Expert opinion on management of moderate-to-severe atopic dermatitis in Qatar.

Atopic dermatitis (AD), a chronic-relapsing inflammatory skin disorder, manifests with intense itching and eczematous lesions impairing quality of life. A heterogeneous population, and regional clinical practices for treating AD warrant the development of guidelines in Qatar. Therefore, guidelines for the management of moderate-to-severe AD in Qatar have been developed and discussed. Experts, including dermatologists and immunologists, used the Delphi technique for developing guidelines. Consensus was defined as ≥75% agreement or disagreement. AD is highly prevalent in primary and tertiary dermatology centers. AD-associated foot eczema and psoriasiform eczema are more frequent in Qatar than in Europe or USA. SCORing Atopic Dermatitis Index quantifies disease severity and itch. Dermatology Life Quality Index assesses the quality of life. Atopic Dermatitis Control Tool assesses long-term disease control. Moderate-severe AD benefits from new topicals like Janus-kinase-inhibitors or PDE4-inhibitors combined with phototherapy. Currently approved systemic agents are dupilumab, baricitinib, abrocitinib, and upadacitinib. New anti-IL-13 and anti-IL-31 therapies will soon be available. Patient education, allergy testing, and comorbidity consideration are critical in the management of AD. The expert panel established a comprehensive and pragmatic approach to managing moderate-to-severe AD, thereby assisting clinical decision-making for healthcare professionals in Qatar.

Factors associated with treatment satisfaction in patients with hidradenitis suppurativa: results from the Global VOICE project.

BACKGROUND: Nearly half of patients with hidradenitis suppurativa (HS) report dissatisfaction with their treatment. However, factors related to treatment satisfaction have not been explored. OBJECTIVES: To measure associations between treatment satisfaction and clinical and treatment-related characteristics among patients with HS. METHODS: Treatment satisfaction was evaluated utilizing data from a cross-sectional global survey of patients with HS recruited from 27 institutions, mainly HS referral centres, in 14 different countries from October 2017 to July 2018. The primary outcome was patients' self-reported overall satisfaction with their current treatments for HS, rated on a five-point scale from 'very dissatisfied' to 'very satisfied'. RESULTS: The final analysis cohort comprised 1418 patients with HS, most of whom were European (55%, 780 of 1418) or North American (38%, 542 of 1418), and female (85%, 1210 of 1418). Overall, 45% (640 of 1418) of participants were either dissatisfied or very dissatisfied with their current medical treatment. In adjusted analysis, patients primarily treated by a dermatologist for HS had 1·99 [95% confidence interval (CI) 1·62-2·44, P < 0·001] times the odds of being satisfied with current treatment than participants not primarily treated by a dermatologist. Treatment with biologics was associated with higher satisfaction [odds ratio (OR) 2·36, 95% CI 1·74-3·19, P < 0·001] relative to treatment with nonbiologic systemic medications. Factors associated with lower treatment satisfaction included smoking (OR 0·78, 95% CI 0·62-0·99; active vs. never), depression (OR 0·69, 95% CI 0·54-0·87), increasing number of comorbidities (OR 0·88 per comorbidity, 95% CI 0·81-0·96) and increasing flare frequency. CONCLUSIONS: There are several factors that appear to positively influence satisfaction with treatment among patients with HS, including treatment by a dermatologist and treatment with a biologic medication. Factors that appear to lower treatment satisfaction include active smoking, depression, accumulation of comorbid conditions and increasing flare frequency. Awareness of these factors may support partnered decision making with the goal of improving treatment outcomes. What is already known about this topic? Nearly half of patients with hidradenitis suppurativa report dissatisfaction with their treatments. What does this study add? Satisfaction with treatment is increased by receiving care from a dermatologist and treatment with biologics. Satisfaction with treatment is decreased by tobacco smoking, accumulation of comorbid conditions including depression, and higher flare frequency. What are the clinical implications of this work? Awareness of the identified factors associated with poor treatment satisfaction may support partnered decision making and improve treatment outcomes.

Evaluating patients' unmet needs in hidradenitis suppurativa: Results from the Global Survey Of Impact and Healthcare Needs (VOICE) Project.

