Successful Treatment of Erosive Lichen Planus With Tofacitinib: A Case Series and Review of the Literature.

Lichen planus (LP) is an inflammatory disease that affects the skin, hair, nails and mucous membranes. Erosive LP is a chronic and difficult-to-treat subtype of lichen planus, characterized by lesions on mucosal surfaces, particularly in the oral and genital areas. The prevalence of erosive LP has not been determined. To date, treatment has consisted of surgical intervention, photodynamic therapy, laser therapy, and systemic or topical drugs, including steroids and immunomodulatory agents. LP usually need longer periods of treatment and are known as precancerous lesions with a 0.4% to 12% conversion rate. In addition, nearly 25% of patients who develop erosive LP of the vulva are resistant to topical corticosteroids, which are the first choice of treatment. This study reports 6 cases with a mean age of 3.33 years, who were diagnosed with erosive LP lesions and previously failed in treatment with local, intralesional, and systemic steroids, and hydroxychloroquine. These patients were then treated with 10 mg of tofacitinib per day. Interestingly, with the new treatment, the patients' mean overall satisfaction score was 9.16 out of 10 (range: 8-10), the mean pain relief score was 9.16 out of 10 (range: 9-10) and patients' symptom improvement also began an average of 1.33 months after starting treatment (range: 1-2.5 months).

Efficacy of oral tofacitinib in refractory chronic spontaneous urticaria and urticarial vasculitis.

The treatment of chronic urticaria (CU) is difficult, currently, antihistamines (AH) are the mainstay of treatment, however, up to 40% of patients do not respond to even high (four-fold) daily doses of AH. Tofacitinib is, a small-molecule that blocks JAK1/3 and inhibits intracellular signaling of multiple key cytokines involved in the inflammatory cascade and its beneficial effects were reported in patients with mast cell activation disease but there is no report in patients with urticaria. Here, we present four cases of refractory CU and one case of urticarial vasculitis (UV) that were managed with tofacitinib. Despite the long-term unresponsiveness of various treatments in our patients, the addition of tofacitinib significantly improved the urticarial activity and ultimately led to tapering and discontinuation of cyclosporine or AH. In conclusion, tofacitinib appears to downregulate inflammatory phenomena associated with mast cells and might be a new therapeutic option for patients with refractory CU or UV.

The Immunogenetics of Lichen Planus.

Lichen planus (LP) is a multifaceted autoimmune disease affecting the skin, nails, hair, and mucous membranes, with several clinical subgroups. Cell-mediated immunity plays a key role in its progression. This chapter reviews the known genetic associations of lichen planus including HLA as well as non-HLA genes.

Stevens-Johnson Syndrome due to COVID-19 vaccination.

As public COVID-19 vaccination programs are being implemented, it is possible that more rare and serious adverse effects such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis (TEN) may occur.

COVID-19 and Dermatology in Iran.

COVID-19 infection may affect the individuals with many underlying conditions including skin diseases. This cross-sectional study was conducted to provide an overview regarding the prevalence of COVID-19 disease in the patients with several skin diseases. Overall, 703 patients with several skin diseases participated in the study and completed our online-designed questionnaire. Among the total participants, only 32(4.6%) subjects reported the COVID-19 infection. The prevalence rate was equal to 0.04%. In the patients with psoriasis, 14 out of 322 people (4.3%) developed the COVID-19. Three out of 159 patients (1.9%) with alopecia areata had been affected with the COVID-19 and 4 (5.2%) patients with vitiligo had caught the disease. Only one subject (2%) with the lichen planus, and 6 (6.8%) patients with other skin diseases had developed the COVID-19 but in the patients with GVHD (Graft Versus Host Disease), 4 (80%) out of 5 patients had caught the COVID-19 disease. The frequency of COVID-19 infection was low in the studied population however; more studies with larger sample size are needed to determine the exact prevalence of the infection in the patients with skin diseases undergoing the treatment with several systemic medications.

Immunosuppressive and immunomodulatory therapies in dermatology and coronavirus disease 2019 (COVID-19).

