Virgin Coconut Oil Attenuates Deficits in Rats Undergoing Transient Cerebral Ischemia

@#Background and Objectives. Neuroprotection agents may help improve the outcomes of large vessel ischemic stroke. This study aims to explore the role of Virgin Coconut Oil (VCO), with its well-documented anti-oxidant properties, in neuroprotection after transient occlusion of the extracranial internal carotid artery in a rat model of stroke. Methods. Twenty-three Sprague-Dawley rats were randomized into two groups: 1) control group (n=11) given distilled water, and 2) treatment group (n=12) given virgin coconut oil at 5.15 ml/kg body weight for seven days. Subsequently, the rats underwent transient right extracranial internal carotid artery occlusion (EICAO) for 5 minutes using non-traumatic aneurysm clips. At 4 and 24 hours after EICAO, the animals were examined for neurologic deficits by an observer blinded to treatment groups, then sacrificed. Eight brain specimens (4 from each group) were subjected to histopathologic examination (H & E staining) while the rest of the specimens were processed using triphenyltetrazolium chloride (TTC) staining to determine infarct size and area of hemispheric edema. Results. VCO treatment significantly improved the severity of neurologic deficit (1.42 ± 2.31) compared to the control distilled water group (4.09 ± 2.59) 24 hours after EICAO. Whereas, infarct size and percent hemispheric edema did not significantly differ between the two groups. Conclusion. Prophylactic treatment of VCO is protective against EICAO-induced neurologic deficits in a rat model. VCO shows great potential as a neuroprotective agent for large vessel ischemic stroke. However, more studies are necessary to elucidate the neuroprotective mechanisms of VCO therapy in ischemic stroke.

Long-term consumption of virgin coconut (Cocos nucifera) oil diet impairs learning and memory in CD1 mice / 中草药·英文版

Objective: Virgin coconut oil (VCO) has been used in the management of dementia in Alzheimer's disease (AD). Therefore, this research investigated the effect of long-term consumption of VCO diet on learning and memory in CD1 mice. Methods: Thirty male CD1 mice (divided into three groups, n = 10) were fed with standard rodent chow (control), 5% and 20% VCO diets (respectively) for 28 d. The Morris Water Maze (MWM) test was used to test the effect of VCO on visuo-spatial learning and memory, while the Novel Object Recognition Test (NORT) was used to measure short- and long-term recognition memory. Results: Learning performance of mice did not differ in the MWM. During the probe trial, duration in the retention quadrant and annulus crossings were lower (P 0.05). The discrimination index was also lower in the 20% VCO group compared to control and 5% VCO diet groups indicating impaired long-term cognitive memory in mice given 20% VCO diet. Histological examination of brains showed damage within the CA1 pyramidal cell layer of the hippocampus in the 20% VCO diet group, in line with the behavioural observations. Conclusion: Long-term consumption of virgin coconut oil diet impairs memory in mice.

A randomized double-blind study on the efficacy of 20% VCO cream versus a commercial emollient for Atopic Dermatitis in children

Objective@#To assess the effects of a formulated 20% VCO cream on symptoms of atopic dermatitis in children relative to a commercial emollient with skin barrier protective property indicated for dry, itchy skin.@*Methods@#In a randomized, double-blind, pilot study, pediatric patients with atopic dermatitis according to the modified Hanifin and Rajka criteria were enrolled and assigned to use either formulated VCO cream or commercial emollient. Treatments were applied twice daily for four (4) weeks. Outcome measures were investigator- and patient-assessed clinical efficacy based on Severity Scoring of Atopic Dermatitis (SCORAD) severity index, and incidences of documented adverse events.@*Results@#Twenty-nine patients were recruited in the study and in an intention-to-treat analysis, mean SCORAD indices were reduced by 41.79% and 29.77% in the VCO cream group and commercial emollient group, respectively. Both study groups showed significant reduction in the mean subjective SCORAD index relating to pruritus and sleep loss. Mean objective SCORAD index, based on intensity items and total surface with eczema, was also significantly improved in the VCO cream group after four weeks of product usage. The study products were generally well-tolerated, with minor adverse events reported for the VCO cream group.@*Conclusion@#Results of the study suggest that application of VCO at 20% in a cream formulation is more effective than the tested commercial emollient in alleviating symptoms of AD in children.