BACKGROUND: A needs assessment for patients with hidradenitis suppurativa (HS) will support advancements in multidisciplinary care, treatment, research, advocacy, and philanthropy. OBJECTIVE: To evaluate unmet needs from the perspective of HS patients. METHODS: Prospective multinational survey of patients between October 2017 and July 2018. RESULTS: Before receiving a formal HS diagnosis, 63.7% (n = 827) of patients visited a physician ≥5 times. Mean delay in diagnosis was 10.2 ± 8.9 years. Patients experienced flare daily, weekly, or monthly in 23.0%, 29.8%, and 31.1%, respectively. Most (61.4% [n = 798]) rated recent HS-related pain as moderate or higher, and 4.5% described recent pain to be the worst possible. Access to dermatology was rated as difficult by 37.0% (n = 481). Patients reported visiting the emergency department and hospital ≥5 times for symptoms in 18.3% and 12.5%, respectively. An extreme impact on life was reported by 43.3% (n = 563), and 14.5% were disabled due to disease. Patients reported a high frequency of comorbidities, most commonly mood disorders. Patients were dissatisfied with medical or procedural treatments in 45.9% and 34.6%, respectively. LIMITATIONS: Data were self-reported. Patients with more severe disease may have been selected. CONCLUSION: HS patients have identified several critical unmet needs that will require stakeholder collaboration to meaningfully address.

Highly Vascularized Primarily Inflammatory Pseudotumor of the Omentum in an Adult Male: A Case Report.

BACKGROUND: Inflammatory pseudotumors can affect any organ, whereas primary omental tumors are very rare. A few cases have been reported in the literature, all affecting adult patients. They are usually difficult to diagnose preoperatively and pathology remains the criterion standard for diagnosis. Surgical resection is considered the first-line treatment in limited disease, whereas recurrent or metastatic disease is treated by re-excision. There is no role for chemo- or radio-therapy in limited disease. Here, we present a rare case of omental myofibroblastic tumor in an adult male. CASE REPORT: A 38-year-old healthy man presented to our clinic complaining of lower abdominal pain associated with anorexia and low-grade fever, and he also reported weight loss. His initial hemoglobin was 9.7 g/dl. Magnetic resonance imaging (MRI) showed an enhancing solid mass in the lower abdomen, with close proximity to the appendix and the urinary bladder. The patient was treated successfully with laparotomy and excision of the tumor. Histopathology of the mass revealed spindle cells of vague fascicular pattern. Further immunohistochemical staining showed presence of reaction for CD68, CD34, and ALK. No omental infiltration was noted. No adjuvant treatment was applied and the patient was free of disease after 1-year follow-up. CONCLUSIONS: Omental pseudotumors are a rare pathology. They are usually slowly- growing, circumscribed tumors with a low malignant potential. They have a predilection for children. The overall mortality is reported to be 5-7% in cases with multiple recurrences.

Large ileocecal submucosal lipoma presenting as hematochezia, a case report and review of literature.

INTRODUCTION: Colonic lipomas are rare subepithelial benign tumors affecting mainly middle-aged women. They are usually asymptomatic and, hence, are discovered incidentally on autopsy, surgery, or colonoscopy. There is a wide range of presentations like abdominal pain, bleeding per rectum, intussusception, etc. The latter picture constitutes the usual presentation of an ileocecal lipoma. Only few cases of ileocecal lipomas presenting as lower GI bleeding have been reported in the literature. PRESENTATION OF CASE: We present a case of an adult female patient who was admitted to our institution complaining of hematochezia and right lower quadrant pain. She was found to have chronic anemia. She was investigated by CT scan of the abdomen & pelvis and by colonoscopy which showed a fungating, submucosal mass with ulcerated base near the ileocecal valve. She underwent a colonic resection. The pathology came out as a submucosal benign pedunculated ileocecal lipoma. DISCUSSION: Colonic lipomas represent 4% of benign lesions of the gastrointestinal tract. They are usually asymptomatic hence are often discovered incidentally on colonoscopy, surgery or autopsy. The definitive diagnosis is made by pathological evaluation. Colonic lipomas are usually treated if they are symptomatic or there is any suspicion of malignancy. The treatment modalities include endoscopic and surgical resection. CONCLUSION: We, hereby, describe a case of benign ileocecal lipoma that presented with hematochezia which is an unusual presentation. Also, there is a great controversy regarding the treatment of colonic lipomas. In this article, we tried to answer several questions concerning the management of ileocecal lipomas.

