The Impact of Pyschological Stress on Acne.

Acne is one of the most common skin disorders. It is a multifactorial and complex disease, originating in the pilosebaceous follicle where a hereditary background, androgens, skin lipids, disorders of keratinization, inflammatory signaling, and regulatory neuropeptides seem to be mainly involved. Even though emotional stress has long been suspected to trigger or exacerbate acne, its influence on acne severity has been mostly underestimated until recently when studies have brought new data about the different mechanisms and possible factors involved in this interaction. A point to note is that there have been relatively few studies examining stress as a possible cause of acne or acne exacerbation; more studies have focused on stress and mental health problems occurring as a result of acne. In this review, we have tried to identify the underlying mechanisms that link stress to acne according to the latest scientific findings, and we summarize this perplexing connection. The basis for the association between emotional stress and the onset or exacerbation of acne is in several cutaneous neurogenic factors which interact with a pathogenic cascade in acne. This bidirectional intimate relationship of the skin and the mind emphasizes the importance of a holistic and interdisciplinary approach to caring for patients with acne that involves not only dermatologists but also psychologists and psychiatrists.

PERIORAL DERMATITIS: STILL A THERAPEUTIC CHALLENGE.

Perioral dermatitis is a common and often chronic dermatosis. In its classic form, it primarily affects women aged 15 to 45 years, but there are also variants including lupus-like and granulomatous perioral dermatitis, where granulomatous form is more common in childhood and affects mostly prepubescent boys. The etiopathogenesis of the disease remains unclear, but there is a frequent finding of prolonged use of topical products, especially corticosteroids, in the treatment of rosacea and seborrheic dermatitis, preceding the clinical manifestation of perioral dermatitis. Other causes important for the occurrence of the disease include various skin irritants, as well as other physical and hormonal factors, which all share the epidermal barrier dysfunction as an underlying main pathogenic factor. Clinical presentation of papulovesicular eruption in the perioral region with a typical narrow spared zone around the edge of the lips is characteristic. Therapeutic approach should be individually addressed, depending on the severity of clinical presentation and patient's age, with special attention to patient's education and continuous psychological support. In mild forms of perioral dermatitis, 'zero therapy' is the treatment of choice. In the initial treatment period, patients with steroid-induced perioral dermatitis should be closely followed up because the rebound phenomenon usually develops after cessation of previous topical treatment. In moderate disease, treatment includes topical metronidazole, erythromycin, and pimecrolimus, whereas in more severe cases the best validated choice is oral tetracycline in a subantimicrobial dose until complete remission is achieved. Systemic isotretinoin should be considered as a therapeutic option for patients refractory to all standard therapies.

Skin changes in primary psychiatric disorders.

Primary psychiatric disorders where skin changes appear most frequently include: delusions of parasitosis, body dysmorphic disorder, neurotic excoriations, dermatitis artefacta, and trichotillomania. In all these diseases the primary pathologic condition is of psychiatric nature, and the skin changes are secondary and self-induced. In this review we wanted to present the epidemiology, clinical pictures, and treatment options for these disorders. These patients are more frequently seen in dermatology clinics, as they may be unwilling to acknowledge a psychiatric basis for their psychical symptoms. If we want the treatment to be effective and timely, it is important for the dermatologist to understand the underlying psychopathology of these conditions. Treatment should be gradual. An initially supportive, nonconfrontational, empathic approach to the patient is indicated. Immediate confrontation regarding the suspicion that the patient's lesions are self-induced can be counterproductive in that the patient will often refuse treatment. Frequent visits and symptomatic topical treatments are useful in the beginning. The goal is to establish a trusting and supportive enough relationship with the patient so that he or she will accept a psychiatric referral to explore the complex personality and behavioral issues that often underlie these conditions.

Chancroid, lymphogranuloma venereum, granuloma inguinale, genital herpes simplex infection, and molluscum contagiosum.