Efeito do tratamento com óleo de coco na perda óssea de camundongos alimentados com dieta rica em gordura / Effect of coconut oil treatment on bone loss in mice fed a high-fat diet

A obesidade é caracterizada pelo acúmulo de gordura corporal associada a uma inflamação crônica de baixo grau, sendo relacionada ao aumento do risco para o desenvolvimento de perda óssea, e consequentemente osteoporose. A perda óssea acontece devido a diversos fatores, dentre eles a presença de resposta inflamatória. As doenças crônicas como a obesidade apresentam aumento na síntese e secreção de mediadores inflamatórios que poderiam favorecer a perda óssea. Apesar de abordagens dietéticas serem propostas para tratar a perda óssea, elas ainda são pouco exploradas. O óleo de coco virgem (OCV) é um alimento funcional devido à sua quantidade significativa de ácidos graxos de cadeia média. Nos últimos anos, o OCV tem sido amplamente utilizado como possível tratamento de diversas doenças incluindo Alzheimer, doenças cardíacas, obesidade, entre outras. Contudo, conhecimentos a respeito da suplementação com OCV no tratamento da perda óssea ainda é incipiente. Esse estudo objetivou avaliar o efeito da suplementação dietética com OCV no tratamento na perda óssea de camundongos alimentados com dieta rica em gordura 45% (HF). Camundongos machos C57BL/6 foram inicialmente divididos em dois grupos e alimentados com dieta controle AIN-93M (C) ou dieta HF por oito semanas. Na 9ª semana, os camundongos alimentados com dieta HF foram reagrupados em quatro grupos até a 12ª semana: (i) dieta HF; ou dieta HF suplementada com diferentes doses de OCV, (iii) 1000 mg/kg, (iv) 3000 mg/kg ou (v) 9000 mg/kg. Apesar do ganho de peso não apresentar diferença estatística entre os grupos, o peso corporal final foi maior no grupo HF em relação ao grupo controle, mas sem alteração naqueles tratados com OCV em relação ao controle. Não houve diferença significativa na ingestão alimentar entre os grupos avaliados. Ao serem avaliados parâmetros ósseos, as concentrações séricas de RANKL, um marcador de perda óssea, e OPG, opositora a essa sinalização, não se alteraram entre os grupos. Contudo, somente os animais que receberam a dose média de OCV apresentaram tendência para menor relação RANKL/OPG, sendo essa a dose escolhida para a avaliação da microarquitetura óssea. No geral, o grupo HF apresentou menor densidade mineral óssea e volume ósseo, trabéculas de menor espessura com maior espaço entre elas, caracterizando aumento da reabsorção óssea na estrutura óssea do fêmur e maxila. Quando tratados com a dose média de OCV ocorreu uma piora da densidade mineral óssea e da separação trabéculas na maxila, sem alteração nos outros parâmetros quando comparados com o grupo HF. Contudo, a perda óssea presente no fêmur não foi alterada. Como esperado, a adiposidade, área de adipócitos e concentrações séricas de leptina foram maiores no grupo alimentado com dieta HF em relação ao controle. No grupo tratado com a dose alta de OCV foi observado um aumento da área dos adipócitos, mas nos demais parâmetros não foram observadas alterações após os diferentes tratamentos com o OCV. A intolerância à glicose observada no grupo HF não foi alterada com a adição do OCV à dieta HF, e ainda se mostraram hiperglicêmicos. Apesar de alteradas no grupo HF, as concentrações séricas de colesterol total e triglicérides não se modificaram com os tratamentos. Portanto, o uso da suplementação com OCV em camundongos alimentados com a dieta HF parece não ser benéfico para tratar perda óssea, a obesidade e ainda as disfunções metabólicas associadas.

