Direct immunofluorescence staining patterns compared between oral and cutaneous lichen planus.

This retrospective study performed to investigate direct immunofluorescence (DIF) findings in oral and cutaneous lichen planus (LP), and to identify any differences between them. There were 147 patients with a definite diagnosis of LP by clinical and histological criteria, with 87 (59.2%) oral and 60 (40.8%) cutaneous specimens. Of these, 125 (85%) had positive DIF findings, with positive yields being significantly lower in oral (79.3%) than in cutaneous (93.3%) LP. Deposition of immunoreactants at the dermoepidermal junction (DEJ) was significantly greater in oral than in cutaneous LP, and fibrin deposition with shaggy pattern at the DEJ was also significantly greater in oral than in cutaneous LP. Deposition of immunoreactants at colloid bodies (CBs) with or without DEJ was significantly greater in cutaneous than in oral LP. IgM deposition at CBs was commonly detected in both groups. We propose that fibrin deposition with shaggy pattern at the DEJ is the best diagnostic indicator of oral LP.

The global burden of chronic urticaria for the patient and society.

Chronic urticaria (CU) affects about 1% of the world population of all ages, mostly young and middle-aged women. It usually lasts for several years (> 1 year in 25-75% of patients) and often takes > 1 year before effective management is implemented. It presents as chronic spontaneous urticaria (CSU), chronic inducible urticaria (CIndU) or both in the same person. More than 25% of cases are resistant to H1 -antihistamines, even at higher doses, and third- and fourth-line therapies (omalizumab and ciclosporin) control the disease only in two-thirds of H1 -antihistamine-resistant patients. Here we review the impact of CU on different aspects of patients' quality of life and the burden of this chronic disease for the patient and society. CU may have a strong impact on health-related quality of life (HRQoL), particularly when CSU is associated with angio-oedema and/or CIndU (Dermatology Life Quality Index > 10 in 30% of patients). Comorbidities, such as anxiety and depression, which are present in more than 30% of patients with CSU, compound HRQoL impairment. Severe pruritus and the unpredictable occurrence of weals and angio-oedema are responsible for sleep disorders; sexual dysfunction; limitations on daily life, work and sports activities; interfering with life within the family and in society; and patients' performance at school and work (6% absenteeism and 25% presenteeism). Apart from treatment costs, with annual values between 900 and 2400 purchasing power parity dollars (PPP$) in Europe and the USA, CU is associated with a high consumption of medical resources and other indirect costs, which may reach a total annual cost of PPP$ 15 550.

The EAACI/GA²LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria.

This evidence- and consensus-based guideline was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. The conference was held on 1 December 2016. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the EU-founded network of excellence, the Global Allergy and Asthma European Network (GA²LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO) with the participation of 48 delegates of 42 national and international societies. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease, presenting with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria are disabling, impair quality of life and affect performance at work and school. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.

Physical urticaria: prevalence, type and natural course in a tropical country.

BACKGROUND: Physical urticarias (PU) are an urticarial response to different specific physical stimuli. PU can occur concurrently with chronic spontaneous urticaria or another type of PU. OBJECTIVE: We aimed to study the prevalence, type, clinical data and natural course of each type of PU and other inducible urticarias and also the prognostic factors for remission of patients visiting a tertiary referral hospital. METHOD: We performed a retrospective study of 1200 chronic urticaria patients who visited our Urticaria Clinic during a period of 5 years. RESULTS: Of the 1200 chronic urticaria patients, 86 (7.2%) were diagnosed as PU and other inducible urticarias. The most common type of PU was symptomatic dermographism (n = 35, 40.7%) followed by cold urticaria (n = 20, 23.3%) and delayed pressure urticaria (n = 11, 12.8%), respectively. Twelve patients (13.9%) had associated chronic spontaneous urticaria. None of the cases had multiple types of PU. Erythrocyte sedimentary rate elevation was the most common abnormal laboratory result. Nevertheless, only 4.6% declared a related infection. For each type, the median time after onset before 50% remission showed that cholinergic urticaria took the shortest course (34 months) and delayed pressure urticaria took the longest period (110 months). After 1 year and 5 years from the onset of symptoms, 13% and 50% of PU patients were free of symptoms, respectively. CONCLUSION: This study emphasized the variety of PU, other inducible urticarias and natural courses based on tertiary hospital care. PU and other inducible urticarias have tendency to have a longer course than chronic spontaneous urticaria.

Drug-induced angioedema without urticaria: prevalence and clinical features.