Chancroid, lymphogranuloma venereum, and granuloma inguinale may be considered as tropical venereal diseases. These diseases were a major diagnostic and therapeutic challenge in past centuries. Currently, patients with these bacterial infections that are endemic to the tropics occasionally consult with dermatologists in temperate climates. Due to the increasing frequency of travel to the tropics for tourism and work, as well as the increasing number of immigrants from these areas, it is important for dermatologists practicing in temperate climates to be familiar with the dermatologic manifestations of such infections, to be prepared to diagnose these diseases, and to treat these patients. All three "tropical" infections respond well to prompt and appropriate antimicrobial treatment, although herpes progenitalis still cannot be cured, and the number of people infected keeps growing; moreover, genital herpes can be transmitted by viral shedding before and after the visual signs or symptoms. Acyclovir, valacyclovir, and famciclovir can shorten outbreaks and make them less severe or even stop them from happening. There is currently no etiologic treatment for molluscum contagiosum, and the majority of treatment options are mechanical, causing a certain degree of discomfort. The molluscum contagiosum virus, unlike the other infectious agents mentioned, does not invade the skin.

Acne and diet: facts and controversies.

Acne is a common skin disorder characterized by follicular hyperkeratinization and obstruction of the pilosebaceous follicles, androgen stimulated sebum production, colonization of the follicles by Propionibacterium acne, and inflammation. A large number of epidemiological studies have shown a low incidence of acne in non-Western societies, suggesting that diet might be an important factor in acne pathogenesis, particularly in mediating inflammation, oxidative stress and androgen stimulation in the acne process. Consequently, it has been hypothesized that diet might have a preventive or therapeutic effect in this skin disorder. Since the majority of recent data have not been consistent, the aim of this article is to present current knowledge and scientific assumptions on the relationship between diet and acne.

Seborrheic dermatitis: an update.

Seborrheic dermatitis is a chronic relapsing inflammatory skin disorder clinically characterized by scaling and poorly defined erythematous patches. The prevalence of adult seborrheic dermatitis is estimated at 5%. Although the exact cause of seborrheic dermatitis has yet to be understood, Malassezia yeasts, hormones (androgens), sebum levels and immune response are known to play important roles in its development. Additional factors including drugs, winter temperatures and stress may exacerbate seborrheic dermatitis. A variety of treatment modalities are available, including antifungal agents, topical low-potency steroids and calcineurin inhibitors (immunomodulators). This review summarizes current knowledge on the etiopathogenesis and therapy of adult seborrheic dermatitis.

Current therapeutic approach to acne scars.

The occurrence and incidence of acne scarring is different. Lasting for years, acne can cause both physical and psychological scarring. Scarring frequently results from severe inflammatory nodulocystic acne but may also result from more superficial inflamed lesions or from self-manipulation. There are two general types of acne scars: hypertrophic (keloid) scars, and atrophic (icepick, rolling and boxcar) scars. The management of acne scarring includes various types of resurfacing (chemical peels, lasers, lights, cryotherapy), use of dermal fillers, and surgical methods such as dermabrasion, subcision or punch excision. Individual scar characteristics, including color, texture and morphology, determine the treatment choice. Combining treatment methods may provide additional improvement compared with one method alone. It should be noted that none of the currently available treatments can achieve complete resolution of the scar. The best method of preventing or limiting scarring is to treat acne early enough to minimize the extent and duration of inflammation.

Hypertrophic lupus erythematosus: case report.

Discoid lupus erythematosus is the most common form of cutaneous lupus erythematosus. It is more common in women than in men, in individuals between 20 and 40 years of age. It is an inflammatory autoimmune disease in which genetically predisposed individuals are stimulated by hormonal and a variety of exogenous factors including UV radiation, stress, infections, and even temperature changes. Lesions are characterized by erythema, hyperkeratosis and atrophy. Typical sites are light-exposed areas, i.e. forehead, nose, cheeks, upper part of the back, upper chest, and dorsal aspects of the hands and feet. A case of lupus erythematosus hypertrophicus with very good and rapid treatment results with antimalarials and topical corticosteroid is presented.

Gorlin syndrome patient with large deletion in 9q22.32-q22.33 detected by quantitative multiplex fluorescent PCR.