Pruritic vesicular eruption on the lower legs in a diabetic female.

A 50-year-old diabetic female presented with highly pruritic vesicles and excoriated lesions over the anterior aspect of both lower legs. The lesions were recurrent over the last two years. She received a lot of medications with partial response. Hb A1c was 10.8% (normal up to 7%). CBC showed microcytic, hypochromic anemia. Serum zinc, folate, IgE, TSH and T4 were all within normal ranges. Biopsy showed epidermal separation secondary to keratinocyte necrosis and minimal monocytic, perivascular infiltrate. Direct immunofluorescence was negative for intraepidermal and subepidremal deposition of immunoglobulin. The dermis was positive for mucin deposition stainable by both PAS and Alcian blue while it was negative for Congo red and APC immunoperoxidase staining for amyloid material. In conclusion, the case was diagnosed as bullosis diabeticorum by distinctive clinical and pathological features and after exclusion of other possible differentials. Pruritus was partially controlled by topical potent steroid and the case was resolved spontaneously after eight months.

Hepatitis and Lupus-Like Syndrome during Infliximab Therapy for Psoriasis.

Biologics are very useful medications that changed the lives of many patients in the last decade. However, we still do not know about the long-term side effects of these drugs. Infliximab is an anti-TNF chimeric antibody widely used and approved for the treatment of many diseases. Lupus-like syndrome and hepatitis are among the uncommon side effects of infliximab. Most of the written literature was published for cases of rheumatology and gastroenterology. We report here a case of both hepatitis and lupus-like syndrome that occurred sequentially in the same patient and compare our finding with two case reports of the same side effects, drug and disease.

Diphenylcyclopropenone-induced vitiligo in a patient with alopecia universalis.

Alopecia areata and vitiligo are autoimmune diseases, both associated with multiple autoimmune comorbidities. Many studies show colocalization of these diseases at the same anatomical site. Here, we have a case where both disorders were reported to present in the same patient. Diphenylcyclopropenone (diphencyprone, DCP) is used in the treatment of alopecia areata and may induce vitiligo in some patients. We report on one case of vitiligo that was induced by DCP during therapy for alopecia universalis. Alopecia areata and vitiligo share many susceptibility genes. Follicular melanocyte destruction may represent the link between the two diseases.

Ulcerated nasal infantile haemangioma treated by oral propranolol.

Infantile hemangioma affects about 10% of neonates, but usually involutes without significant complications. Complications may include disfigurement, bleeding, and ulceration, along with airway, cardiac, hepatic, and spinal complications depending upon site. Oral propranolol is now the treatment of choice in many situations. Herein we present an infant with a large hemangioma on the nose tip and show the dramatic results with the use of propranolol. The patient received seven months of therapy at 2 mg/kg/day propranolol orally in three divided doses. The response started within a few weeks and by the eighth week ulceration had healed completely without scarring.

Fatal metastatic cutaneous squamous cell carcinoma evolving from a localized verrucous epidermal nevus.

A malignant transformation is known to occur in many nevi such as a sebaceous nevus or a basal cell nevus, but a verrucous epidermal nevus has only rarely been associated with neoplastic changes. Keratoacanthoma, multifocal papillary apocrine adenoma, multiple malignant eccrine poroma, basal cell carcinoma and cutaneous squamous cell carcinoma (CSCC) have all been reported to develop from a verrucous epidermal nevus. CSCC has also been reported to arise from other nevoid lesions like a nevus comedonicus, porokeratosis, a sebaceous nevus, an oral sponge nevus and an ichthyosiform nevus with CHILD syndrome. Here we report a case of progressive poorly differentiated CSCC arising from a localized verrucous epidermal nevus, which caused both spinal cord and brain metastasis.

Disseminated superficial actinic porokeratosis on the face treated with imiquimod 5% cream.

Porokeratoses are a group of hereditary or acquired disorders characterized by annular lesions with an atrophic center and a prominent peripheral ridge. Pathologically, porokeratosis is characterized by the presence of abnormal clones of keratinocytes that form a column of parakeratotic cells, called the cornoid lamella. Fifteen percent of patients of disseminated superficial actinic porokeratosis (DSAP) have facial lesions; other regions like the extensor surface of extremities constitute the majority of reported cases. Exclusively facial lesions are probably less frequent. Rarely, actinic porokeratosis is confined to the nose only. Of reported porokeratosis cases, 7.5% have revealed a malignancy arising within the lesion. We present a case of facial sporadic DSAP that was treated with imiquimod 5% cream in conjunction with a regular sunscreen. Follow-up of this case is important to rule out the possibility of malignant transformation of the lesions.

