Efficacy and safety of diphenylcyclopropenone alone or in combination with anthralin in the treatment of chronic extensive alopecia areata: a retrospective case series.

BACKGROUND: Some patients with chronic extensive alopecia areata (AA) may be refractory to topical immunotherapy. Combination therapy is recommended for such patients. Efficacy and safety of a combination therapy with diphenylcyclopropenone (DPCP) and anthralin in chronic extensive AA is unknown. OBJECTIVE: We sought to determine whether the combination therapy of DPCP and anthralin is superior to DPCP alone in chronic extensive AA. METHODS: We retrospectively analyzed the efficacy, side effects, and relapse rates of DPCP (alone or with anthralin) in chronic extensive AA. RESULTS: A total of 47 patients (22 were treated only with DPCP, and 25 with DPCP and anthralin for at least 30 weeks) were evaluated. Complete hair regrowth was observed in 36.4% and 72% of the patients who received DPCP and combination therapy, respectively (P = .01). Hair regrowth duration was shorter with combination therapy (P = .01). Regrowth rates of the eyebrows, eyelashes, and beard in patients on combination therapy were higher than those in patients on DPCP (P = .01). Side effects such as folliculitis, hyperpigmentation, and staining of skin, hair, and clothes were more common in combination therapy group. LIMITATIONS: The retrospective design and small number of patients are limitations. CONCLUSION: Combination therapy with DPCP and anthralin is superior to DPCP alone in chronic extensive AA.

Diagnostic reliability of the Tzanck smear in dermatologic diseases.

BACKGROUND: The Tzanck smear is a simple, easily applicable, rapid, and inexpensive test for the diagnosis of erosive vesiculobullous, tumoral, and granulomatous diseases. The diagnostic accuracy of the Tzanck smear is known, but its diagnostic reliability has been evaluated only in herpetic infections and basal cell carcinoma. OBJECTIVES: The aim of this study was to evaluate the diagnostic reliability of the Tzanck smear in erosive vesiculobullous, tumoral, and granulomatous diseases. METHODS: Patients evaluated by Tzanck smear at Baskent University Faculty of Medicine, Department of Dermatology, between February 2009 and July 2010, were included. Three dermatologists were involved in the study. Dermatologist A performed a clinical dermatologic examination, took the smear material, made a clinical diagnosis, and compared the clinical and cytological diagnoses. Dermatologists B and C evaluated the smears. Agreement between the latter two dermatologists on the cytological diagnoses was determined. RESULTS: In 500 patients, a total of 272 (54%) erosive vesiculobullous, 190 (38%) tumoral, and 38 (8%) granulomatous lesions were diagnosed. The diagnostic reliability of the Tzanck smear was reasonably substantial (κ = 0.59) for all types of lesions, substantial for erosive vesiculobullous (κ = 0.79) and granulomatous (κ = 0.68) lesions, and moderate (κ = 0.50) for tumoral lesions. CONCLUSIONS: The Tzanck smear may be used for the evaluation of erosive vesiculobullous and granulomatous lesions with brief training. However, the evaluation of tumoral lesions by Tzanck smear requires more experience.

The contribution of teledermatoscopy to the diagnosis and management of non-melanocytic skin tumours.

We examined the contribution of dermatoscopy to the reliability of the diagnosis and management of non-melanocytic skin tumours using store-and-forward teledermatology. A total of 150 patients with non-melanocytic skin tumours were enrolled into the study. The reliability of the diagnoses and management plans was measured by comparing teledermatology with face-to-face examination; the effect of adding dermatoscopy images was also analysed. The accuracy of the diagnoses was measured by comparing teledermatology with histology; the effect of adding dermatoscopy images was also analysed. Diagnostic reliability (kappa) for teledermatology without dermatoscopy was 0.75 and 0.77 for two different dermatologists, A and B. The reliability increased significantly when dermatoscopy was added, to 0.86 and 0.88 respectively (P < 0.05). The reliability of management plans without dermatoscopy was 0.67 and 0.70, but it did not increase significantly when dermatoscopy was added. The accuracy of the diagnoses was significantly increased by the addition of dermatoscopic images, from 85% to 94% for dermatologist A and from 88% to 95% for dermatologist B. Teledermatology is a reliable technique for the diagnosis and management of non-melanocytic skin tumours and the addition of dermatoscopic images increases the reliability and the accuracy of teledermatology.

Dermatoscopy versus Tzanck smear test: a comparison of the value of two tests in the diagnosis of pigmented skin lesions.

