Successful Treatment of Cutaneous Larva Migrans With Combined Albendazole and Ivermectin Therapy: A Report of Two Cases From Sudan.

Cutaneous larva migrans (CLM), caused by third-stage filariform larvae of cat and dog hookworms, presents as pruritic, serpiginous tracks upon skin penetration by larvae from contaminated soil. Herein, we report the successful treatment of two CLM patients using albendazole and ivermectin combination therapy. A 42-year-old man from Kordofan and a 38-year-old man from White Nile State presented with characteristic lesions on their lower extremities, resolving completely within one week post-treatment without recurrence. This report highlights the potential of combined albendazole-ivermectin therapy in managing CLM amid emerging antihelminthic resistance, suggesting that its broader application warrants further investigation.

Real-world Experience in Managing Atrial Fibrillation in Patients with Renal Impairment; Rivaroxaban versus Warfarin.

Background: The use of rivaroxaban in patients with atrial fibrillation (AF) and chronic kidney disease (CKD) poses the risk of over- or underdosing. We aimed to compare rivaroxaban and warfarin in AF patients with moderate and severe renal impairment. Methods: This retrospective study was conducted between 2015 and 2016 to compare the use of warfarin (n = 164) and rivaroxaban (n = 149) in patients with AF and moderate or severe CKD. The study outcomes were survival, stroke, and major bleeding events. The median follow-up was 50 months (interquartile range: 23-60). Results: Thirty-six patients had major bleeding: 24 with rivaroxaban and 12 with warfarin (P = 0.01). The rivaroxaban group had major bleeding in 3 patients with moderate CKD, 4 with severe CKD, and 17 on dialysis. Multivariable analysis of factors affecting major bleeding revealed that warfarin use lowered the risk of bleeding (hazard ratio: 0.34; P = 0.004). Stroke occurred in 14 patients: 6 in the rivaroxaban group and 8 in the warfarin group (P = 0.44). Survival at 1, 3, and 5 years was 89%, 77%, and 71% with warfarin and 99%, 94%, and 88% with rivaroxaban, respectively (P < 0.001). Multivariable analysis showed higher mortality in patients with lower creatinine clearance and those on warfarin. Conclusions: The safety of warfarin could be better than rivaroxaban in patients with CKD with fewer bleeding complications but similar stroke rates. Further studies on rivaroxaban dosing in patients on dialysis are required.

Better Survival in Morbidly Obese Patients with Atrial Fibrillation Treated with Non-vitamin K-dependent Oral Anticoagulants.

Background: The efficacy and safety of non-vitamin K-dependent anticoagulants (NOAC) are not well investigated in the obese population, and fixed dosing could lead to under-anticoagulation. Our objective was to evaluate the effect of obesity on anticoagulation outcomes and survival in non-valvular atrial fibrillation (AF) patients. Methods: We enrolled 755 patients who required anticoagulation for AF from 2015 to 2016. We grouped the patients into four groups. Group 1 (n = 297) included patients with BMI< 40 kg/m2 treated with NOACs, Group 2 (n = 358) included patients on warfarin with BMI< 40 kg/m2, Group 3 (n = 57) had patients on NOACs with BMI≥ 40 kg/m2 and Group 4 (n = 43) included patients on warfarin and BMI≥ 40 kg/m2. Study outcomes were the composite endpoint of stroke, bleeding, and survival. Results: Competing risk regression showed that stroke and bleeding were not affected by obesity or treatment (SHR: 1.09 (95% CI: 0.79-1.51); P = 0.62). Older age was the predictor of stroke/bleeding (HR:1.03 (95% CI:1.01-1.06); P = 0.02). Predictors of mortality were heart failure (HR:2.23 (95% CI:1.25-3.97); P = 0.007), lower creatinine clearance (HR: 0.98 (95% CI:0.97-0.98): P < 0.001), non-obese patients on warfarin (HR:3.51 (95%CI:1.6-7.7): P = 0.002) and obese patients on warfarin (HR: 6.7 (95% CI:2.51-17.92); P < 0.001). Conclusion: NOACs could have a similar risk profile to warfarin in obese and non-obese patients with non-valvular AF but could have better survival. Larger randomized trials are recommended.

