The COVID-19 Pandemic and Recent Earthquake in Zagreb Together Significantly Increased the Disease Severity of Patients with Atopic Dermatitis.

BACKGROUND/OBJECTIVE: Stress may affect patients with atopic dermatitis (AD). The aim of this study was to examine the impact of the COVID-19 pandemic and the earthquake in Zagreb, Croatia (March 2020), on AD patients and their disease severity, symptoms/itch, and perceived stress. METHODS: Our observational cross-sectional study included three groups of AD patients diagnosed by a physician: group 1 (n = 50), who experienced both the pandemic (quarantine) and the earthquake; group 2 (n = 50), who experienced only the pandemic; and group 3 (n = 50), the comparison group, who experienced neither disaster (patients examined 2018-2019). Groups 1 and 2 were examined May-June 2020, immediately after the national lockdown/quarantine. Disease severity (SCORAD), data from the Perceived Stress Scale (PSS), and information on patients' confirmed allergies were recorded for all groups, while groups 1 and 2 additionally completed a questionnaire concerning their disease, hand hygiene, and experience during the pandemic and/or earthquake. RESULTS: The patients exposed to both disasters reported more pronounced AD worsening (p < 0.001; r = 0.388) and more frequent itching (p < 0.001; r = 0.350) than those exposed to the pandemic only. Notably, we found certain differences by gender: during the pandemic, women significantly more frequently washed their hands (81% of women washed "very frequently," while 52% of men washed "quite often") and had significantly higher PSS levels than men (p < 0.05). Concerning allergies, present or absent, during the pandemic, there was no significant difference in SCORAD between groups 1 and 2, neither when analyzed separately for indoor nor for outdoor allergens. The most commonly reported psychological disturbances during the pandemic were concern (46%), anger (18%), anxiety (16%), depression (9%), and increased alcohol, cigarette, and opioid agent use (6%). CONCLUSION: The COVID-19 pandemic together with the earthquake significantly increased disease severity and influenced AD worsening, itching, and psychological disturbances. This indicates that stressful events meaningfully affect the course of AD.

he Influence of Academician Franjo Kogoj on Global Dermatology.

Academician Franjo Kogoj graduated medicine in 1920 in Prague, where he then pursued training in dermatovenerology. During later years, he also visited other dermatology clinics in Europe, where he collaborated with renowned dermatologists of the time, such as in Breslau (present day Wroclaw in Poland) with Josef Jadassohn and in Strasbourg with Lucien-Marie Pautrier. He was also active in the famous Saint-Louis hospital in Paris. Academician Kogoj's scientific interests were especially focused on allergies, exanthemas, skin tuberculosis, and keratodermas. Kogoj was very active in defining a precise and useful terminology for various dermatological conditions, where the terminology was in many ways confusing and often overlapping, such as in cases of eczema and dermatitis. Kogoj performed experimental studies of allergic reactions in eczema and atopic dermatitis and introduced the term pruridermatitis (Pruridermatitis allergica chronica) into dermatological terminology instead of the name neurodermitis and other synonyms essentially describing atopic dermatitis (endogenous eczema, prurigo-asthma, prurigo Besnier). Academician Kogoj managed to define Mal de Meleda as a separate form of hereditary keratoderma and was engaged in the clinical symptomatology, serology, and therapy of syphilis, whereby he emphasized the so-called "critical moment" in the treatment of syphilis. Academician Kogoj's most famous scientific achievement was his histological definition of the spongiform pustule in the pathomorphology of psoriasis, which became a groundbreaking histological novelty in the classification of psoriasis, thus bearing Kogoj's name in the medical literature to this date. Academician Kogoj published many scientific and professional articles, books, monographs and contributions to manuals and textbooks. He was honored nationally as well as internationally as a leading expert in the field of medicine and dermatology, receiving many eminent awards and recognitions throughout his scientific career.

Baclofen-Induced Dyshidrosiform Bullous Pemphigoid in a Paraplegic Patient Complicated by Methicillin-Resistant Staphylococcus aureus (MRSA) and Urinary Infection.

Bullous pemphigoid (BP) is an autoimmune disorder which is usually chronic, with blistering that predominantly affects the skin and occasionally the mucosa, and which includes several different types. One of them is a very rare dyshidrosiform type which is localized on the hands and feet with small or large blisters on the palmoplantar surfaces. BP resulting from a drug reaction is a relatively rare occurrence, and so far more than 50 different medications have been identified as triggers. The aim of this article was to present the case of a paraplegic patient who developed this rare dyshidrosiform type of BP while he was being neurologically treated with baclofen. In spite of therapy with systemic and topical corticosteroids and other measures, successful treatment was achieved only after eliminating baclofen from the patient's regimen. His general state of health was seriously endangered due to nasal and skin methicillin-resistant Staphylococcus aureus (MRSA), urinary infection, and oral mycosis (soor), and he was at high risk of sepsis and a fatal outcome. Through our efforts, however, we managed to achieve an excellent outcome. According to our knowledge, this was the first case of baclofen-induced dyshidrosiform BP.