BACKGROUND: Angioedema without urticaria can be caused by drugs. The purpose of our study was to assess the prevalence and clinical features of patients with drug-induced angioedema without urticaria. METHODS: This study retrospectively reviewed case records at Siriraj Hospital, between January 2007 and December 2008. Patients aged at least 15 years were included. RESULTS: The prevalence of drug-induced angioedema without urticaria among patients with adverse drug reactions was 2.3%/year. Non-steroidal anti-inflammatory drugs (NSAID) were the most common cause (50%), followed by antibiotics (20%). The commonest NSAID which induced angioedema were ibuprofen and diclofenac. The common sites were periorbital area (67.3%) and lips (27.6%). The median duration of suspected drug therapy before the development of angioedema was 1 day with the range of 10 min to 23 days. CONCLUSIONS: Non-steroidal anti-inflammatory drugs and antibiotics were the most common drugs causing angioedema without urticaria. The duration of onset ranged from minutes to days. After stopping the suspected drugs, symptoms disappeared within 2-5 days in most patients.

Angiocentric T-cell lymphoma of the pancreas presenting as late-onset diabetes mellitus with diabetic retinopathy.

Pancreatic lymphoma presenting with clinical diabetes mellitus (DM) is rare. We report angiocentric T-cell lymphoma of the pancreas in a 65-year-old Thai woman who presented with progressive deterioration of visual acuity of both eyes. She had diabetic retinopathy (DR) diagnosed only 20 months after the diagnosis of DM at the age of 63. She later developed erythematous rashes, fever, and deterioration of consciousness; she eventually died of shock. A skin biopsy and bone marrow examination revealed angiocentric T-cell lymphoma. At autopsy, the pancreas and both eyes were extensively infiltrated by lymphoma. Widespread involvement of nearly all organs but superficial lymphadenopathy was detected. In contrast to other typical cases of long-standing DM, only mild atherosclerosis was noted, and no DR was found. To the best of our knowledge, this is the first case of lymphoma involving the pancreas and both eyes producing clinical DM and DR.

Multicenter study of the efficacy and safety of fexofenadine 60 mg. twice daily in 108 Thai patients with chronic idiopathic urticaria.

Fexofenadine is a non-sedating antihistamine indicated for relieving symptoms from allergic conditions with a rapid onset of action without cardiotoxic risks. Controlled studies showed that fexofenadine 180 mg daily provides significant relief of symptoms of chronic idiopathic urticaria (CIU). The purpose of this study was to demonstrate the efficacy and safety of fexofenadine 60 mg twice daily in Thai patients with CIU in a multicenter trial. Patients were assigned to receive twice daily doses of fexofenadine 60 mg for 6 weeks. Patients rated symptom severity every night, investigators rated patients' signs and symptoms at recruitment and at 1, 3 and 6 weeks. Ninety eight out of 108 patient (90.7%) completed the study. The patients reported 95 per cent improvement and, of those, 91 per cent had very favorable responses (excellent 15%, very good 42%, good 30%, fair 8%). The objective assessment by their physicians paralleled those responses. Fexofenadine provided a rapid clinical response that was significantly superior to before treatment in relieving symptoms of CIU (p < 0.001). Adverse events occurred in 20 cases (18.5%), mostly mild headache and drowsiness. Fexofenadine 60 mg twice daily provides effective relief of the symptoms of CIU with minimal adverse events.

Linear IgA bullous dermatosis of childhood: a long-term study.

BACKGROUND: Linear IgA bullous dermatosis (LAD) of childhood is a rare acquired subepidermal blistering disease of young children. Most of the studies were reported from the USA and European countries. METHOD: Twelve cases of Thai patients diagnosed as LAD of childhood were analyzed concerning clinical, histopathological, immunopathological findings including treatment responses and courses compared with those of Caucasians. RESULT: The mean age of onset was 5.1 years. The areas of common involvement were the perioral region, lower abdomen, perineum, buttock, inner thighs and extremities. Histopathology in half of the cases showed features of dermatitis herpetiformis or bullous pemphigoid. All patients had positive linear IgA band at the basement membrane zone (BMZ) by direct immunofluorescence. Only one patient had positive circulating anti BMZ antibody at the titer of 1:10. Most patients responded well to dapsone. The mean duration before remission was 1.9 years. CONCLUSION: Our study in Thai patients with LAD of childhood produced data similar to previous studies carried out in the Caucasian nations.

Erythroderma in Thai patients.