Follicular Becker's Nevus: A New Clinical Variant.

Becker's nevus, also known as pigmented hairy epidermal nevus, is characteristically described as a unilateral, hairy, light to dark brown macule with sharply outlined but irregular border. The etiopathogenesis of Becker's nevus is still not clearly understood. Perifollicular pigmentation has been described earlier by some authors. But, Becker's nevus presenting exclusively with follicular lesions has not been described. We are reporting a series of patients of Becker's nevus with follicular lesions. The diagnosis in all the patients was made after clinicopathological correlation. Follicular epithelium may hold a significant role in the etiopathogenesis of Becker's nevus.

Prevalence of HPV Genotypes in Adult Male Patients with Cutaneous Warts: A Cross-Sectional Study.

AIM: This study was aimed at determining the distribution of type-specific human papillomavirus (HPV) in men with cutaneous warts and correlating this with the clinical and morphological presentation of warts. METHODS: Cutaneous wart samples were obtained from 167 adult men presenting to a dermatology clinic. The tissues were fixed and screened for HPV DNA using real-time PCR. The HPV genotype was determined by PCR-based sequencing. RESULTS: Nine different HPV genotypes were detected, comprising 6 from the α genus (HPV2, 6, 27b, 57b, 57c, and 94), 2 from the γ genus (HPV4 and 65), and HPV1a from the mu genus. Single HPV infection was encountered in 93.4% of the patients, whereas multiple infections were encountered in only 6.6%. The prevalence of HPV27b was highest among four body sites, followed by HPV57c, 1a, and 2. HPV1a was the most common genotype encountered in multiple infections, followed by HPV27b. Patient age, the number of warts, the duration of the presence of warts, and contact with people who have warts were not predictors of wart location. However, a high number of patients with palmar or common body warts had wart sizes of <1 cm. CONCLUSIONS: This study shows that genus α HPV types are detected in about 82% of patients with cutaneous warts.

Association of HPV genotypes with external anogenital warts: a cross sectional study.

BACKGROUND: This study was undertaken to determine the distribution of type-specific human papillomavirus (HPV) in external anogenital warts, and the correlation with clinical presentation of warts and demographic data of patients. METHODS: Genital warts specimens were obtained from 129 men and 27 women attending a dermatology clinic, who had been advised surgical excision. The tissues were fixed and screened for HPV DNA by using real-time PCR. HPV genotype was determined by PCR-based sequencing. RESULTS: Sixteen different HPV genotypes were detected, comprising 4 oncogenic HPV genotypes (16, 18, 33, 38), 2 low-risk HPV types (LR) (6, 81), HPV 9, and other types associated with common warts (1a, 2, 4, 7, 27b, 27, 57b, 57c, 65). Oncogenic HPV types were found in 34.62% of patients, LR HPV types in 14.4%, HPV 9 in 0.64%, and common warts type in 50.6%. The prevalence of HPV infection with a single type was 88.4, 9.0% for two types, and 2.6% for three types. Multiple logistic regression model showed that age, gender, nationality, number of warts, size of each wart, and positive history of wart in sexual partner, were not predictors of HPV type. However, patients with anogenital warts of one to six months duration were three times more likely to have oncogenic HPV infection compared to those with less than one month. CONCLUSIONS: This study shows that oncogenic HPV types are detected in around 35% of patients with genital warts, and are prevalent in warts of one to six months duration.

Prevalence of metabolic syndrome in children with moderate to severe psoriasis treated with TNF inhibitors in comparison to conventional agents.