COVID-19 infection may affect the individuals with many underlying conditions including skin diseases. This cross-sectional study was conducted to provide an overview regarding the prevalence of COVID-19 disease in the patients with several skin diseases. Overall, 703 patients with several skin diseases participated in the study and completed our online-designed questionnaire. Among the total participants, only 32(4.6%) subjects reported the COVID-19 infection. The prevalence rate was equal to 0.04%. In the patients with psoriasis, 14 out of 322 people (4.3%) developed the COVID-19. Three out of 159 patients (1.9%) with alopecia areata had been affected with the COVID-19 and 4 (5.2%) patients with vitiligo had caught the disease. Only one subject (2%) with the lichen planus, and 6 (6.8%) patients with other skin diseases had developed the COVID-19 but in the patients with GVHD (Graft Versus Host Disease), 4 (80%) out of 5 patients had caught the COVID-19 disease. The frequency of COVID-19 infection was low in the studied population however; more studies with larger sample size are needed to determine the exact prevalence of the infection in the patients with skin diseases undergoing the treatment with several systemic medications.

Genital Lesions Masquerading as Condyloma Acuminata: A Case Series Report.

Herein we report three married women referred to Dermatology Clinic of Loghman Hakim Hospital, Tehran, Iran in 2017 for evaluation and treatment of genital warts. Two patients were complaining of flat-topped papules on their labia major and the third one was presented with asymptomatic papillary projections on her vestibule and inner aspect of both labia minora. Histological examination revealed the diagnosis of syringoma, lymphangioma circumscriptum (LC) and vestibular papillomatosis respectively. Familiarity with these uncommon conditions which clinically mimic genital warts helps to prevent labeling a patient with sexually transmitted disease before histological confirmation and prevent unnecessary treatment.

Turmeric tonic as a treatment in scalp psoriasis: A randomized placebo-control clinical trial.

BACKGROUND: Psoriasis is an autoimmune and recurrent chronic inflammatory skin disorder with a strong genetic basis. The characteristic features are hyperproliferation of keratinocytes, leading to redness, thickening, and scaling of the epidermis followed by itching and the appearance of lesions, which in most cases can affect the patients both medically and psychologically. The scalp is one of the most common sites for psoriasis. This condition is predominantly managed with steroids, which are associated with various side effects. Turmeric (Curcuma longa L.), a spice commonly used throughout the world, has been shown to exhibit anti-inflammatory, antimicrobial, antioxidant, and antineoplastic properties. It has been reported to exhibit inhibitory activity on potassium channels in T cells and plays a key role in psoriasis. AIM: We were prompted to investigate the turmeric tonic as an immune modulation and anti-inflammatory therapy on scalp psoriasis. METHOD: Forty patients with mild-to-moderate scalp psoriasis who fulfilled the inclusion criteria were randomly allocated into two groups. The case group received turmeric tonic twice a day for 9 weeks, whereas the other group received a placebo applied in the same manner. Patients were evaluated at the following points: baseline, weeks 3, 6, and 9. The dermatology life quality index (DLQI) questionnaire and PASI (psoriasis area & severity index) scores, as well as medical photos before, during and after treatment were also evaluated. The probable adverse effects were also recorded and reported. RESULTS: Compared to the placebo, turmeric tonic significantly reduced the erythema, scaling and induration of lesions (PASI score), and also improved the patients' quality of life (P value < .05). CONCLUSIONS: The clinical effects of turmeric tonic on scalp psoriasis were satisfactory overall. This formulation could be considered as a treatment for scalp psoriasis.

Evaluation the efficacy of trichloroacetic acid (TCA) 33% in treatment of oral retinoid-induced cheilitis compared with placebo (Vaseline): a randomized pilot study.

BACKGROUND: Oral Isotretinoin (13-cis-retinoic acid) is a gold standardtreatment for severe forms of acne with cheilitis as a most frequent complication. We designed this novel study to investigate the therapeutic effect of trichloroacetic acid (TCA) 33% as compared with placebo to treat cheilitis. METHODS: In this pilot study, 90 acne vulgaris patients between 18 and 50 years, who referred dermatologic clinic with cheilitis, were assigned to either case (TCA) or control (Vaseline) group using permuted-block randomization from 2013 to 2015 with data analysis in 2016. Patients had follow-up visits after 2 and 6 weeks, at which their lesions were photographed. Two blinded expert dermatologists recorded physician International global score for each image. RESULTS: Ninety eligible patients were randomly allocated into two groups. This included 45 patients in each group. At the end of follow-up, 44 patients in the intervention group and 37 patients in control group completed the final assessment. Compared to the control group, the TCA group had a greater reduction in the mean ICGS value from baseline to Week 6 (mean difference 2.59 points, p < .0001). CONCLUSIONS: TCA can be considered as a good strategy in improvement of cheilitis to isotretinoin therapy.