Erythroderma is a clinical manifestation of dermatoses from different causes. Our objective was to determine its incidence, causes and clinicopathological features. Clinical, laboratory, and biopsy materials of 49 patients diagnosed as having erythroderma were reviewed. They were treated in our department over a 10-year period (1985 through 1994). The male-female ratio was 2:1. The mean age at diagnosis was 51.7 years. The most common causative factors were drugs (38.77%) and preexisting dermatoses (26.5%). Hepatomegaly, jaundice and abnormal liver function tests were found more commonly in the drug allergy group, while in cases with preexisting dermatoses nail involvement was a common finding. Clinicopathologic correlation in our study did not inform the etiology because it showed chronic nonspecific dermatitis or psoriasiform dermatitis, without any clue as to its origin. Drug-induced-erythroderma had an acute onset and a good prognosis with rapid resolution when the causative drug was withdrawn, while histopathology and laboratory findings were largely unrewarding.

Clinical and microbiologic findings in cellulitis in Thai patients.

BACKGROUND: Cellulitis is an inflammation of subcutaneous tissue in which infective, generally bacterial cause is proven or assumed. However, attempts to culture bacteria from lesions are often unsuccessful. METHOD: One hundred and fifty cases diagnosed as cutaneous cellulitis at Siriraj Hospital between 1992 and 1995 were retrospectively studied. RESULTS: Our study in 150 adult Thai patients with cellulitis showed that the most common site of infection was the lower extremity. Forty two per cent of the patients had history of preceding local trauma. Fever and regional lymphadenopathy were detected in 77.3 per cent and 22.6 per cent respectively. Sixty nine per cent of patients had leukocytosis with a mean neutrophil ratio of 79.7 per cent of patients with underlying diseases predisposed to the infection, 61.6 per cent had positive lesional culture results in contrast to 31.6 per cent in patients without. Needle aspiration and blood gave low positive culture yields. The common organisms detected were S.aureus and Streptococcus group A (83%) in immunocompetent patients. Of immunocompromised patients, in one half of the cases gram negative bacteria were found. CONCLUSIONS: This study showed that in immunocompetent patients, the major bacterial isolated in cellulitis were S.aureus and Streptococcus group A. In immunocompromised patients, gram negative bacteria were found in one half. These findings may help in the selection of antimicrobials before the results of bacterial cultures are available or in culture negative cases.

Lesional T-cell subset in leprosy and leprosy reaction.

BACKGROUND: The T-cell-mediated immune response plays an important role in leprosy. The in situ proportion and pattern of distribution of T-cell subsets in leprosy skin lesions have been studied, but no conclusion could be drawn. METHODS: We used monoclonal antibodies for T-helper and T-suppressor surface antigen to define the nature of dermal infiltration in 17 cases of nonreactional leprosy and 20 cases of reactional leprosy. RESULTS: We found T helper admixed with T suppressor in an aggregated pattern in the granulomas of most cases of nonreactional leprosy and in type I reactional leprosy, but a diffuse infiltrate throughout the dermis of type II reactional leprosy. The T-helper/suppressor ratio was 1.68 in tuberculoid and 1.5 in lepromatous cases. The T-helper/ suppressor ratios of borderline tuberculoid (3.11) and type I reactional leprosy (2.54) were not statistically different. The T-helper/suppressor ratio of type II reactional leprosy (5.83) was statistically higher than nonreactional lepromatous cases. CONCLUSIONS: The alteration of the T-helper/suppressor ratio in our study is mainly due to the reduction of T-suppressor cells in the dermal infiltrates, especially in type II reactional leprosy. Further studies of T-suppressor functions may be important in the pathogenesis of leprosy.

Pruritic papular eruption in HIV seropositive patients: a cutaneous marker for immunosuppression.

BACKGROUND: Previous reports have shown the correlation between certain skin disorders and immune status in human immunodeficiency virus (HIV) infected patients. Pruritic papular eruption (PPE) is the most common cutaneous manifestation in HIV infected patients. The purpose of this study is to define the relationship between the presentation of PPE and the immune status in HIV infection, as measured by the T-cell subset, and to establish the usefulness of this common eruption as a predictor of CD4 count. METHOD: In this cross-sectional study, 20 HIV-positive patients with characteristics of PPE were studied. Clinical data, skin biopsy, and immune status, evaluated by measuring CD4, CD8, and CD4/CD8, were investigated. RESULTS: Seventy-five per cent of patients already had antecedent skin disorders, so PPE is not a leading symptom in HIV infected patients; 81.25% of PPE patients had an advanced degree of immunosuppression with a CD4 count below 100/mm3 and 75% below 50/mm3. CONCLUSIONS: PPE can be regarded as a cutaneous marker of advanced HIV infection.

Diagnostic value of IgM deposition at the dermo-epidermal junction.