Differential Diagnosis of Cheilitis - How to Classify Cheilitis?

Although cheilitis as a term describing lip inflammation has been identified and recognized for a long time, until now there have been no clear recommendations for its work-up and classification. The disease may appear as an isolated condition or as part of certain systemic diseases/conditions (such as anemia due to vitamin B12 or iron deficiency) or local infections (e.g., herpes and oral candidiasis). Cheilitis can also be a symptom of a contact reaction to an irritant or allergen, or may be provoked by sun exposure (actinic cheilitis) or drug intake, especially retinoids. Generally, the forms most commonly reported in the literature are angular, contact (allergic and irritant), actinic, glandular, granulomatous, exfoliative and plasma cell cheilitis. However, variable nomenclature is used and subtypes are grouped and named differently. According to our experience and clinical practice, we suggest classification based on primary differences in the duration and etiology of individual groups of cheilitis, as follows: 1) mainly reversible (simplex, angular/infective, contact/eczematous, exfoliative, drug-related); 2) mainly irreversible (actinic, granulomatous, glandular, plasma cell); and 3) cheilitis connected to dermatoses and systemic diseases (lupus, lichen planus, pemphi-gus/pemphigoid group, -angioedema, xerostomia, etc.).

Drug-Induced Photosensitivity - a Continuing Diagnostic Challenge.

When taking different drugs, their possible side effects on the skin should be considered, including skin reactions connected to photosensitivity. This photosensitivity caused by drugs can appear as phototoxic reactions (which occur more often) or photoallergic reactions (which occur less often and include allergic mechanisms). The following drugs stand out as medications with a high photosensitivity potential: nonsteroidal anti-inflammatory drugs (NSAIDs), cardiovascular drugs (such as amiodarone), phenothiazines (especially chlorpromazine), retinoids, antibiotics (sulfonamides, tetracyclines, especially demeclocycline and quinolones), etc. In recent years, photosensitive reactions to newer drugs have appeared, e.g., targeted anticancer therapies such as BRAF kinase inhibitors (vemurafenib, dabrafenib), EGFR inhibitors, VEGFR inhibitors, MEK inhibitors, Bcr-Abl tyrosine kinase inhibitors, etc. In patients taking drugs over a longer period of time (e.g., NSAIDs, cardiovascular drugs, etc.), a particular problem arises when an unrecognized drug-induced photosensitivity on the skin manifests in summer months. When taking patient histories, the physician/dermatovenereologist should bear in mind that any drug the patient is currently taking may be the cause of skin reactions. Therefore, patients who use potentially photosensitive drugs and treatments on a long term basis should be warned of the possibility of these side effects on their skin and advised to avoid direct exposure to sunlight and to use adequate photoprotection. If patients carefully protect themselves from the sun, it is often not necessary to stop treatments that include photosensitive drugs. If such reactions appear, anti-inflammatory and antiallergic therapies should be introduced.

OCCUPATIONAL CONTACT DERMATITIS AMONGST DENTISTS AND DENTAL TECHNICIANS.

Since the working medical personnel including dentists and dental technicians mainly use their hands, it is understandable that the most common occupational disease amongst medical personnel is contact dermatitis (CD) (80%-90% of cases). Development of occupational CD is caused by contact of the skin with various substances in occupational environment. Occupational etiologic factors for dental personnel are foremost reactions to gloves containing latex, followed by various dental materials (e.g., metals, acrylates), detergents, lubricants, solvents, chemicals, etc. Since occupational CD is relatively common in dental personnel, its timely recognition, treatment and taking preventive measures is needed. Achieving skin protection at exposed workplaces is of special importance, as well as implementing necessary measures consequently and sufficiently, which is sometimes difficult to achieve. Various studies have shown the benefit of applying preventive measures, such as numerous protocols for reducing and managing latex sensitivity and other forms of CD in dentistry. Active involvement of physicians within the health care system, primarily dermatologists, occupational medicine specialists and general medicine doctors is needed for establishing an accurate medical diagnosis and confirmation of occupational skin disease.

Oral allergy syndrome--the need of a multidisciplinary approach.