Skin Complications of Orthopedic Procedures and Devices.

BACKGROUND: Knowledge of skin complications and contributing factors in orthopedic patients is important for design and development of preventive approaches. Therefore, this study was designed to assess skin complications in orthopedic patients. METHODS: In this case-series study, 126 orthopedic patients referred to Rasoul-e-Akram and Bahman hospitals from 2012 to 2016 with skin complications were analyzed. The adverse effects were assessed with respect to type and contributing factors. Fisher's exact test, Chi-square, and independent sample t-test were performed to assess the associations between skin complications and other variables. RESULTS: Skin complications in orthopedic patients included infections in 33 (26.1%) cases and hypersensitivity reactions in 88 (40%) cases. In total, 66 (55%) cases of fracture and 35 (29.2%) cases of cellulitis were detected, while the remaining cases involved complications such as disc herniation, nerve involvement, and osteoarthritis-related arthroplasty. Severe reactions presenting as toxic epidermal necrolysis were observed in 3 patients, 2 of whom died eventually. Age and gender were not related to the type of skin complications (P>0.05). CONCLUSION: Complications due to orthopedic treatments were not common. However, since the disease may become fatal on certain occasions, patients should receive more attention from physicians and nurses.

Relieving Pain in Oral Lesions of Pemphigus Vulgaris Using the Non-ablative, Non-thermal, CO2 Laser Therapy (NTCLT): Preliminary Results of a Novel Approach.

Introduction: Pemphigus vulgaris (PV) is a chronic, serious autoimmune mucocutaneous bullous disease. Oral lesions in PV may be extremely painful. This pain may adversely affect the patients' oral intake and quality of life. This before-after clinical trial was designed to assess the pain relieving effects of single session of non-ablative, non-thermal CO2 laser therapy (NTCLT) in oral lesions of PV. Methods: Fifty painful oral lesions of fourteen patients with PV were illuminated by CO2 laser (power: 1 W, scanning the lesions with rapid circular motion of the handpiece) passing through a thick layer of transparent gel with high water content. The pain severity of the oral lesions was reported by the patients up to the fourth postoperative day. They were also asked to continue their existing systemic treatment during the course of this study as a precondition for the participation. Results: The severity of contact and non-stimulate (non-contact) pain declined immediately and significantly after NTCLT (P < 0.001). The pain relieving effect was sustained during the four successive days of follow-up. The procedure was pain free and no kind of analgesics was required. Following NTCLT, there were no visible thermal complications such as destruction, ablation or irritation of the oral lesions. Conclusion: The results of the trial proposed that single session of NTCLT could immediately and significantly relieve pain in oral lesions of PV, without any visible thermal complications.

Investigation on the effects of the atmospheric pressure plasma on wound healing in diabetic rats.

It is estimated that 15 percent of individuals with diabetes mellitus suffer from diabetic ulcers worldwide. The aim of this study is to present a non-thermal atmospheric plasma treatment as a novel therapy for diabetic wounds. The plasma consists of ionized helium gas that is produced by a high-voltage (8 kV) and high-frequency (6 kHz) power supply. Diabetes was induced in rats via an intravascular injection of streptozotocin. The plasma was then introduced to artificial xerograph wounds in the rats for 10 minutes. Immunohistochemistry assays was performed to determine the level of transforming growth factor (TGF-ß1) cytokine. The results showed a low healing rate in the diabetic wounds compared with the wound-healing rate in non-diabetic animals (P < 0.05). Moreover, the results noted that plasma enhanced the wound-healing rate in the non-diabetic rats (P < 0.05), and significant wound contraction occurred after the plasma treatment compared with untreated diabetic wounds (P < 0.05). Histological analyses revealed the formation of an epidermis layer, neovascularization and cell proliferation. The plasma treatment also resulted in the release of TGF-ß1 cytokine from cells in the tissue medium. The findings of this study demonstrate the effect of plasma treatment for wound healing in diabetic rats.

Pulsed dye laser in treatment of steroid-induced atrophy.