BACKGROUND: Dermatoscopy is the most commonly used noninvasive tool for the diagnosis of pigmented skin lesions, but few studies have investigated the value of cytology in the identification of those lesions. OBJECTIVE: We compared the accuracy of dermatoscopy with that of the Tzanck smear test in the diagnosis of pigmented skin lesions, and in differentiating melanocytic from nonmelanocytic lesions. METHODS: Two dermatologists used either dermatoscopy or the Tzanck smear test to evaluate pigmented skin lesions, and the diagnostic accuracy of those methods was determined. RESULTS: Two hundred pigmented skin lesions (110 melanocytic and 90 nonmelanocytic) were evaluated. Cytology was superior to dermatoscopy in differentiating melanocytic pigmented lesions from nonmelanocytic pigmented lesions, but the overall diagnostic accuracy of those methods was the same (90.5%) for all lesions. The diagnostic accuracy of the Tzanck smear test was higher than that of dermatoscopy for both melanocytic and nonmelanocytic malignant pigmented lesions; however, those differences were not significant. LIMITATIONS: Pigmented skin lesions were not evaluated by a dermatologist who used a combination of dermatoscopy and the Tzanck smear test. No conclusion was made about the reliability of those two methods or whether the experience of the dermatologist affected the results. Immunohistochemical staining of the cytologic samples was not performed. CONCLUSION: The diagnostic accuracy of the Tzanck smear test in assessing pigmented skin lesions is similar to that of dermatoscopy. The Tzanck smear test may be a useful diagnostic adjunct to dermatoscopy for determining the melanocytic or nonmelanocytic origin of certain pigmented skin lesions.

The Tzanck smear test: rediscovery of a practical diagnostic tool.

The Tzanck smear test is a simple, rapid, valuable, and cost-effective diagnostic method based on the investigation of characteristics of individual cells. In this method, materials are obtained by various techniques and then transferred to a glass slide. Slides can be stained with various dyes and then are examined under a light microscope. To date, cytology has mostly been used in the diagnosis of various erosive-vesiculobullous and nodular lesions, including many tumors. The sampling methods for Tzanck smears and the cytologic findings of a broad range of skin diseases that could provide a rapid diagnosis are described.

A case with two unusual findings: cutaneous leishmaniasis presenting as panniculitis and pericarditis after antimony therapy.

BACKGROUND: Cutaneous leishmaniasis is a parasitic disease caused by a Protozoan. Clinically and histopathologically, it can be confused with various dermatologic diseases. METHODS: We report a case of cutaneous leishmaniasis (CL) with two unusual findings. A 49-year-old male patient presented to our clinic with a 3-month history of multiple nodules exhibiting arciform arrangement on the lateral side of the left leg. RESULTS: Histopathologic examination revealed it as nodular vasculitis. Leishmania smear showed suspicious parasites. Although leishmania culture was negative, PCR was positive for Leishmania. The patient was considered to have CL and was treated with systemic meglumine antimoniate for 14 d. Three days after the end of the treatment, the patient presented to emergency room with a sharp, pleuritic chest pain. He was diagnosed with pericarditis based on clinical and electrocardiogram findings. As other causes of pericarditis were absent, it was thought to be related to antimony therapy. CONCLUSION: The histopathologic presentation of CL as panniculitis is a very rare and this is the first case of pericarditis after the antimony treatment.

A useful alternative approach for the treatment of well-demarcated Basal cell carcinoma: surgical excision and margin control with tzanck smear test.

OBJECTIVE: To analyze the accuracy of the Tzanck smear test (TST) for margin control in surgery for well-demarcated basal cell carcinoma (BCC). METHODS AND MATERIALS: Twenty-one patients with well-demarcated BCC were included in this study. After local anesthesia, the tumors were excised. The pathologist examined the frozen sections. If the tumor cells were observed in the margin, a re-excision was done. This procedure was repeated until the margin was tumor free. After each excision, Tzanck smear samples were taken from the defect area. The samples obtained were stained with May-Grünwald-Giemsa and examined. The accuracy of TST was then analyzed by comparison of the TST results with those of frozen section examination. RESULTS: The sensitivity and specificity of TST for margin assessment were 1.00 (95% confidence interval (CI)=1.00-1.00) and 0.99 (95% CI=0.98-1.00), respectively. Positive and negative predictive values and the diagnostic accuracy for TST were 0.94 (95% CI=0.84-1.05), 1.00 (95% CI=1.00-1.00), and 1.00 (95% CI=0.99-1.00), respectively. No recurrences were observed in the average 2-year follow-up period. CONCLUSION: The high accuracy of TST for margin control is encouraging to develop a practical alternative approach for the treatment of well-demarcated BCC.

More experiences with the Tzanck smear test: cytologic findings in cutaneous granulomatous disorders.