BACKGROUND: Gorlin syndrome is a rare autosomal-dominant disorder characterized by a wide range of developmental abnormalities and various tumors. The syndrome is caused by mutations in PTCH1, a tumor suppressor gene located at 9q22.32. We describe a Gorlin syndrome case with typical features of the syndrome and no mutations in PTCH1, but with a large deletion of the 9q22 region that has rarely been described. OBJECTIVE: To fully characterize the large deletion in the patient. METHODS: In order to map the size and position of the deletion, we developed quantitative multiplex fluorescent PCR with polymorphic markers surrounding the PTCH1 gene, followed by long-range PCR and sequencing. RESULTS: The deleted segment of 4.5 Mb in the 9q22.32-q22.33 region was determined, and included the entire PTCH1, its promoter and 22 OMIM genes. CONCLUSION: We suggest that screening for large deletions should be included in standard mutation screening for Gorlin syndrome patients.

Treatment of massive rhinophyma by combined electrosurgery and CO2 laser.

A case of massive rhinophyma that produced significant functional and cosmetic difficulties was treated using electrosurgery and carbon dioxide laser. Minimal bleeding occurred during the operative procedure despite grotesque enlargement and high degree of vascularity of the skin and soft tissue. Using this technique, restoration of normal function and excellent cosmetic effect was achieved without any complication.

Oxidative stress and ferritin expression in the skin of patients with rosacea.

BACKGROUND: Rosacea is a common chronic light-sensitive inflammatory skin disease of unknown origin. The purpose of this work was to determine the parameters of oxidative stress, antioxidative capacity, and the pathophysiologic role of ferritin expression in skin cells of patients with rosacea. OBJECTIVES: The investigation consisted of measurements of serum peroxide levels, serum total antioxidative potential levels, and immunohistochemical analyses of ferritin in skin tissue samples. RESULTS: Serum peroxide levels were significantly higher and serum total antioxidative potential levels were significantly lower in patients with rosacea than in healthy control subjects (P < .05). Compared with control subjects, the number of ferritin-positive cells was significantly higher (P < .001) in skin samples from patients with rosacea, especially those with severe disease. LIMITATIONS: Patients with rosacea in the study were aged 30 to 70 years (average age was 56 years). Younger patients with flushing only were not included according to the request of the ethics committee, limiting the use of diagnostic biopsies only to the necessary cases. CONCLUSION: The statistically significant differences in the expression of ferritin, higher peroxide levels, and lower antioxidative potential support the onset of systemic oxidative stress in patients with rosacea.

A dose-finding study of azithromycin in the treatment of acne vulgaris.

This open, multicenter, comparative, randomized study included 120 subjects with papulopustular stage of acne vulgaris. Subjects were randomized to one of the three treatment groups (A, total dose 4.5 g of azithromycin in 7 weeks; B, total dose 6.0 g in 10 weeks; and C, total dose 7.5 g in 13 weeks). The aim was to identify the optimum azithromycin dose in the treatment of acne vulgaris through monitoring the efficacy and safety of three dosage regimens. Clinical efficacy was assessed upon completion of study therapy and six months of therapy initiation. Post-therapeutic efficacy assessment was available in 104 subjects. The difference between three treatment groups was most pronounced in the "cure" category (36.11% in group A, 58.82% in group B and 55.88% in group C) and "failure" category (8.33% in group A, and no failures in groups B and C). Follow up efficacy assessment was available in 87 subjects. The group percentage of "cure" was lower and group percentage of "treatment failure" higher in group A than in groups B and C. Azithromycin in a total dose of 6.0 g in 10 weeks seems to be a promising agent in the treatment of papulopustular acne vulgaris with few side effects and good patient compliance.

Mutation in exon 7 of PTCH deregulates SHH/PTCH/SMO signaling: possible linkage to WNT.

The novel PTCH mutation and clinical manifestations within Gorlin syndrome family links PTCH haploinsufficiency and aberrant activation of the Wnt pathway. We report a family case with Gorlin syndrome, characterized by the usual phenotype features such as widespread basocellular tumors and craniofacial and bone malformations, but also including a less common appearance of craniopharyngioma. These clinical manifestations might be associated with a novel constitutional mutation of the PTCH gene, 1047insAGAA, which we found in exon 7. It changes the normal amino acid sequence leading to termination of the PTCH protein at exon 9. The analyzed tumors of the family show extensive loss of heterozygosity in the PTCH region, both basocellular and in particular craniopharyngioma, and in the latter a high expression of beta-catenin was detected. Our findings suggest involvement of the SHH/PTCH/SMO pathway in pathogenesis of the analyzed disorders, including its possible contribution to aberrant activation of the Wnt pathway in craniopharyngioma.

