.36 ± 0.19 nmol/mL) were significantly higher than both the inactive BD group (0.25 ± 0.18 nmol/mL) and controls (0.18 ± 0.41 nmol/mL). NO levels were significantly lower in the active group compared to the inactive group (18.0 ± 2.80 vs. 19.40 ± 2.70 µmol/L). MDA levels correlated negatively with NO levels in the active group. CONCLUSION: Decreased NO levels mediated by increased oxidative stress significantly contribute to endothelial dysfunction observed in BD.

Patients' knowledge about psoriasis and comorbidities; their participation in treatment decisions.

BACKGROUND: Psoriasis is a common chronic inflammatory disease. Having more information about psoriasis and comorbid diseases means that patients have more involvement in treatment. AIM: Evaluate the knowledge levels of psoriasis patients about the disease and comorbidities and also to determine participation in treatment decisions. METHODS: Totally 103 patients over the age of 18 with diagnosed psoriasis were included into the study. A questionnaire including items on knowledge about disease and treatment options, comorbid diseases were filled out by the patients. Total knowledge score (TKS) was found by giving 1 point to the questions that the patients knew correctly. RESULTS: Patients were well informed about their risk of depression (64.1%), but were less well informed about their risk of atherothrombotic disease (14.6%). About 50.4% of the patients thought that psoriasis may be due to an internal organ disease. There was a negative correlation between the patient's age, the age of diagnosis and TKS. About 42.7% wanted to leave the decision entirely to the physician. CONCLUSION: The results of this study showed that majority of patients with psoriasis are not aware of the increased risk of comorbid diseases and do not have enough knowledge about psoriasis.

Therapeutic hotline: Treatment of prurigo nodularis and lichen simplex chronicus with gabapentin.

Psychocutaneous conditions are frequently encountered in dermatology practice. Prurigo nodularis and lichen simplex chronicus are two frustrating conditions that are classified in this category. They are often refractory to classical treatment with topical corticosteroids and antihistamines. Severe, generalized exacerbations require systemic therapy. Phototherapy, erythromycine, retinoids, cyclosporine, azathiopurine, naltrexone, and psychopharmacologic agents (pimozide, selective serotonin reuptake inhibitor antidepressants) were tried with some success. Here five cases with lichen simplex chronicus and four cases with prurigo nodularis, who responded well to gabapentin, are presented.

Acute generalized exanthematous pustulosis with lymphangitis triggered by a spider bite.

Acute generalized exanthematous pustulosis (AGEP) is a rare, severe cutaneous reaction pattern that, in the majority (>90%) of cases, is related to administration of medication. It can be seen in both genders and in all ages. The cutaneous manifestations of AGEP are usually seen 1-14 days after drug administration. A 39-year-old woman presented to our outpatient clinic with the complaint of generalized erythema, burning, and rash. She explained that 2 days before presentation a spider bite had occurred on her left forearm, after which she had experienced pain and erythema spreading gradually to the left upper extremity. On her dermatologic examination, she had an indurated necrotic plaque on the left forearm, which had an upward-spreading linear erythema. Additionally, she had diffuse erythema on her body and small pustules over erythematous skin, especially located on the left popliteal fossa and gluteal region. Based on the clinical and histopathologic findings, she was diagnosed as having AGEP. Because there was no drug use in her history, we attributed her AGEP lesions to the spider bite. This case is interesting, because the patient also had lymphangitis. Herein, we present the fifth case reported in the literature of AGEP caused by a spider bite.

Pyogenic granuloma in two children successfully treated with imiquimod 5% cream.

Pyogenic granulomas are sometimes difficult to treat in children, especially very young children in whom surgical procedures may be difficult. Here, we present two children with pyogenic granuloma who were successfully treated by topical imiquimod cream with excellent results.

Efficacy of terbinafine 1% cream on seborrhoeic dermatitis.

Seborrhoeic dermatitis (SD) is a common chronic inflammatory skin disease. Although the exact pathogenesis of SD is unknown, Malassezia yeasts as well as genetic and environmental factors have been implicated. The aim of this study was to evaluate the efficacy of terbinafine 1% cream on SD lesions with face localisation. Thirty-five patients with SD were included in the study. Patients applied terbinafine 1% cream twice daily for four weeks. The severity of the signs (erythema, scaling, infiltration) was assessed using a 4-point score (0=absent, 1=mild, 2=moderate, and 3=intense) at baseline and at the 2nd and 4th weeks of the therapy. Also, self-assessment was done by the patients on a 100 mm visual analogue score (VAS) at each visit. Complete remission was observed in 10 (32.3%) patients at the end of the therapy. Statistically significant reductions in the scores of all parameters were observed at both the 2nd and 4th weeks of the therapy. Patients' self assessments in the 2nd and 4th weeks were similarly better than at the baseline.

