Dermoscopy in the Diagnosis of Mycosis Fungoides: Can it Help?

INTRODUCTION: The diagnosis of mycosis fungoides (MF) is challenging since it can mimic a variety of benign skin conditions. Multiple biopsies for histopathologic and immunohistochemical examination are required to diagnose MF. Dermoscopy is an affordable, non-invasive device with expanding indications in dermatology, OBJECTIVES: To investigate the dermoscopic morphology of MF variants and assess the correlation between dermoscopic criteria, histopathologic, and immunohistochemical findings, METHODS: We included 88 patients with several MF variants (classic, hypopigmented, hyperpigmented, poikilodermatous, erythrodermic, and folliculotropic). The diagnosis was histopathologically and immunohistochemically confirmed. Dermoscopic findings were collected, statistically analyzed, and correlated with the results of histopathology and immunohistochemistry, RESULTS: All patients had MF diagnosis in H&E-stained sections. The majority revealed positive staining with CD3, 4, 8 and negative CD7. Orange-red areas of discoloration, short linear, and spermatozoa like blood vessels are the most frequent dermoscopic findings, while an analysis per MF variant was also performed. The frequently observed dermoscopic structures in classic MF were patchy whitish scales, dotted, short linear vessels, and spermatozoa-like vessels, CONCLUSIONS: Dermoscopy reveals a repetitive dermoscopic pattern in MF (non-homogenous pink to erythematous background, patchy areas of orange discoloration, patchy whitish scales, dotted and short linear blood vessels with some variations according to the clinical variant.

Unusual presentation of telangiectasia macularis eruptiva perstans at the site of healed herpes zoster; Wolf's isotopic response.

There are several reported cases of Wolf's isotopic response, including infections, cancers, inflammatory and immune-related disorders. It is interesting that the majority of these occurred after herpes zoster (HZ) had healed. In this article, we describe an unusual case of adult mastocytosis/telangiectasia macularis eruptiva perstans (TMEP) at the location of recovered HZ. Given that adult mastocytosis is thought to be caused by dysregulation of the mast cell growth factor receptor, the c-Kit proto-oncogene (CD117), and the fact that the varicella zoster virus-infected cutaneous lesions contain CD117-positive mast cells (CD117+MCs), we hypothesize that CD117+ MCs may be in charge of the local immunological response and cytokine release those results in TMEP after HZ.

Safety and efficacy of the combination of cryotherapy and photodynamic modalities with imiquimod in patients with actinic keratosis: a systematic review and meta-analysis.

INTRODUCTION: Actinic keratosis (AK) is an intraepithelial tumor that, in most cases, arises in chronically sun-exposed areas. The combination of cryotherapy and photodynamic modalities with imiquimod has been proven to be a potential therapeutic option for AKs. However, there is no comprehensive systematic study that discussed this concept in literature taking into consideration both efficacy and safety. EVIDENCE ACQUISITION: We performed a comprehensive search of the literature for studies assessing the efficacy and toxicity of the combinatorial tripartite regimen, consisting of cryotherapy and photodynamic modalities with imiquimod in AK. Metanalysis was performed using comprehensive meta-analysis version 3.0. EVIDENCE SYNTHESIS: After the screening of 1031 studies, five studies were included. Two trials compared the effect of imiquimod/cryotherapy versus cryotherapy alone or versus cryotherapy/vehicle. Our meta-analysis indicated that imiquimod/cryotherapy effectively induces complete clinical clearance in patients with AKs (OR: 6.26; 95%CI: 1.56-24.1; P=0.01). Moreover, another two studies, which were not meta-analyzed, indicated a substantial clinical clearance in the number of AK lesions in the imiquimod plus photodynamic therapy arm as compared to 5% imiquimod or PDT alone. No serious systemic adverse events were reported in all the treatment arms. CONCLUSIONS: Combined PDT or cryotherapy with imiquimod is more effective in the complete recovery of AK than treatment with imiquimod alone.

Uses of eye drops in dermatology, literature review.

Background: Since medication absorption through the skin and eye tissue seems similar, commercially available eye-drops could be used to treat skin diseases when topical therapies are unavailable or unaffordable. The FDA-approved and off-label applications of various eye drops used as topical treatments in dermatological clinical practice were highlighted in this review.Methodology: A thorough PubMed and Google Scholar library search using various combinations of the keywords (Eye drop, ocular solution, conjunctival installation, and skin diseases, topical, local, beta-blockers, prostaglandin, cyclosporin, apraclonidine, atropine, oxymetazoline).Results and conclusions: Based on the findings of the studies reviewed, timolol is highly recommended for infantile hemangioma and other vascular skin conditions such as angiomas, Kaposi sarcoma, acne, rosacea, and wound healing. Bimatoprost is a drug that can be used to treat hypotrichosis of any kind, as well as mild localized alopecia areata and leukoderma. Oxymetazoline ispromising for treating facial erythema. We recommend apraclonidine for mild upper eyelid ptosis induced botulinum neurotoxin. We don't recommend atropine for hyperhidrosis, although it can help with hydrocystomas and pruritis produced by syringomas. Tobramycin will need to be tested in RCTs before it can be confirmed as a viable alternative to systemic treatments for treating green nail syndrome.