Obesity is characterized by the accumulation of body fat associated with low-grade chronic inflammation, which is related to an increased risk of developing bone loss, and consequently, osteoporosis. Bone loss occurs due to several factors, including the presence of an inflammatory response. Chronic diseases such as obesity show an increase in the synthesis and secretion of inflammatory mediators that could favor bone loss. Although dietary approaches are proposed to treat bone loss, they are still poorly explored. Virgin coconut oil (VCO) is a functional food due to its significant amount of medium-chain fatty acids. In recent years, VCO has been widely used to treat several diseases, including Alzheimer's, heart disease, obesity, among others. However, knowledge about VCO supplementation in the treatment of bone loss is still incipient. This study aimed to evaluate the effect of dietary supplementation with VCO in the treatment of bone loss in mice fed a 45% high-fat (HF) diet. Male C57BL / 6 mice were initially divided into two groups and fed either the AIN-93M (C) control diet or the HF diet for eight weeks. At the 9th week, the mice fed the HF diet were regrouped in four groups until the 12th week: (i) HF diet; or HF diet supplemented with different doses of VCO, (iii) 1000 mg / kg, (iv) 3000 mg / kg or (v) 9000 mg / kg. Although the weight gain does not present a statistical difference between the groups, the final body weight was higher in the HF group than the control group, but without changes in those treated with VCO in relation to the control. There was no significant difference in food intake between the groups evaluated. When bone parameters were evaluated, the serum concentrations of RANKL, a bone loss marker, and OPG, opposed to this signaling, did not change between the groups. However, only animals that received the medium dose of VCO showed a tendency towards a lower RANKL / OPG ratio, which was the dose chosen for bone microarchitecture evaluation. In general, the HF group showed lower bone mineral density and bone volume, thinner trabeculae with greater space between them, characterizing increased bone resorption in the femur and maxilla's bone structure. When treated with the medium dose of VCO, there was a worsening of bone mineral density and trabecular separation in the maxilla, with no change in other parameters when compared with the HF group. However, the bone loss present in the femur was not altered. As expected, adiposity, area of adipocytes and serum leptin concentrations were higher in the group fed with HF compared to the control group. In the group treated with the high dose of VCO an increase in the area of adipocytes was observed, but in the other parameters, no changes were observed after the different treatments with the VCO. The glucose intolerance observed in the HF group was not altered with the addition of VCO to the HF diet, and they were also shown to be hyperglycemic. Despite being changed in the HF group, serum concentrations of total cholesterol and triglycerides did not change with treatments. Therefore, the use of VCO supplementation in mice fed the HF diet does not seem to be beneficial for treating bone loss, obesity, and even the associated metabolic disorders.

Antimicrobial and barrier repair properties of virgin coconut oil and mineral oil in pediatric atopic dermatitis patients, a randomized, double-blind, control trial

BACKGROUND@#Atopic dermatitis (AD) is a chronic relapsing skin disease in childhood, managed by topical therapies. In the Philippines, use of affordable, widely available and effective alternative therapies such as mineral oil (MO) and virgin coconut oil (VCO), are practical especially in the far-flung areas.@*OBJECTIVES@#This study compares the antimicrobial and barrier repair properties of MO and VCO in mild to moderate atopic dermatitis, using SCORAD (SCORing for Atopic Dermatitis), bacterial culture, tewameter, mexameter and corneometer.@*METHODS@#This is a randomized controlled doubleblind trial conducted in two tertiary hospitals. Bacterial colonies, transepidermal water loss (TEWL), level of hydration and erythema were determined at baseline and after 4 weeks using bacterial culture, tewameter, corneometer and mexameter, respectively. SCORAD and adverse effects were also determined at baseline, 2nd and 4th week of treatment.@*RESULTS@#Baseline patient demographics were similar for both treatment groups. The SCORAD, TEWL and level of erythema were significantly decreased throughout the 4-week duration for both treatment groups, but much lower in the VCO group. The hydration level was significantly increased throughout the 4-week duration but much higher for the VCO group. Lastly, there is more proportion of cultures with "no growth" after the 4-week treatment duration in VCO group.@*CONCLUSION@#The antimicrobial and barrier repair properties of VCO are very important alternative which is affordable, readily available, safe and effective for children with mild to moderate AD.