Atypical clinical appearance of pemphigus vulgaris on the face: case report.

Pemphigus vulgaris is an organ-specific autoimmune mucocutaneous disorder. In the majority of cases, the disease manifests initially with oral lesions, and may be limited to a single site for months before spreading. A 78-year-old woman with yellowish crusted areas on her left preauricular region and close to the medial angle of her right eye is presented. Although she described an episode of erosions on her lower lip, the involvement of mucosal surfaces was not noticed on examination. Before she presented to our Department, she was misdiagnosed as an actinic cheilitis and malignant skin tumor. Histopathologic examination and direct immunofluorescence confirmed the diagnosis of pemphigus vulgaris. Immunoblotting of epidermal extracts detected IgG antibodies against desmoglein 3 but not desmoglein 1, which was also confirmed by ELISA test. The patient responded favorably to systemic corticosteroid therapy combined with adjuvant immunosuppressive therapy, with complete clearance of the lesions.

[What should we know about contact hypersensitivity to local glucocorticoids?]. / Sto treba znati o kontaktnoj preosjetljivosti na lokalne glukokortikoide?

Local glucocorticoids are still the most frequently used drugs in dermatology. In recent years there have been an increasing number of reports on contact allergic reactions to glucocorticoid. Patients with contact allergy to glucocorticoid generally present with chronic dermatitis that is exacerbated by and fails to respond to glucocorticoid therapy. Most patients react in patch test to more than one glucocorticoid, but mostly to tixocortol pivalate and budesonide. In patients with prolonged eczematous skin disease and other chronic inflammatory disease who do not improve, or who deteriorate during topical glucocorticoid therapy, contact allergy should be suspected and patch test should be preformed.

Cytokeratin 10 and Ki-67 nuclear marker expression in keratoacanthoma and squamous cell carcinoma.

The most frequent consideration in the clinical and histologic differential diagnosis of keratoacanthoma is squamous cell carcinoma. In the present study, cytokeratin 10 expression and proliferation rate as measured by Ki-67 expression were compared between 50 clinically and histologically diagnosed keratoacanthomas and 50 squamous cell carcinomas. Tissue sections from the skin were immunohistochemically stained with anti-cytokeratin 10 and anti-Ki-67 monoclonal antibodies. The distribution of cytokeratin 10 expression and proliferative cell count were analyzed. Study results showed higher cytokeratin 10 expression in keratoacanthomas than in squamous cell carcinomas and different distribution of staining in the two entities. The analysis of cytokeratin 10 expression showed a much wider range of values and statistically higher median (p<0.001) in keratoacanthomas than in squamous cell carcinomas. Additionally, the proliferation index of keratinocytes as measured by Ki-67 expression was significantly higher in squamous cell carcinomas than in keratoacanthomas (p<0.01). These results may prove helpful in histologic differentiation of these disorders.

Etiopathogenesis, classification, and current trends in treatment of rosacea.

Rosacea is a common chronic dermatosis characterized by varying degrees of flushing, erythema, telangiectasia, edema, papules, pustules, ocular lesions, and phymas. Etiology and pathogenesis of rosacea are still unknown. Many possible causes have been described as inducing the disease or contributing to its manifestation, such as genetic predisposition, abnormal vascular reactivity, changes in vascular mediating mechanisms, Helicobacter pylori infection, Demodex folliculorum infestation, seborrhea, sunlight, hypertension, and psychogenic factors. However, none of these factors has been proved. Rosacea shows a wide spectrum of clinical presentations, which vary over time and with age. Successful management of rosacea requires careful patient evaluation and individualized therapy with appropriate variations and modifications, as the severity of the disorder fluctuates. In mild cases of rosacea, patients are instructed to avoid sun, to apply sun-protective creams, and to avoid facial irritants and other triggers that provoke symptoms. At later stage, drug therapy is often necessary. The disease commonly requires long-term treatment with topical or oral medicaments. Surgical correction may be required for rhinophyma and telangiectasia. We reviewed the current literature on the aspects of the pathogenesis, diagnostic criteria, and treatment options for rosacea.