Dupilumab therapy in atopic dermatitis is safe during COVID-19 infection era: A systematic review and meta-analysis of 1611 patients.

The aim of this meta-analysis is to evaluate the safety of dupilumab use in the management of atopic dermatitis (AD) during the current pandemic regarding the risk and the hazards of COVID-19 infection. Seven databases (Google Scholar, Web of Science, Scopus, Virtual Health Library, PubMed, System for Information on Gray Literature in Europe, and The New York Academy of Medicine) were searched for eligible studies from inception until November 24, 2021. The quality of evidence was rated using the National Institute of Health and the Joanna Briggs Institute Critical Appraisal tool. Meta-analysis was performed when the outcome is presented ≥2 studies. A total of 12 papers including 1611 AD patients were included in the study. The prevalence of COVID-19 in AD treated with dupilumab was 3.2% (95% confidence interval [CI]: 1.7-5.8). COVID-19 symptoms were reported by five patients who were presented with one or more of the following symptoms (fatigue, loss of taste and smell, runny nose, conjunctivitis, gastrointestinal symptoms, fever, cough, and dyspnea). Only three cases of COVID-19 were hospitalized with a prevalence of 4.5%, while no patients with COVID-19 died. Dupilumab is safe regarding the risk and the hazards of COVID-19 in AD patients. Thus, based on these results continuation of dupilumab in AD patients is recommended, since dupilumab seems to be safe and crucial for a better disease outcome.

Psoriasis Exacerbation after Candida Antigen Immunotherapy Injection.

BACKGROUND: Immunotherapy as wart treatment has been proposed as a successful and well-tolerated treatment option. However, as their action is not confined to the site of injection, the activation of the immune system in a way may alter the immune state of the patient. CASE PRESENTATION: A case of 29-year-old patient who experienced psoriasis exacerbation and psoriatic arthritis within days following Candida antigen immunotherapy injection for resistant filiform wart management. CONCLUSION: Candida antigen injection may cause psoriasis exacerbation, as TNFα and subsequent T-helper 1 induction is crossroad in both psoriasis and Candida antigen immunotherapy. Therefore, we report this case to state that besides the effectiveness of Candida antigen for wart therapy, caution should be considered if used in patients who are susceptible to psoriasis with meticulous follow-up or better to apply an alternative treatment option.

Efficacy of retinoids alone or in combination with other remedies in the management of warts: A systematic review and network meta-analysis.

The use of combined systemic retinoids and intralesional immunotherapy in the management of warts is still debatable without straightforward evidence. Through network meta-analysis, the current study evaluated the efficacy and safety of systemic retinoids alone or combined with other remedies in the treatment of warts. We searched six literature databases for clinical trials that compared systemic retinoids to local treatments or placebo in wart management. Outcomes were calculated as odds ratios (OR) with 95% confidence-interval. We used the R software to perform conventional and network meta-analyses (with a frequentist approach). Network meta-analysis of eight trials showed that oral acitretin plus intralesional Candida Ag (OR = 367.71), INF-α plus oral isotretinoin (OR = 223.77), oral acitretin (OR = 117), Candida Ag (OR = 91.93), oral isotretinoin (OR = 62.26) and topical isotretinoin (OR = 17.69) had higher complete recovery rates than placebo. Regarding the P-score, oral acitretin plus intralesional Candida Ag had the highest efficacy in achieving complete response (P-score = 0.88), followed by INF-α plus oral isotretinoin (P-score = 0.79), then oral acitretin (P-score = 0.60). Variable baseline characteristics and lack of data on some outcomes. The current study shows the efficacy for systemic retinoids in the treatment of warts, especially reluctant or recurrent types. Moreover, combinations of systemic retinoids with intralesional immunotherapy yield higher rates of complete clearance with lower recurrence.

Saline in Dermatology: A literature review.