Evaluation of Efficacy of Virgin Coconut Oil in Maintaining Hygiene in Orthodontics Patients

Background: Fixed orthodontic appliances are considered to jeopardize dental health due to the accumulation of oral microorganisms that may cause enamel demineralization. Oil pulling involves the use of edible vegetable oils as oral antibacterial agents. It is a practice of swishing oil in the mouth for oral and systemic health benefits. Aims and Objectives: To assess the effect of oil pulling therapy with virgin coconut oil on Streptococcus mutans count in patients undergoing orthodontic treatment. Methods: A total of thirty subjects were included in the study. They were divided in to 2 groups. Group A subjects were asked to swish coconut oil and Group B normal saline for a week. Streptococcus mutans colony forming units were estimated and compared. Results: A statistically significant reduction in S. mutans CFU was seen with Group A after oil pulling with coconut oil when compared to saline group (P = 0.0003. Conclusion: Edible oil-pulling therapy is natural, safe and has no side effects. Hence, it can be considered as a preventive therapy at home to maintain oral hygiene

Fatty Acid Evaluation and Antimicrobial Activity of Virgin Coconut Oil and Activated Virgin Coconut Oil on Streptococcus mutans

@#For decades, coconut oil was reported to possess a broad spectrum of antimicrobial activity due to its abundant fatty acid’s contents. Streptococcus mutans (S. mutans) has been strongly implicated as the main etiological factor in dental caries. Regardless of the ongoing medical advances, the therapeutic resources for dental caries remain ineffectual, and this has led to renewed interest in using virgin coconut oil (VCO) as a possible choice for dental caries control. In this study, the ability of VCO and activated virgin coconut oil (AVCO) combatting cariogenic S. mutans ATCC 25175 has been evaluated. Fatty acids contents were compared through gas chromatography-mass spectrum (GC-MS) analysis, and their antimicrobial activity was determined using disc diffusion and minimum inhibitory concentration (MIC) test. From the GC-MS analysis, AVCO (59%) was found to have a slightly higher medium-chain fatty acids (MCFA) as compared to VCO (54.1%), and the long-chain fatty acids (LCFA) contents in VCO (45.9%) was found to be higher than AVCO (41%). Interestingly, S. mutans ATCC 25175 was found to be susceptible towards AVCO (MIC: 6.24 mg/ml) and resistance towards VCO in vitro. The excellent antimicrobial activity of AVCO as a result from (i) the release of individuals fatty acids after activation of VCO by lipase digestion and (ii) the present of MCFA and LCFA that are significant in antimicrobial activity. Further study can be designed to specifically examine the activity of individuals fatty acids present in oils against S.mutans virulence genes/protein using molecular dynamic assessment.

A randomized, double-blind, comparative study on the safety and efficacy of virgin coconut (Cocos nucifera l.) oil against 1% Hydrocortisone lotion as an anti-inflammatory and anti- pruritic preparation for mosquito reactions

Background@#Virgin coconut oil (VCO) has been reported to have anti-inflammatory and anti-pruritic properties and can be used as an alternative to corticosteroids for mosquito bites. No studies on VCO for mosquito bites have been published.@*Objective@#To compare the safety and efficacy of VCO against 1% Hydrocortisone as an anti-inflammatory and anti- pruritic preparation for mosquito bites.@*Method@#This is a randomized, double-blind study comparing the anti-inflammatory and anti-pruritic effect of VCO versus 1% Hydrocortisone on Aedes aegypti bites, by measuring the mean lesion size, subjective assessment of the effects on bites, pruritus intensity through the visual analog, and verbal rating scale in 91 subjects at baseline, 1 hour, days 1, 3, and 7.@*Results@#During the first hour and throughout the seven-day period, there was a decrease in the mean lesion size, visual, and verbal scale score for both VCO and Hydrocortisone groups. The mean lesion size for both groups were not statistically significant on the 1st and 24th hour. On day 3, the mean lesion size for the VCO group was 0.02 and 0.71 for the Hydrocortisone group which was statistically significant in favor of VCO. The mean visual and verbal scale scores for pruritus for both treatment groups were not statistically significant. As early as the 1st hour, the proportion of patients who reported total clearance of lesions in the VCO group was 34.09% compared to 6.38% in the Hydrocortisone group. On day 7, both treatment groups had resolution of lesions. No adverse reactions were noted.@*Conclusion@#Virgin coconut oil is safe, cost-effective, and comparable to 1% Hydrocortisone as an anti- inflammatory and anti-pruritic agent.