Association of childhood psoriasis with metabolic syndrome has not been studied well. TNF-alfa contributes to the inflammation seen in metabolic syndrome, and recently etanercept has shown to reduce the levels of inflammatory markers. Assessment of prevalence of metabolic syndrome in juvenile psoriasis patients in Kuwait. We included 236 patients with moderate to severe psoriasis below 18 years treated for at least 24 weeks with TNF inhibitors (Group A), and equal number of age and sex matched cases treated with conventional medications (Group B). The metabolic syndrome (MBS) was defined according to the International Diabetes Foundation (IDF 2007 criteria for children). Increased waist circumference was seen in 56.77% of cases in Group A. Triglyceridemia was less frequent in Group A. MBS was higher in Group B [41·52% vs. 50·42%, odds ratio (OR) 1·76, 95% CI 1.19-2.41; p = .005]. Psoriasis is associated with higher prevalence of metabolic syndrome in children. Six months of anti TNF treatment showed lesser association with metabolic syndrome. With fasting blood glucose, and serum TG seen in significantly lesser number of patients in this group.

The effect of tumor necrosis factor inhibitor therapy on the incidence of myocardial infarction in patients with psoriasis: a retrospective study.

BACKGROUND: Psoriasis has been shown to be associated with increased incidence of myocardial infarction (MI). The data on the effect of tumor necrosis factor (TNF) inhibitors on MI in psoriasis are scarce. OBJECTIVE: To evaluate the effect of TNF inhibitors on the risk of MI in psoriasis patients compared with methotrexate (MTX) and topical agents. METHODS: Data were obtained from the Electronic Health Records database of Farwaniya Hospital from psoriasis patients seen from January 2008 to December 2014. Patients were categorized into TNF inhibitor, MTX and topical cohorts. RESULTS: The study included 4762 psoriasis patients. Both TNF inhibitor and MTX cohorts showed a statistically lower rate of MI compared with topical cohort. However, there was no statistically significant difference in MI rate between TNF inhibitor and MTX cohorts (P = .32). The probability of MI was lower in TNF inhibitor responders compared with non-responders (p = .001). CONCLUSIONS: The use of TNF inhibitors in psoriasis showed a significant reduction in the risk of MI compared with topical agents and a non-significant reduction compared with MTX. Responders to TNF inhibitor therapy showed a reduction in MI rate compared with non-responders.

De-regulation of diabetic regulatory genes in psoriasis: Deciphering the unsolved riddle.

The purpose of our study was to identify the currently lacking molecular mechanism that accounts for the co-occurrence of two seemingly disparate diseases: psoriasis and type II diabetes. We aimed to investigate a panel of 84 genes related to the diabetic regulatory network in psoriasis (Ps), psoriasis type II diabetes (Ps-T2D), type II diabetes (T2D) and healthy control (HC). We hypothesize that such attempts would provide novel diagnostic markers and/or insights into pathogenesis of the disease. A quantitative Real Time-PCR Human Diabetes RT(2) Profiler PCR Array was chosen to explore the expression profile 84 diabetic genes in study subjects. Statistical analysis was carried out using appropriate software. The analysis revealed three candidate genes GSK3B, PTPN1, STX4 that are differentially expressed in study subjects. GSK3B was highly significant in Ps-T2D (P=0.00018, FR=-26.6), followed by Ps (P=0.0028, FR=-14.5) and T2D groups (P=0.032, FR=-5.9). PTPN1 showed significant association only with PS-T2D (P=0.00027, FR=-8.5). STX4 showed significant association with both Ps (P=0.0002, FR=-20) and Ps-T2D (P=0.0016, FR=-11.2). ACE represents an additional marker that showed suggestive association with Ps (P=0.0079, FR=-9.37). Our study highlights the complex genetics of Ps-T2D and present biomarkers for the development of T2D in Ps cases.

Psoriasis Patients Treated With Biologics and Methotrexate Have a Reduced Rate of Myocardial Infarction: A Collaborative Analysis Using International Cohorts.

Psoriasis is a chronic inflammatory skin condition characterised by the formation of red scaly plaques on the skin. It is an autoimmune disease cause by the dysregulation of cytokines controlling the inflammatory pathways, a mechanism likely contributing to various comorbidities observed in patients with psoriasis. Cardiovascular disease is one comorbidity observed more frequently in the psoriasis patient population. Biologic treatments specifically target the dysregulation of cytokines in the inflammation pathway and have shown to be an effective treatment for moderate to severe psoriasis where other systemic treatments have failed. More recently, biologics have been shown to reduce the incidence of myocardial infarction in patients with psoriasis compared to patients treated with topical agents. In the present study, 4 international psoriasis patient cohorts are combined and analyzed to examine the effect that biologic or methotrexate treatment has on reducing the incidence of myocardial infarction. Both methotrexate and biologic treatments were found to lower the incidence of myocardial infarction in moderate to severe psoriasis patient populations.