BACKGROUND: Granulomatous dermatitis is a distinctive histopathologic cutaneous reaction pattern against various infectious and noninfectious agents. Cytologically, granulomatous dermatitis shows granulomas and multinucleated giant cells. Various etiologic agents of granulomatous diseases can also be identified. OBJECTIVE: We aimed to investigate Tzanck smear findings in granulomatous skin diseases. METHODS: Patients who had granulomas and/or multinucleated giant cells of Langhans, foreign body- and/or Touton type in Tzanck smear tests were included in the study. In these patients, Tzanck preparations were then further evaluated for additional cytologic findings. Samples stained with May-Grünwald-Giemsa stain were evaluated by the same dermatologist throughout the study. In some patients, methylene blue, Gram and/or Erlich-Ziehl-Nielsen stains were also performed. In all of the study cases, the final diagnosis was established after the evaluation of clinical and laboratory findings (including, when appropriate, potassium hydroxide examination; bacterial, leishmanial, and fungal cultures; histopathology; tuberculosis and leishmania polymerase chain reaction). We also calculated the sensitivity and specificity of the Leishman-Donovan body for cutaneous leishmaniasis. RESULTS: Over a 2-year period, 94 of 950 patients (9.9%) in whom Tzanck smear tests were performed had cytologic findings consistent with a granulomatous reaction. In 74 (78.7%) and 20 (21.3%) patients, the granulomatous reaction was due to infectious and noninfectious causes, respectively. Infectious causes included cutaneous leishmaniasis in 65 patients (87.8%), candidal granuloma in two patients, botyromycosis in two patients, and aspergillosis, blastomycosis, mucormycosis, leprosy, and cutaneous tuberculosis in one patient each. In 58 of 74 patients (78.4%) with infectious granulomatous dermatitis, the causes of the granulomas were identified. Noninfectious granulomatous reactions were due to granuloma annulare in 7 patients, sarcoidosis in 5 patients, a foreign body in 4 patients, necrobiosis lipoidica in 2 patients, and juvenile xanthogranuloma in 2 patients. In 17 of 20 patients (85%) with noninfectious granulomatous reactions, the cytologic findings were characteristic of the final diagnoses. The sensitivity and specificity of Leishman-Donovan bodies for cutaneous leishmaniasis were 76.9% and 100%, respectively. LIMITATIONS: All of the samples were evaluated by the same dermatologist throughout the study; therefore no comment could be made regarding the reliability of the Tzanck smear test. In addition, the sensitivity and specificity of Tzanck smear test findings for diseases other than cutaneous leishmaniasis could not be calculated because of an insufficient number of patients. CONCLUSION: The Tzanck smear test may be a useful diagnostic tool for certain granulomatous skin diseases.

The value of Tzanck smear test in diagnosis of erosive, vesicular, bullous, and pustular skin lesions.

BACKGROUND: Tzanck smear is generally used for the diagnosis of the pemphigus group of autoimmune bullous diseases and mucocutaneous herpesvirus infections. There are only a few studies in the literature investigating its diagnostic value. OBJECTIVES: We aimed to investigate Tzanck smear findings and to determine the diagnostic value of this test in moist (erosive, vesicular, bullous, and pustular) skin lesions. We also aimed to develop an algorithmic approach for the diagnosis of these types of skin lesions according to the Tzanck smear findings. METHODS: Samples were stained with May-Grünwald-Giemsa and evaluated by the same dermatologist. In some patients, methylene blue and Gram staining or direct immunofluorescence examinations were additionally performed. In all of the study cases, after the evaluation of clinical and laboratory findings (including, when appropriate, potassium hydroxide examination; viral serology; bacterial and fungal cultures; histopathology; direct and indirect immunofluorescence; patch testing), the definite diagnosis was established. We also determined the sensitivity and the specificity of certain Tzanck smear findings. RESULTS: Tzanck smear was performed in a total of 400 patients with moist skin lesions. The sensitivities of multinucleated giant cells and acantholytic cells in herpetic infections, dyskeratotic acantholytic cells and cocci in bullous impetigo, pseudohyphae in candidiasis, acantholytic cells in pemphigus and more than 10 tadpole cells (magnification x100) in spongiotic dermatitis were 84.7%, 92%, 100%, 100%, and 81.5%, respectively. LIMITATIONS: Because Tzanck smears were evaluated by the same dermatologist, no comment could be made regarding the interobserver reliability of this test and how the level of experience with this technique might affect the results. Also, the sensitivity and the specificity of Tzanck smear test findings for certain diseases could not be calculated because of an insufficient number of patients. CONCLUSION: The Tzanck smear test is an inexpensive, useful, and an easy diagnostic tool for certain skin diseases.

Cutaneous manifestations in brucellosis: a prospective study.

