Iranian guideline for rituximab therapy in pemphigus patients.

Pemphigus vulgaris (PV) is an autoimmune blistering disease affecting the skin and/or mucosa. Rituximab (RTX) has been approved recently by US FDA as an effective and safe treatment of PV. The high incidence of PV in Iran encouraged our team to prepare a consensus guideline for RTX administration based on literature review and a decade experience of an expert panel. RTX is recommended for the treatment of new cases of PV as well as patients not responding to conventional therapy. Contraindications include history of anaphylaxis or IgE-mediated hypersensitivity to murine proteins of RTX, severe active infections, pregnancy, breastfeeding, severe heart failure, and arrhythmia. Prophylactic antiviral therapy is recommended in patients at risk of reactivation of HBV and isoniazid for those at risk of reactivation of tuberculosis. Concomitant use of systemic corticosteroids is recommended as a rule. Except for methotrexate, the combination with other immunosuppressive drugs is discouraged. Intravenous immunoglobulin is recommended for those at risk of infections or with extensive disease. The recommended dosage of RTX for the first cycle is 2 g either 500 mg weekly or 1 g biweekly. There is no general consensus whether the next doses of RTX be administered upon relapse or as maintenance therapy. We strongly recommend RTX sooner in the course of pemphigus.

The potential roles of herpesvirus and cytomegalovirus in the exacerbation of pemphigus vulgaris.

BACKGROUND: Among exogenous etiologies, the critical role of microbial agents such as herpesviruses (HSV1/2) and cytomegalovirus (CMV) in triggering and flaring autoimmune conditions such as pemphigus vulgaris (PV) has been recently discovered. OBJECTIVES: The present study aimed to investigate the plausible role of these viruses in the exacerbation of PV using serological and molecular methods. PATIENTS/METHODS: Sixty patients with PV (30 with relapse type and 30 with remission type) were recruited for the purpose of this case-control study. Skin, mucosal, and throat specimens were obtained and examined for viruses by reverse transcriptase polymerase chain reaction. To determine the immunoglobulin G (IgG) titer, enzyme-linked immunosorbent assay was used. RESULTS: Desmoglein1-specific IgG was positive in 56.7% of patients with the relapse form and in 20.0% of those with the remission form indicating a significant difference across the 2 groups (P = 0.003), but the rate of positivity for desmoglein3-specific IgG in the relapse and remission types was 76.7% and 63.3%, respectively, with no significant difference (P = 0.260). There was no difference in the mean levels of HSV-IgG and CMV-IgG in the relapse and remission groups. HSV and CMV positivity in PV patients was independent of the site of the samples. Using the multivariable linear regression model, the level of CMV-IgG in PV patients was directly affected by female sex and advanced ages. CONCLUSIONS: Our study could not demonstrate the role of HSV1/2 and CMV as triggering factors for PV exacerbation. Further studies are needed to evaluate the potential role of these viruses in PV exacerbation especially considering demographic variables.

Comparison of long-pulsed alexandrite laser and topical tretinoin-ammonium lactate in axillary acanthosis nigricans: A case series of patients in a before-after trial.

BACKGROUND: Acanthosis nigricans (AN) is a brown to black, velvety hyperpigmentation of the skin that usually involves cutaneous folds. Treatment of AN is important regarding cosmetic reasons and various therapeutic modalities have been used for these purposes. The goal of this study was to compare the effectiveness of long-pulsed alexandrite laser and topical tretinoin-ammonium lactate for treatment of axillary-AN. METHODS: Fifteen patients with bilateral axillary-AN were studied in Razi Hospital, Tehran, Iran. Diagnosis was confirmed by two independent dermatologists. Each side skin lesion was randomly allocated to either topical mixed cream of tretinoin 0.05%- ammonium lactate 12% or long-pulsed alexandrite laser. Duration of treatment was 14 weeks. At endpoint, the mean percent reduction from baseline in pigmentation area was compared between the two groups. RESULTS: The study population consisted of 15 patients three males and 12, females. The mean age of patients was 28.5±4.9 years. The mean percent reduction was 18.3±10.6%, in tretinoin/ammonium lactate group and 25.7±11.8% in laser group (P=0.004). CONCLUSION: These findings indicate that the application of alexandrite laser is a relative effective method for treatment of axillary-AN. However, this issue requires further studies with prolonged follow-up period.

Comparison of topical 8-methoxypsoralen and narrowband ultraviolet B with narrowband ultraviolet B alone in treatment-resistant sites in plaque-type psoriasis: a placebo-controlled study.

BACKGROUND: Combination of topical methoxsalen and narrowband ultraviolet B (NBUVB) was shown to be more effective than NBUVB alone in treating plaque-type psoriasis. OBJECTIVE: To find out whether topical methoxsalen and NBUVB had any benefit in induction of remission on treatment-resistant plaques of psoriasis on the legs in comparison with NBUVB alone. METHODS: Ten patients were included. Two symmetric lesions with similar Psoriasis Severity Index score on the lower legs were randomly assigned to be treated with cold cream as placebo or 0.1% 8-methoxypsoralen (8MOP) cream 15 min before phototherapy with NBUVB. Phototherapy was given three times per week for up to three months. Severity scores were recorded each week and side effects were observed before each session. RESULTS: Significant decrease in the severity score was observed in both groups (P-value < 0.001), but none of the lesions cleared completely at the end of the study. The decrease of the score in the 8MOP arm was greater than the control arm; however, the difference was not significant. The only side effect was pigmentation that occurred in all of the 8MOP-treated patients after 2 weeks. CONCLUSION: We could not confirm any significant benefit of topical methoxsalen and NBUVB in comparison to NBUVB alone in treating resistant plaques of psoriasis on the legs.

Isotretinoin in acne agminata.

Acne agminata is an asymptomatic papulopustular eruption. This condition typically occurs in young adults. The eruption generally runs a self-limited course, but disfiguring scars can occur. Histological examination shows scattered dermal granulomas composed of epitheloid and some giant cells with central caseation. A variety of agents such as wide-spectrum antibiotics, oral steroids, dapsone, and clofazimine have been used with varying degrees of success. Herein, we report 2 Caucasian males with acne agminata, successfully treated with isotretinoin.

Methotrexate-induced acral erythema with bullous reaction.

Chemotherapy-induced acral erythema (CIAE), a toxic reaction to a number of different chomotherapeutic agents, causes a symmetrical, painful erythema of both the palms and soles which is self-limiting. The association of this syndrome with methotrexate is unusual; only nine cases have been reported in the literature. We describe the tenth case of this syndrome associated with methotrexate, which is also the third case of the bullous variant of methotrexate-induced acral erythema. Our case is unusual in that the acral erythema was present only on the soles of the feet and in that it was associated with the presence of diffuse maculopapular lesions over the legs and trunk.

Langerhans' cell histiocytosis.

Adult onset Langerhans cell histiocytosis is uncommon. A 29 year old man is presented who developed classic cutaneous disease with severe systemic involvement. He responded completely to a two month course of thalidomide.