BACKGROUND: Granular immunoglobulin M (IgM) deposits at the dermo-epidermal junction (DEJ) are common in lupus erythematosus (LE); however, weak, interrupted, linear and granular patterns of IgM at the DEJ have been reported in sun-exposed skin in normal adults and in a heterogeneous group of diseases. MATERIALS AND METHODS: We analyzed 200 patients with positive IgM direct tissue immunofluorescence deposition at the DEJ, alone or in combination with other immunoreactants, in order to determine the diagnostic significant of IgM deposition at the DEJ. RESULTS: IgM deposition at the DEJ, commonly in combination with other immunoreactants, was associated with LE in 57.5% of patients. In cases with IgM deposition alone at the DEJ, only 12% had LE (strong intensities). IgM deposition at the DEJ was associated with other dermatoses in 42.5% of patients. In non-lupus patients, IgM deposition was the sole finding in 59% of cases, and was weaker and more focal than in LE patients. CONCLUSIONS: IgM deposition at the DEJ in patients with LE tends to exhibit a strong intensity and is commonly detected in combination with other immunoreactants. IgM deposition alone at the DEJ, especially of weak intensity or focal in pattern, is noted in non-lupus patients, and has less diagnostic significance.

Bullous pemphigoid in an infant: a case report and literature review.

Bullous pemphigoid is an autoimmune bullous disease that is rare in children and infants. It seems indistinguishable from the disease in adults although mucous membrane, palms and soles involvement appear more commonly in childhood bullous pemphigoid. There is no association with malignancy. The most reliable diagnostic criterias are the linear deposition of IgG and C3 along the basement membrane zone and the presence of circulating IgG antibasement membrane zone antibodies. The literature of bullous pemphigoid is reviewed and a case of a 7-month-old girl with typical clinical manifestations and immunofluorescence studies is reported. She responded very well to a high dose of systemic corticosteroid. The disease can be spontaneously resolved and the prognosis for children is good in most cases.

Chronic discoid lupus erythematosus in Thailand: direct immunofluorescence study.

BACKGROUND: Studies of chronic discoid lupus erythematosus (DLE) lesions by direct immunofluorescence (DIF) were heterogeneous with respect to classes of immunoglobulins and sites where these were deposited. Most of the studies were done in the USA and European countries. MATERIALS AND METHODS: To obtain representative data from Asiatic countries, we analyzed the direct immunofluorescent abnormalities of 100 DLE lesions in Thai patients who were diagnosed on the basis of clinical and histologic criteria. RESULTS: Granular deposits at the dermoepidermal junction (DEJ) were detected in 90% of cases. The common immunoreactants at the DEJ were IgG (63%) and IgM (47%). The deposits were usually combinations of various classes of immunoglobulins, mostly IgG (53%) and IgM (41%). Deposits of IgG and IgM alone at the DEJ were observed in 12% and 8%, respectively. Deposits at colloid bodies, dermal blood vessel walls, and epidermal nuclei were sometimes also seen. CONCLUSIONS: The DIF test of skin biopsy specimens is diagnostically significant in chronic DLE. Our study in Thai patients showed that the most common deposit was a combination of various classes of immunoglobulins, mostly IgG and often IgM as well as C3, and occurred at the DEJ of the involved area.

Molecular cloning and mapping of 16S-23S rRNA gene complexes of Staphylococcus aureus.

Staphylococcus aureus BB255, a derivative of NCTC8325, had six rRNA operons, and each operon contained two SmaI sites about 3 kb apart. By molecular cloning and pulsed-field gel electrophoresis, all operons were mapped at the junctions of SmaI fragments in the published map of NCTC8325 except one, which was connected to a previously unidentified 23-kb SmaI fragment.

Clinical efficacy and side effects of acitretin on the disorders of keratinization: a one-year study.

Acitretin, Ro 10-1670, the principal and free acid metabolite of etretinate, was used to treat twenty patients with disorders of keratinization. An open, prospective study of clinical efficacy, tolerability, and the effects of acitretin on lipid metabolism, hepatic function, and the osteoarticular system was performed over a one year period. Each patient was initially treated with 30 mg/day of acitretin or approximately 0.6 mg/kg/day. Doses were adjusted according to the clinical efficacy and maintained for one year. There were no statistically significant changes in liver function tests or lipid profile. Twelve of eighteen evaluated patients developed asymptomatic skeletal changes; the most common change was disc space narrowing, especially at thoracic-spine level (7 of 18 patients). The earliest bone change was detected 9 months after treatment. Acitretin is effective in improving the disorders of keratinization with mild mucocutaneous side effects and asymptomatic osteoarticular changes.