Cyclic lymphocytic vasculitis associated with chronic lymphocytic leukemia.

Lymphocytic cutaneous vasculitis associated with a haematological malignancy has rarely been reported. Here, we describe a 61 year-old woman with chronic lymphocytic leukemia (CLL) who presented with cutaneous lesions on both hands. These lesions improved after all combination chemotherapy courses and recurred before each course. Repetitive skin biopsies revealed lymphocytic vasculitis. After 7 courses of chemotherapy, she had a complete remission. Skin lesions disappeared and did not recur. The cyclic pattern of lymphocytic vasculitis and its relation with CLL disease activity are interesting clinical features in this case.

Solid facial edema of acne: failure of treatment with isotretinoin.

Solid facial edema of acne is a rare persistent skin condition which occurs as a late complication of acne vulgaris. It is difficult to treat and isotretinoin seems to be the most effective agent. Here we present a 25-year-old man with a facial edema which arose after the complete remission of acne. Treatment with isotretinoin for 4 months was unsuccessful in this case.

Palmoplantar lichen planus presenting with vesicle-like papules.

Palmoplantar lichen planus is a rare, localized variant of the disease that may create difficulty in diagnosis if it is present as an isolated finding. Although several morphological patterns may be seen, plaques or small papules with compact hyperkeratosis are usually observed. We present a 25-year-old woman with a one-month history of slightly pruritic, red papules on her palms and soles. Dermatologic examination revealed numerous, asymptomatic, unscaly, red papules on her palms and soles, some of them resembling vesicles and white reticulate plaques on both sides of the buccal mucosa. The diagnosis was established by the typical histopathological features of lichen planus. Although resistant to topical corticosteroids, she responded well to systemic corticosteroid therapy, and no recurrence was observed during the follow-up period of one year.

Inguinal keratotic Basal cell carcinoma mimicking giant solitary trichoepithelioma.

Keratotic basal cell carcinoma may not only clinically but also histologically share more or less the same features with giant solitary trichoepithelioma. It can be difficult to distinguish these two entities from each other, even for an experienced dermatopathologist. We present an unusual case of inguinal keratotic basal cell carcinoma mimicking giant solitary trichoepithelioma in a 56-year-old woman with a finger-like tumor of 20 years duration. The patient presented with an asymptomatic, skin colored, firm, nonulcerative, nodular lesion. Scanty mitotic activity and apoptotic cells were the histopathologic findings against basal cell carcinoma, whereas absence of papillary mesenchymal bodies, presence of peritumoral lacunae detected only around the solid areas, and accumulation of amyloid-like hyalinized material were the findings in favor of basal cell carcinoma. This case illustrates that keratotic basal cell carcinoma must be taken into account in the differential diagnosis of inguinally located solitary, polypoid masses, especially giant solitary trichoepithelioma.

Efficacy of 5% imiquimod cream in a patient with classic Kaposi sarcoma.

BACKGROUND: The classic Kaposi sarcoma is most common in the Mediterranean population over 50 years of age and presents with reddish-brown papules and nodules particularly on the lower limbs. Treatment depends on the clinical presentation and extension of lesions. Imiquimod is as an immune response modifier with antiangiogenic activity. MAIN OBSERVATIONS: We present a 74-year-old man with classic Kaposi sarcoma who had multiple, small, violaceous papules and nodules on the trunk and extremities with a history of 14 years. He complained particularly from plantar hyperkeratotic painful nodules. Treatment with imiquimod 5% cream under occlusion resulted with almost complete regression within 12 weeks. No local or systemic side effects were observed. CONCLUSIONS: Topical imiquimod was a safe and effective therapy in our patient with classic Kaposi sarcoma.

Expression of nuclear factor kappa B and survivin in psoriasis.

Background and Objective. Suppression of apoptosis has been proposed as a mechanism responsible for epidermal thickness in psoriasis. Survivin is a member of the inhibitor of apoptosis family. Nuclear factor kappa B (NF-κB) is one of the transcriptional factors that regulate many genes affecting apoptosis. The aim of this study was to determine survivin and NF-κB expressions in psoriasis in comparison with normal epidermis. Patients and Methods. Immunohistochemical expressions of survivin and NF-κB were investigated in 41 psoriatic and 21 normal skin samples. Results. Diffuse nuclear survivin expression in all epidermal layers was seen in all of the psoriatic samples. NF-κB expression in different epidermal locations was seen in all of the psoriatic samples. Nuclear staining was positive in 40 psoriasis samples. Similar survivin and NF-κB expressions were observed in normal skin samples. Conclusion. Since similar expressions are seen in both normal and psoriatic epidermis, no important roles for survivin and NF-κB can be attributed in epidermal proliferation and thickness seen in psoriasis.