Efficacy of Virgin Coconut Oil supplemented-milk feeding in augmenting weight gain among very low birth weight preterm infants: A meta-analysis

@#<p style="text-align: justify;"><strong>BACKGROUND:</strong> Nutritional status is crucial in neonatal survival, especially among the Very Low Birthweight (VLBW) preterm infants. They have low nutrient reserves with increased metabolic needs and immature gut system. Several studies have proven the efficacy of medium-chain triglycerides (MCT) as a good source of calories among pre-term infants. However, such is not commercially available. Virgin coconut oil (VCO) has the most concentrated content of MCT's, hence a possible source of MCT.</p><p style="text-align: justify;"><strong>OBJECTIVES:</strong> This review aims to determine the efficacy of VCO-supplementation to milk feeding in augmenting weight gain among very low birth weight preterm infants.</p><p style="text-align: justify;"><strong>METHODS:</strong> Pubmed (1975-September 2016), Cochrane Central Register of Controlled Trials (The Cochrane Library, September 2016), HERDIN (1966 -September 2016), Google Scholar (September 2016), and https://clinicaltrials.gov (last searched September 2016) were thoroughly searched. Manual search in reference and citation lists of the eligible studies and list of abstracts from the Philippine Pediatric Society was also reviewed. Only randomized controlled trials comparing VCO-supplemented milk versus standard care in weight gain among very low birth weight preterm infants were included. The author reviewed each study's quality and extracted data on weight gain. Weighted mean differences with 95% confidence intervals were reported. Risk of biases among studies were also evaluated.</p><p style="text-align: justify;"><strong>RESULTS:</strong> Three randomized controlled trials involving 290 infants were included. All trials were of good quality with relatively low heterogeneity (39%), and low risk of biases. Overall, infants receiving VCO-supplemented milk feeding had statistically significant weight gain compared to those given non-fortified milk (mean difference 5.31, 95% CI: 3.83 to 11.93).</p><p style="text-align: justify;"><strong>CONCLUSION:</strong> Virgin coconut oil is effective in augmenting weight gain among very low birth weight preterm infants.</p><p style="text-align: justify;"><strong>RECOMMENDATIONS:</strong> Small trials were used in this review, and a single multicenter randomized controlled trial would be ideal to further establish these findings.</p>

Coconut oil on biochemical and morphological parameters in rats submitted to normolipidic and hyperlipidic diets / Óleo de coco em parâmetros bioquímicos e morfológicos de ratos submetidos à dieta normolipídica ou hiperlipídica

ABSTRACT: This study aimed to evaluate the influence of replacing soybean oil with extra virgin coconut oil in normolipidic and hyperlipidic diets, on the lipid metabolism of Wistar rats. In the first stage of the experiment (30 days), 36 rats were divided into 2 groups and fed with a control or a hyperlipidic diet. Six animals from each group were then killed, and the remaining rats were redistributed into 4 new groups: 2 groups remained on the control and hyperlipidic diets, and in the diets of the other 2 groups, the soybean oil was replaced with coconut oil (30 days). At the end of the assay, the biological models were decapitated for blood collection and removal of organs and peritoneal fat. Although the diet intake differed among groups during both stages of the experiment, no differences were noted with regard to weight gain and peritoneal fat. Replacing soybean oil with coconut oil in the rat diet lowered triglyceride and low-density lipoprotein serum concentrations in both groups. Liver parameters, namely, total cholesterol and triacylglycerols, increased with the substitution of soybean oil by coconut oil in the normolipidic diet and decreased in the hyperlipidic diet. Thus, replacing soybean oil by coconut oil may improve serum and liver lipid levels in Wistar rats.

RESUMO: O estudo teve como objetivo avaliar a influência da substituição do óleo de soja por óleo de coco extravirgem em dietas normolipídicas e hiperlipídicas, sobre o metabolismo lipídico de ratos Wistar. Na primeira fase do experimento, 30 dias, 36 ratos foram distribuídos em dois grupos, receberam dieta controle e dieta hiperlipídica. Após eutanásia de seis animais por grupo, os ratos de ambos os grupos foram redistribuídos em quatro novos grupos, dois permaneceram com as dietas controle e hiperlipídica e nos outros dois houve substituição do óleo de soja por óleo de coco (30 dias). Ao final do ensaio, os modelos biológicos foram decapitados, para coleta de sangue, retirada de órgãos e gordura peritoneal. O consumo de dieta foi diferente entre os grupos durante as duas fases do experimento, porém sem diferença no ganho de peso e gordura peritoneal. A substituição, na dieta, do óleo de soja por óleo de coco diminuiu as concentrações séricas de triacilgliceróis e de lipoproteínas de baixa densidade, em ambos os grupos. Os parâmetros hepáticos colesterol total e triacilgliceróis aumentaram com a substituição do óleo de soja por óleo de coco em dieta normolipídica e diminuíram na dieta hiperlipídica. A substituição do óleo de soja por óleo de coco pode ter benefícios com relação aos lipídeos séricos e hepáticos em ratos Wistar.