Effects of tumor necrosis factor α inhibitors extend beyond psoriasis: insulin sensitivity in psoriasis patients with type 2 diabetes mellitus.

Psoriasis is a chronic inflammatory disease that has been associated with an increased incidence of insulin resistance and diabetes mellitus (DM). Tumor necrosis factor (TNF) α inhibitors and IL-6 blockers, which are routinely used for the treatment of psoriasis, have been positively associated with insulin sensitivity. The aim of this study was to assess the effects of treatment with TNF-α inhibitors on insulin sensitivity in psoriatic patients with type 2 DM. This study confirms a beneficial effect of anti-TNF-α agents on insulin resistance and insulin sensitivity in psoriasis patients with type 2 DM.

Spatial assessment of monitoring network in coastal waters: a case study of Kuwait Bay.

Spatial analyses of water-quality-monitoring networks in coastal waters are important because pollution sources vary temporally and spatially. This study was conducted to evaluate the spatial distribution of the water-quality-monitoring network of Kuwait Bay using both geostatistical and multivariate techniques. Three years of monthly data collected from six existing monitoring stations covering Kuwait Bay between 2009 and 2011 were employed in conjunction with data collected from 20 field sampling sites. Field sampling locations were selected based on a stratified random sampling scheme oriented by an existing classification map of Kuwait Bay. Two water quality datasets obtained from different networks were compared by cluster analysis applied to the Water Quality Index (WQI) and other water quality parameters, after which the Kriging method was used to generate distribution maps of water quality for spatial assessment. Cluster analysis showed that the current monitoring network does not represent water quality patterns in Kuwait Bay. Specifically, the distribution maps revealed that the existing monitoring network is inadequate for heavily polluted areas such as Sulaibikhat Bay and the northern portion of Kuwait Bay. Accordingly, the monitoring system in Kuwait Bay must be revised or redesigned. The geostatistical approach and cluster analysis employed in this study will be useful for evaluating future proposed modifications to the monitoring stations network in Kuwait Bay.

Resistant palmoplantar lesions in patients of psoriasis: evaluation of the causes and comparison of the frequency of delayed-type hypersensitivity in patients without palm and sole lesions.

OBJECTIVE: To examine the reasons for resistance to treatment in cases of palmoplantar psoriasis, and also to compare the frequency of delayed-type hypersensitivity to common sensitizers with those cases of psoriasis without palmoplantar involvement. SUBJECTS AND METHODS: One hundred and three patients with resistant palmoplantar psoriasis were examined for a possible drug reaction, fungal infection or contact allergy. Patch testing was done for another 100 patients with psoriasis vulgaris without palm and sole involvement. χ(2), Fischer's exact test, Mann-Whitney U test and logistical regression analysis were done using SPSS 15.0. RESULTS: Of the 103 patients with resistant palmoplantar lesions, 26 (25.24%) had a positive patch test to at least one of the tested allergens, 6 (5.8%) had psoriasiform spongiotic dermatitis on biopsy, 5 (4.8%) reported exacerbation after starting biologic therapy and 3 (2.9%) were potassium hydroxide positive in the sole lesions. In comparison, of the 100 patients with no palm or sole lesions, 11 (11%) had a positive patch test to at least one of the allergens. There was a direct relationship between the increase in the prevalence of dermatitis and the duration of psoriasis. There was no correlation between the clinical type of psoriasis and patch-test positivity. CONCLUSION: Secondary fungal infection, allergic contact dermatitis to topical agents or common allergens, or at times an unusual reaction to the antipsoriatic therapeutic agents sometimes led to treatment failure in patients with psoriasis vulgaris with palmoplantar lesions. Also, psoriasis patients with palm and sole lesions tended to have higher rates of contact hypersensitivity than patients without lesions on their palms and soles.