Oral allergy syndrome (OAS) is one of the most common types of food allergy. The syndrome includes itching and swelling of the lips, palate and tongue, usually after consuming fresh fruits and vegetables. The underlying pathogenic mechanism is cross-reactivity between IgE antibodies specific to pollen, and antigens in food, such as fresh fruits, vegetables and nuts that are structurally similar to pollen. Both pollen and food antigens can bind to IgE and trigger type I immune reaction. Diagnosis is primarily based on the patient's history, and confirmed by skin tests, in vitro tests, and oral provocation tests. Differential diagnoses include many diseases (such as burning mouth syndrome, angioedema, hay fever, various other oral diseases, etc.), and for this reason a multidisciplinary approach is necessary, as different specialists need to be involved in the diagnostic procedure. Therapy includes avoiding, or thermal processing of, fruit and vegetables known to trigger a reaction, and antihistamine medications. If a more severe anaphylactic reaction develops, more aggressive therapy is required. The goal of this article is to present OAS, its etiopathogenesis, clinical picture, and symptoms, diagnostic approach and therapy for OAS.

Dermatitis artefacta: case report.

Automutilating behavior is becoming ever more frequent in patients seeking dermatologic care. Psychocutaneous disorders encompass a wide range of dermatologic conditions, all of which have in common the important role of psychological factors. Dermatitis artefacta syndrome is characterized by unconscious self-injury behavior, while dermatitis para-artefacta syndrome is labeled with manipulation of an existing specific dermatosis. Consciously stimulated injuries with the purpose of obtaining material gain is known as malingering. Here we present a 20-year-old female patient with a sudden pain and an oval, yellowish skin defect on her left lower leg, 3 x 3.5 cm in diameter, with an erythematous, clearly defined border, surrounded by erythematous, painful skin resembling pyoderma gangrenosum. The patient had a clinically typical skin presentation but with atypical therapeutic outcome. The diagnosis of dermatitis artefacta was made. Liaison psychiatry can reaffirm the diagnosis of dermatitis artefacta and provide necessary psychopharmacotherapy and psychotherapy.

SDRIFE (baboon syndrome) due to paracetamol: case report.

The term "baboon syndrome" (BS) (recently known as symmetrical drug related intertriginous and flexural exanthema, SDRIFE) was introduced in 1984 to describe a specific skin eruption (resembling the red gluteal area of baboons) that occurred after systemic exposure to contact allergens. The crucial characteristics include a sharply defined symmetric erythema in the gluteal area and in the flexural or intertriginous folds without any systemic symptoms or signs. Because the term BS does not reflect the complete range of symptoms and is ethically problematic, it was replaced with a new term of SDRIFE. This term specifically refers to the distinctive clinical pattern of drug eruption induced by exposure to a systemically administered drug, presented as sharply demarcated symmetric erythematous areas of the gluteal/perianal area and/or V-shaped erythema of the inguinal/perigenital area (at least one other intertriginous/flexural localization) and absence of systemic symptoms and signs. We present a case of a 33-year-old man with SDRIFE due to Panadol® tablets (paracematol). On admission, there was a densely disseminated, symmetric, livid to erythematous maculopapular exanthema present in both axillae, the sides of the trunk, inguinally spreading towards the thighs, in cubital and popliteal fossae, on the back sides of the upper legs, and in the gluteal regions. Awareness of SDRIFE (BS) as an unusual drug reaction is especially important since the connection between skin eruption and drug exposure may easily be overlooked or misdiagnosed.

Diabetic foot syndrome--dermatological point of view.

Patients with diabetes mellitus often suffer from diabetic foot syndrome, a condition leading to foot ulceration or even amputation of lower extremity. Peripheral neuropathy combined with repetitive trauma to the foot and peripheral vascular disease are the main etiological factors in the development of foot ulcers. Other major contributive factors include the effects of callus, increased plantar pressures, and local infections. Patient education concerning their disease has a central role in the prevention of foot ulcers. Ordinary preventive measures taken by the patient include regular self-inspections, appropriate daily hygiene of the feet, appropriate footwear to reduce plantar pressures, and medical pedicure performed by a pedicurist experienced in diabetic foot patients. The importance of callus in diabetic patients has been shown in several studies by high predictability of subsequent ulcer development in patients with plantar calluses. For removing callus, urea based preparations are considered to be the treatment of choice. In case of local bacterial and fungal diabetic foot infections, systemic antibiotic and systemic antimycotic therapy is indicated, respectively. Wound dressings of various types are the mainstay in the treatment of chronic foot ulcers with avoidance of occlusive dressings in infected ulcers. Since the vast majority of ulcers and amputations can be prevented in diabetic patients, proper diagnosis and multidisciplinary approach are essential.

[Histamine intolerance--possible dermatologic sequences]. / Intolerancija na histamin--koje su moguce posljedice na kozi?