Randomized controlled trial on the efficacy and safety of virgin coconut oil compared to mineral oil in the treatment of uremic xerosis

BACKGROUND: Uremic xerosis is the most common dermatologic condition present in patients with chronic kidney disease. Emollients were shown to be beneficial and are considered to be the first-line of treatment.OBJECTIVE: To assess the efficacy and safety of virgin coconut oil (VCO) compared to mineral oil as a therapeutic mosturizer for uremic xerosis.METHODS: Adult patients undergoing hemadialysis who have uremic xerosis were randomized using a computer-generated list and were instructed to apply either VCO or mineral oil twice daily on the legs for 4 weeks. Primary outcome measures included investigator-assessed clinical efficacy based on overall dry skin score (ODSS), change in skin hydration (corneometer readings), change in skin lipids (sebumeter readings), and quality of life scores. Secondary outcome measures included patient-assessed efficacy and advent of adverse effects. Overall therapeutic response was determined in which treatment success was defined as total clearance of xerosis or reduction of ODSS score and increased objective measurements (i.e., corneometer and sebumeter readings) plus moderate to marked patient-assessed efficacy, while treatment failure was defined as failure in any one of these parameters.RESULTS: A total of 45 (22 VCO group, 23 mineral oil group) were recruited and 36 (18 VCO group, 18 mineral oil group) completed the study. The majority of patients in both treatment groups showed improved ODSS, corneometer readings, and quality of life scores. Most patients considered both treatment oils to be moderately to markedly effective. Analysis of overall therapeutic response revealed treatment success of 4 out of 22 in the VCO group and 4 out of 23 in the mineral oil group. VCO demostrated a trend to benefit in improving xerotic skin (RRR = 1.0%, 95% CI: -30, 26.3; RR = 0.99, 95% CI: 0.76, 1.3) but results are inconclusive due to the wide confidence interval.CONCLUSION: The application of VCO or mineral oil for 4 weeks may be equally beneficial and safe in improving uremic xerosis. VCO showed a trend to benefit compared to mineral oil in terms of overall therapeutic response but this needs to be confirmed in larger randomized controlled trials.

Virgin coconut oil improves hepatic lipid metabolism in rats–compared with copra oil, olive oil and sunflower oil.

Effect of virgin coconut oil (VCO) on lipid levels and regulation of lipid metabolism compared with copra oil (CO), olive oil (OO), and sunflower oil (SFO) has been reported. Male Sprague-Dawley rats were fed different oils at 8% level for 45 days along with synthetic diet. Results showed that VCO feeding significantly lowered (P<0.05) levels of total cholesterol, LDL+ VLDL cholesterol, Apo B and triglycerides in serum and tissues compared to rats fed CO, OO and SFO, while HDL-cholesterol and Apo A1 were significantly (P<0.05) higher in serum of rats fed VCO than other groups. Hepatic lipogenesis was also down regulated in VCO fed rats, which was evident from the decreased activities of enzymes viz., HMG CoA reductase, glucose-6-phosphate dehydrogenase, isocitrate dehydrogenase and malic enzyme. In addition, VCO significantly (P<0.05) increased the activities of lipoprotein lipase, lecithin cholesterol acyl transferase and enhanced formation of bile acids. Results demonstrated hypolipidemic effect of VCO by regulating the synthesis and degradation of lipids.

Lamellar ichthyosis

Lamellar ichthyosis is an inherited autosomal recessive disorder characterized by non-bullous erythroderma and scaling at birth. We report a patient born encased in a collodion membrane, who later developed generalized, brownish, plate-like scales, anhidrotic skin, scarring alopecia, bilateral ectropion, with a family history of similar-looking skin condition. Skin biopsy demonstrated marked lamellated orthohyperkeratosis and areas of hypergranulosis. Therapeutic trial of four topical agents (extravirgin coconut oil, urea lotion, mineral oil and petroleum jelly) was done which gave minimal improvement of scaling and dryness. Oral retinoids (Acitretin) was then initiated and yielded better results.