Brucellosis remains an important public health problem in Turkey, just as it is in other regions of the world. This study was conducted to determine the types and rates of cutaneous lesions that occur in patients with brucellosis. Brucellosis was diagnosed by standard tube agglutination testing for Brucella antibodies at a titer of 1/160 or higher in the presence of compatible clinical findings. A total of 140 patients who had been given a diagnosis of brucellosis were prospectively observed in the dermatology clinic. Of these patients, 102 (72.9%) were female, with a mean age of 44.11+/-18.22 y, and 38 (27.1%) were male, with a mean age of 46.44+/-14.58 y. The duration of symptoms was less than 2 mo (acute) in 75 patients (53.5%), from 2 to 12 mo (subacute) in 30 patients (21.4%), and longer than 12 mo (chronic) in 35 patients (25.0%). Cutaneous findings related to brucellosis were observed in 8 (5.71%) of the 140 cases. Maculopapular eruptions were observed in 2 patients (25%), erythema nodosum-like lesions in 2 (25%), psoriasiform lesions in 1 (12.5%), palmar erythema in 1 (12.5%), malar eruption in 1 (12.5%), and palmar eczema in 1 (12.5%). The investigators concluded that although cutaneous findings encountered in brucellosis are generally not specific to this disease, the presence of these findings may be useful in diagnosing brucellosis in persons who live in, or used to live in, endemic regions.

Efficacy and safety of the short-pulse erbium:YAG laser in the treatment of acquired melanocytic nevi.

BACKGROUND: Various laser systems have been used in the treatment of acquired melanocytic nevi. However, CO2 lasers may cause scarring, and some nevi cannot be removed with pigment-specific lasers completely. To date, no study has evaluated the efficacy and safety of an erbium:yttrium-aluminum-garnet (YAG) laser, with its small penetration depth and fewer adverse effects, in the treatment of acquired melanocytic nevi. OBJECTIVE: To investigate the efficacy and safety of the short-pulse erbium:YAG laser in the treatment of acquired melanocytic nevi. METHODS: The study included 28 nevi in 14 patients. The lesions were pigmented, flat, or just palpable nevi. Nevi were irradiated with single-pulse laser energy of 1,000 mJ and a pulse duration of 300 microseconds. Fluences between 5.2 and 14.4 J/cm2 were used. Four months following laser treatment, the entire lesion was excised. Each specimen was histopathologically and immunohistochemically examined for the presence of nevus cells. RESULTS: Clinically, all of the nevi and, histopathologically, 27 of 28 nevi (96%) were completely removed without scarring. Post-inflammatory hyperpigmentation was seen in two patients and hypopigmentation in three patients. CONCLUSIONS: Short-pulse erbium:YAG laser treatment is an effective and safe method for removing acquired melanocytic nevi.

A comparison of teledermatology using store-and-forward methodology alone, and in combination with Web camera videoconferencing.

We compared the diagnostic accuracy of conventional asynchronous teledermatology ('store-and-forward' [SAF]) with a combined technique, in which SAF methodology was used first, followed by a videoconference using low-cost Web cameras. The study involved 228 patients with 242 lesions. For each case, two independent teledermatologists (A and B) evaluated digital images and clinical information by the conventional SAF method and gave a single diagnosis. Then, each communicated with the patient via Web cameras and gave a single diagnosis (combined method). Finally, teledermatologist A performed a face-to-face examination of each patient and established the gold standard diagnosis. With the conventional SAF method, the diagnostic accuracy of teledermatologist A was 81%, while that for teledermatologist B was 75%. With the combined method, the corresponding values were 90% and 82% (P<0.001 for both). There was no significant difference in the interobserver agreement between the two methods. Use of Web camera videoconferencing improved patient satisfaction with teledermatology. This method of teledermatology may be a useful alternative to the SAF method alone.

Familial cutis tricolor: a possible example of paradominant inheritance.

Cutis tricolor is a recently described skin disorder characterized by the coexistence of congenital hyper- and hypopigmented macules adjacent to each other on a background of normal skin. It has been considered to represent an example of didymosis (twin spotting), which is a particular form of loss of heterozygosity. Cutis tricolor may occur as a cutaneous feature of various multisystem birth defects. We report two sisters with cutis tricolor. One of them had, in addition, unilateral hypoplasia of the breast. This familial occurrence of cutis tricolor may best be explained by the concept of paradominant inheritance. 2003.

Segmental lentiginosis with ipsilateral nevus depigmentosus: another example of twin spotting?

We report a patient with unilateral lentiginosis and ipsilateral nevus depigmentosus. She had no other cutaneous or extracutaneous abnormalities. The coexistence of segmental lentiginosis and nevus depigmentosus may be explained as a twin-spot phenomenon.