Although histamine intolerance (HIT) is not very frequently encountered, it can have serious consequences. Food intolerance is a non allergic hypersensitivity to food that does not include the immune system even though the symptoms are similar to those of IgE-mediated allergic reactions. HIT apparently develops as a result of an impaired diamine oxidase (DAO) activity due to gastrointestinal disease or through DAO inhibition, as well as through a genetic predisposition which was proven in a number of patients. The intake of histamine-rich foods as well as alcohol or drugs which cause either the release of histamine or the blocking of DAO can lead to various disorders in many organs (gastrointestinal system, skin, lungs, cardiovascular system and brain), depending on the expression of histamine receptors. Dermatologic sequels can be rashes, itch, urticaria, angioedema, dermatitis, eczema and even acne, rosacea, psoriasis, and other. Recognizing the symptoms due to HIT is especially important in treating such patients. The significance of HIT in patients with atopic dermatitis in whom the benefit of a low histamine diet has been proven is becoming increasingly understood recently. Because of the possibility of symptoms affecting numerous organs, a detailed history of symptoms following the intake of histamine-rich foods or drugs that interfere with histamine metabolism is essential for making the diagnosis of HIT. Considering that such symptoms can be the result of multiple factors, the existence of HIT is usually underestimated, but considerable expectations are being made from future studies.

[The role of immunotherapy in the prevention of allergic diseases]. / Uloga imunoterapije u prevenciji alergijskih bolesti.

Immunotherapy through repeated administration of allergens and augmentation of doses (hyposensibilization) with the purpose of decreasing the severity of type I allergic reactions or even its complete elimination is known already for a longer period of time. This type of therapy is especially beneficial in allergies to Hymenoptera venom, allergic rhinoconjunctivitis, allergic asthma and is implemented in patients with previously proven allergy to appropriate allergens (insects, pollen, house dust mite, pet dander and other). The most common form of therapy is subcutaneous immunotherapy which includes a series of injections containing specific allergens (allergy vaccines) with increasingly larger doses administered subcutaneously during a period of 3-5 years. There are also other forms of immunotherapy (for instance sublingual immunotherapy) although these are less effective. Repetition of the hyposensibilization procedure leads to further reduction in severity of allergy disease in the majority of patients. The efficacy of immunotherapy is also proven by a lower risk of allergic rhinitis patients developing asthma as well as by prevention of new sensibilizations.

Prominent features of allergic angioedema on oral mucosa.

Angioedema indicates acute subcutaneous edema that characterizes improperly restricted cutaneous or mucous membrane swelling, which can occur only once or be relapsing. Edema usually occurs in the periorbital area, lips, tongue, extremities and intestinal wall. It has turned out that angioedema is usually caused by the use of angiotensin-converting enzyme inhibitors (ACE) or allergies to certain allergens (allergic or IgE-mediated angioedema), followed by C1 inhibitor deficiency (hereditary and acquired angioedema), or the cause is unknown (idiopathic angioedema). It has been shown that patients with angioedema often have urticaria, which is noted in approximately 50% of cases. Usually there is a type I allergic reaction to some food allergens or drugs or insect stings. The most common causes of allergic angioedema are bee and wasp stings, reactions to medications or injections for sensitivity testing, and certain foods (especially eggs, shellfish and nuts). In diagnostic terms, it is important to determine the potential allergen, which is commonly performed with cutaneous tests, such as prick test, etc. The main risk of angioedema is swelling of the tongue, larynx and trachea, which can lead to airway obstruction and death, therefore tracheotomy is indicated in such cases. The initial treatment of patients with most forms of angioedema included administration of antihistamines and glucocorticoids, while epinephrine is given if there is fear from laryngeal edema.

Actinic reticuloid--photosensitivity or pseudolymphoma?--A review.

Actinic reticuloid (AR) or chronic actinic dermatitis is considered a sunlight-induced pseudolymphoma (PSL) on light exposed areas of the skin, which primarily affects elderly males. The disease is a severe, chronic photosensitive dermatosis, first described by Ive et al. in 1969. PSL is a group of non-cancerous lymphocytic skin disorders that simulate malignant lymphomas, but the changes usually spontaneously regress. The clinical appearance of Actinic reticuloid is variable, usually characterized by an eczematous, pruritic eruption, predominantly present on the head and neck, or other sun exposed areas, but can involve any area of the body. Thereby, crucial characteristic is photosensitivity, where at action spectrum involves UVB, UVA and visible light beyond 400 nm. The disease is considered as PSL which histologically resembles lymphoma with immunohistochemical analysis of the cutaneous infiltrate revealing presence of activated T cells, numerous histiocytes, macrophages and B cells. Moreover, the development of malignant (non-cutaneous) T cell lymphoma in the course of AR has been reported. As the disease has chronic character, it requires significant changes in the patient's lifestyle and avoidance of provoking factors such as contact allergens or sources of intense light. Thus AR should be considered in every patient who presents with persistent, unclear, erythematous skin changes on the face and neck that are related to sun exposure.