Single Blinded Left-to-Right Comparison Study of Excimer Laser Versus Pulsed Dye Laser for the Treatment of Nail Psoriasis.

INTRODUCTION: Nail psoriasis is relatively difficult to treat. Excimer laser has been approved for the treatment of psoriasis since 2000. Pulsed dye laser (PDL) in psoriasis therapy has shown good response rates, with extended remissions. This is the first study assessing both the excimer and PDL lasers in nail psoriasis. METHODS: In a comparison study, excimer laser versus PDL for the treatment of nail psoriasis was evaluated in 42 patients. The right hand nails were treated with excimer laser twice weekly and the left hand nails were treated with PDL once every 4 weeks, for total 12 weeks. The patients were then followed up after a further 12 weeks. Nail Psoriasis Severity Index (NAPSI) scores were recorded at baseline, weeks 4, 8, and 12, and then at week 24. Patients were also asked to grade the clinical response to each treatment. RESULTS: A total of 304 nail changes, 148 with excimer laser and 156 with PDL, were treated. The mean NAPSI score in nails treated with excimer laser was 29.8 at baseline, reduced to 16.3 at week 24. In PDL-treated nails, the NAPSI scores dropped from 29.5 at baseline to 3.2 at week 24. NAPSI improvement was significantly greater in PDL than excimer (P = 0.001; Wilcoxon signed-rank test). Thirty-four (81%) hands achieved NAPSI-50, and 23 (55%) achieved NAPSI-75 at week 12, while complete nail recovery was shown in 6 (14%) hands treated with PDL. Regarding the hands treated with excimer laser, only 16 (38%) hands achieved NAPSI-50, while no hands achieved NAPSI-75 at week 12. In general, subungual hyperkeratosis and onycholysis improved significantly, while nail pitting was least responsive. Oil drops and splinter hemorrhages showed moderate response. CONCLUSIONS: When compared to excimer laser, PDL demonstrated a good response for treating nail psoriasis, with minimal side effects.

The effect of weight reduction on treatment outcomes in obese patients with psoriasis on biologic therapy: a randomized controlled prospective trial.

BACKGROUND: Obesity has long been associated with psoriasis and it is considered to be an independent risk factor for chronic heart diseases in these patients. Recently, some of the biologic drugs used for psoriasis have been reported to cause increase in body weight. It is currently not clear if this increased body weight seen in psoriasis patients on biologics leads to decrease in there efficacy or vice versa. We carried out this study to see if reduction in body weight leads to increased efficacy of biologics in obese psoriasis patients. OBJECTIVE: To evaluate the effect of weight reduction by dietary control on treatment efficacy of biologics in obese patients as indicated by the Psoriasis Area and Severity Index (PASI) score. METHODS: Obese patients with psoriasis receiving biologic therapy, satisfying the inclusion criterion, were randomized in a 1:1 ratio to receive low-calorie diet versus normal diet (control group). We included 262 patients with moderate to severe, stable plaque psoriasis with a PASI score 20:50 on anti TNF-α biologic therapy (infliximab, etanercept, ustekinumab and adalimumab). The patients in the dietary intervention group were given a low calorie diet (≤ 1000 kcal per day) for 8 weeks to induce weight loss. The treatment outcome was assessed using PASI. The PASI scores were assessed at baseline and every 4 weeks up to week 24. RESULTS: There were no significant differences in age, sex distribution, body weight, body mass index, waist circumference, psoriasis duration, or PASI score between the two studied groups at base line. At week 24, the mean (±SD) weight loss was 12.9 ± 1.2 kg in the diet intervention group, and -1.5 ± 0.5 kg in the control group. The average improvement in mean PASI score was 84% for the diet group, and 69% for the control group. PASI 75 was achieved by 85.9% in the diet group, and 59.3% in the control group (p < 0.001). The mean (±SD) body surface area values at week 24 were 3.3 ± 4.4% and 8.1 ± 6.9% in the diet group and control group. CONCLUSIONS: Body weight reduction in obese patients on biologics may increase the efficacy of the drug.