Concise review of recent studies in vitiligo.

Vitiligo is an acquired pigmentry disorder of the skin and mucous membranes which manifests as white macules and patches due to selective loss of melanocytes. Etiological hypotheses of vitiligo include genetic, immunological, neurohormonal, cytotoxic, biochemical, oxidative stress and newer theories of melanocytorrhagy and decreased melanocytes survival. There are several types of vitiligo which are usually diagnosed clinically and by using a Wood's lamp; also vitiligo may be associated with autoimmune diseases, audiological and ophthalmological findings or it can be a part of polyendocrinopathy syndromes. Several interventions are available for the treatment for vitiligo to stop disease progression and/or to attain repigmentation or even depigmentation. In this article, we will present an overall view of current standing of vitiligo research work especially in the etiological factors most notably the genetic components, also, types and associations and various and newer treatment modalities.

Reactivation of Tuberculosis in Three Cases of Psoriasis after Initiation of Anti-TNF Therapy.

New biological therapies for disabling diseases such as psoriasis may carry both short- and long-term risks. Tuberculosis (TB) reactivation is a frequent complication of anti-tumor necrosis factor (TNF) therapy. We present 3 cases of psoriasis that were treated with different types of anti-TNF and developed TB infection (TBI) during therapy. One of the cases was diagnosed as active pulmonary TB and the other 2 cases as latent TBI. All cases received appropriate anti-TB treatment, and the anti-TNF therapy was interrupted and then resumed according to various clinical considerations.

Toxicity, biochemical effects and residue of aflatoxin B(1) in marine water-reared sea bass (Dicentrarchus labrax L.).

Aflatoxicosis and resulting epizootic hepatoma have been reported among a wide range of fish where Aspergillus species-contaminated foodstuffs are incorporated into the diet. Aflatoxin B(1) (AFB(1)) is among the most potent known hepatotoxins and carcinogens. Therefore, it is an important potential toxicant to the most of the popularly cultured fish species. The present study was undertaken to assess the susceptibility and toxicity of AFB(1) to sea bass (Dicentrarchus labrax L.), by behavioral and biochemical evaluations. The estimated oral acute median lethal concentration (96 h LC(50)) of AFB(1) for sea bass was 0.18 mg/kg bwt. The abnormal behavioral responses and signs of toxicity were described. The prolonged oral administration of 0.018 mg/kg bwt AFB(1) to sea bass for 42 successive days induced a significant increase in serum transaminases and alkaline phosphatase activities, and significant decrease in plasma proteins. Residual AFB(1) was detected at high levels ( approximately 5 ppb) in fish musculature at the end of the experimental period. We conclude that marine water sea bass is a species highly sensitive to AFB(1). In addition, consumption of sea bass reared on AFB(1)-contaminated diet could have a negative health impact on human health.

Acute toxicity of ochratoxin-A in marine water-reared sea bass (Dicentrarchus labrax L.).

The toxic effects of ochratoxin-A (OTA) on sea bass, Dicentrarchus labrax L., have not been previously documented. A flow-through bioassay test system was conducted in two series and a total 180 of adult marine-reared sea bass was used to estimate the acute oral 96 h median lethal concentration (LC(50)) value and behavioral changes of OTA. The data obtained were statistically evaluated using Finney's Probit Analysis Method developed by EPA. The 96 h LC(50) value for adult D. labrax was found to be 277 microg kg(-1)bwt with 95% confidence limits of 244-311 microg kg(-1)bwt. This value was calculated to be 285 microg kg(-1) bwt with Behrens-Karber's method. The two methods were relatively comparable. The acute dietary 96 h LC(50) of OTA is 9.23 mg kg(-1) diet. Additionally, the behavioral changes of sea bass were primarily observed as nervous and respiratory manifestations. We concluded that sea bass is a species highly sensitive to OTA making them a useful experimental model for aquatic mycotoxigenic problems.