BACKGROUND: One of the important and distressing cutaneous side effects of steroid therapy is skin atrophy, which has no definite and effective treatment. To the best of our knowledge, laser therapy for steroid-induced atrophic scars has not been investigated to date. OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of pulsed dye laser in the treatment of steroid-induced atrophic scars. METHODS: In this pilot study, 15 patients with at least one atrophic patch were treated with the 585-nm pulsed dye laser at 4-week interval sessions until achieving complete improvement or until patient were lost to follow-up. Clinical outcome was assessed via standard photographic method before each treatment session and after the final visit. An independent dermatologist evaluated the photographs. RESULT: All of the patients (13 females and two males) with 25-59 years of age experienced some degree of improvement, except one patient who withdrew from the treatment after three sessions. The treatment was well tolerated. CONCLUSION: The results of our study indicated that pulsed dye laser therapy could be employed as a new method in the treatment of steroid-induced atrophic scars. Pulsed dye laser might affect the lesions through inducing collagen deposition and production of more superficial dermal elastin as well as less unidirectional collagen in clusters.

The Relationship between Disease, Work and Sickness Absence among Psoriasis Patients.

BACKGROUND: The aim of this study was to assess the prevalence of absenteeism in patients with psoriasis and determine the factors influencing the incidence of absenteeism in these patients. METHODS: A cross-sectional study from December 2012 to November of 2013 was conducted on 192 psoriasis patients referred to the Dermatology Clinic of Imam Khomeini Hospital, Tehran, Iran. The number day of absence from work due to psoriasis in the last year was asked from the patients; the absence of 7 days has been considered as short-term and more than 7 days as long-term. Logistic regression was used to data analysis. RESULTS: Sickness absence in 21.4% of patients was positive. The average numbers of days of absence were 10.25 and the duration of absence from work in 48.7% were long-term ≥7 days. 51.3% had short-term absence (<7 days). Among disease factors: moderate to severe disease (SAPASI score >10), palms and soles involvement, joint problems and radiation therapy and among job factors: hazardous physical and chemical exposures in the workplace, non-office work, disability, exacerbations of disease on work days and problem on employment were associated with high incidence of sickness absence. CONCLUSION: Psoriasis with its chronic and recurrent nature especially in higher severities causes disabilities that deeply affect Work performance and can decrease the efficiency. In better management of psoriasis patients, physicians should pay special attention to occupational factors.

Yeasts as important agents of onychomycosis: in vitro activity of propolis against yeasts isolated from patients with nail infection.

OBJECTIVE: The purposes of this study were to determine the frequency of the yeast species obtained from patients with clinical features of onychomycosis and the in vitro antifungal susceptibility of the yeast species to propolis. METHODS: A prospective study was carried out at the Mycology Research Center in Iran from 2010 to 2011. Clinical diagnosis was performed by direct microscopic examination and culture. Different yeast species were identified by morphological and biochemical tests. An antifungal susceptibility test to fluconazole (FLU) and propolis by the broth microdilution method was performed on each isolate. RESULTS: One hundred and twenty-eight fungal isolates were obtained. The most prevalent fungi were yeasts (81, 63.2%), dermatophytes (36, 28.1%), and nondermatophyte fungi (11, 8.6%). Fingernails were more affected than toenails (65.4% vs. 19.8%, respectively). The most frequently found species was Candida albicans (38.5%), followed by Candida spp. (23.1%), C. tropicalis (10.8%), C. kefyr (6.2%), C. krusei (3.1%), Malassezia globosa (4.6%), M. slooffiae (4.6%), and M. pachydermatis (1.5%). Of all yeast isolates (65), seven showed resistance to FLU. The average MIC of propolis for FLU-susceptible isolates was 5.8 µg/mL, whereas this value was 12.25 µg/mL for FLU-resistant isolates. CONCLUSION: Our results proved that the propolis inhibits the growth of pathogenic yeasts and confirmed the efficiency of propolis as an anti-Candida and anti-Malassezia agent.

The evaluation of the clinical effect of topical St Johns wort (Hypericum perforatum L.) in plaque type psoriasis vulgaris: a pilot study.

In this case series, ten patients with plaque-type psoriasis were treated with Hypericum perforatum ointment. The hypericum ointment was applied to one side of each patient's body and the vehicle to the opposite side twice daily for 4 weeks in a single blinded manner. Modified psoriasis area severity index (PASI) scores were significantly lowered where the formulated ointment had been applied. In determining PASI scores, three factors, erythema, scaling and thickness, were evaluated; all were significantly lower where the formulated ointment had been applied (P = 0.01, P = 0.004, P = 0.04). Hypericum perforatum ointment applied twice daily may be effective in reducing PASI scores in mild plaque-type psoriasis, however, further larger studies need be conducted to achieve a more conclusive result.