Effect of narrowband ultraviolet B therapy on serum vitamin D and cathelicidin (LL-37) in patients with chronic plaque psoriasis.

BACKGROUND: Narrowband ultraviolet B (NB-UVB) has been widely used in the treatment of psoriasis. It has been shown that vitamin D is a major regulator of the expression of human antimicrobial peptide cathelicidin LL-37, which has a critical role in inflammatory cascade in psoriasis. OBJECTIVE: To evaluate the effect of NB-UVB therapy on serum levels of cathelicidin LL-37 and 25-hydroxyvitamin D [25(OH)D] in psoriasis patients. METHODS: Ninety-three psoriasis patients and 50 controls were included in the study. For psoriasis patients, serum levels of 25(OH)D and cathelicidin LL-37 were estimated before and after NB-UVB therapy. RESULTS: Before treatment, serum 25(OH)D levels were significantly lower in psoriasis patients (31.5 ± 14.41 nmol/L) compared to controls (53.5 ± 19.6 nmol/L), p  =  .015. In contrast, serum LL-37 was significantly higher in psoriasis patients (13.24 ± 3.2 ng/mL) than in controls (7.92 ± 5.33 ng/mL), p < .001. After NB-UVB treatment, there was a highly significant elevation of serum 25(OH)D to reach 56.85 ± 5.2 nmol/L (p < .001) and further elevation of serum LL-37 to reach 29.4 ± 4.2 (p  =  .02). CONCLUSIONS: The elevation of serum 25(OH)D and cathelicidin LL-37 could be an additional possible mechanism of action of NB-UVB therapy in the treatment of psoriasis.

Measurement of vitamin D and cathelicidin (LL-37) levels in patients of psoriasis with co-morbidities.

BACKGROUND: During the last decade, a lot of co-morbidities (diabetes, obesity, heart disease, etc.) have been described to be associated with psoriasis, but the exact link at the molecular level is not well-known. Researchers have shown molecular level changes in vitamin D pathway and its relationship to cathelicidin. AIMS: To estimate the levels of cathelicidin (LL-37), and vitamin D in psoriasis patients with co-morbidities, and compare them with matched healthy controls. METHODS: One hundred consecutive patients with stable plaque psoriasis (psoriasis area and severity index ≥10) with no systemic treatment in the past 3 months were investigated for the serum levels of vitamin D and LL-37, and compared with equal number of matched healthy volunteers. RESULTS: The serum vitamin D levels were significantly lower in patients. Furthermore, the levels of serum LL-37 were significantly high. CONCLUSION: Our study showed that the low serum levels of vitamin D, and higher blood levels of cathelicidin could form a molecular level clue in the pathogenesis of psoriasis patients, who are more likely to develop co-morbidities.

Onychomycosis in patients of nail psoriasis on biologic therapy: a randomized, prospective open label study comparing Etanercept, Infliximab and Adalimumab.

INTRODUCTION AND OBJECTIVE: The association between patients of psoriasis on anti TNF therapy and onychomycosis has not been explored. The aim of this study was to determine the rate of onychomycosis in patients of psoriasis with nail involvement on anti TNF therapy. MATERIALS AND METHODS: All patients of psoriasis with nail involvement seen between February 2007 - July 2012 were examined. All the patients with negative nail scrapings for fungus were enrolled. Patients found fit for biologics after investigations were randomly divided into 3 groups (Group A: Infliximab, Group B: Etanercept and Group C: Adalimumab). The patients were followed up every 4 weeks for 24 weeks. Repeat nail scrapings were done at week 24. The results were compared with controls. RESULT: In total, 315 (178 males and 137 females) patients were enrolled. The mean age was 37.5 ± 11.4 years. The results for scraping for fungus at the end of 24 weeks were as follows: 33% (33/100) in patients on Infliximab followed by 15.45% (17/110), 13.33% (14/105) in patients on treatment with Etanercept and Adalimumab respectively as compared to 13.89% (25/180) among controls. Onychomycosis in association with nail psoriasis was more common in males. CONCLUSION: This study revealed statistically significant association between fungal infections of the nail in patients of psoriasis on treatment with Infliximab.