BACKGROUND: Saline, with its different concentrations, is the most used crystalloid solution in medicine. In dermatology, no large studies investigated the benefits of saline. The aim of this article is to review the different possible uses of saline in dermatology, in order to give final recommendations based on the literature review and our experience. METHODS: We performed a literature search based on PubMed, EMBASE, WHO Global Health Library, Virtual Health Library, Web of Science, Scopus, Google Scholar, and Research gate. using the keywords: saline, physiological, hypertonic, isotonic, hypotonic, salt solution, sodium chloride, 0.9% NaCl, solvent, drug delivery, injection mixtures, diluent, sclerosant, intravenous, intralesional, injection, topical, soaks, fomentation, inhalation, alopecia, psoriasis, scars, atopic dermatitis, eczema, bromoderma, iododerma, lipodystrophy, in various combinations with the Boolean operators AND, OR and NOT. We also hand-searched textbooks. RESULTS: Saline was used as a diluent with intralesional injection of steroids to minimize the risk of steroid-induced atrophy, being safe and free from preservatives that may precipitate steroids at site of injection and maximize their side effects. Saline has also been used after surgery, when atrophic scars take place or anticipated, and through injection in leishmaniasis, granuloma annulare, atrophic acne scars before using other expensive and less tolerated treatment options. CONCLUSIONS: The saline represents a helpful option as a diluent with intralesional injection of steroids in various dermatologic therapeutic indications. Moreover, the use of saline in this setting could help to minimize the risk of steroid-induced atrophy. We encourage the use of saline after surgery, when atrophic scars take place or anticipated. Also, we encourage a trial of saline injection in leishmaniasis, granuloma annulare, atrophic acne scars before using other expensive and less tolerated treatment options.

Treatment options for autoimmune bullous dermatoses other than systemic steroids: A systematic review and network meta-analysis.

Autoimmune blistering diseases can eventually cause life-threatening complications if left untreated. Although there is no cure for these bullous diseases; their therapy is based on suppressing the immune system to cease the de novo formation of the generated antibodies. The current study aimed to assess the safety and efficacy of using standing alone alternative therapies beyond systemic steroids for management of autoimmune bullous diseases. We searched six literature databases for both randomized and quasi-randomized clinical trials that assessed the efficacy of drugs other than systemic steroids in autoimmune bullous diseases. Outcomes were calculated as odds ratios with 95% confidence-interval. We used the R software to perform conventional and network meta-analyses with a frequentist approach. The network ranking order for 629 bullous pemphigoid patients, from the best to the worst was, clobetasol propionate cream (40 mg; (P-score = .87), clobetasol propionate cream (10-30 mg; P-score = .77), nicotinamide plus tetracycline (P-score = .56), steroids (P-score = .29) and doxycycline (P-score = .01). Limitations of this study are the small sample of the included studies except for blister trial and lack of randomization in most trials. To conclude, Combined doxycycline and nicotinamides are safer and more effective option for extensive bullous pemphigoid patients than the usual use of systemic steroids. For limited disease, topical corticosteroid (40 mg/d) use provides a safer and better response modality than the other proposed treatments.

Intralesional immunotherapy for the treatment of warts: A network meta-analysis.

BACKGROUND: Without clear evidence, selecting among the existing immunotherapeutic options for warts remains challenging. OBJECTIVE: Through network meta-analyses, we aimed to evaluate the comparative efficacy of different intralesional immunotherapeutic modalities. METHODS: We included randomized controlled trials comparing intralesional immunotherapeutic modalities to cryotherapy, placebo, or imiquimod. All outcomes were presented as odds ratios (ORs) with 95% confidence intervals. Both conventional and network meta-analyses (with a frequentist approach) were conducted on R software. The P-score was used to rank different treatments. RESULTS: Network meta-analysis of 17 randomized controlled trials (1676 patients) showed that PPD (purified protein derivative vaccine, OR 39.56), MMR (measles, mumps, rubella vaccine, OR 17.46) and interferon ß (OR 15.55) had the highest efficacy in terms of complete recovery at the primary site compared with placebo. Regarding complete recovery at the distant site, autoinoculation (OR 79.95), PPD (OR 42.95), and MMR (OR 15.39) were all statistically superior to placebo. According to the P-score, MMR was more effective than other modalities in reducing the recurrence rate at the same site. LIMITATIONS: Relatively small sample size in some comparisons and variability in baseline characteristics. CONCLUSION: PPD and MMR were the most effective in achieving complete primary and distant recovery (along with autoinoculation for distant recovery) and reducing the recurrence rate at the same site compared with cryotherapy and other immunotherapeutic modalities.

Perception and practices of tobacco smoking among medical students in the Nile Delta, Egypt.

This study was conducted to identify medical students' perception and practices towards tobacco smoking, as well as to identify factors affecting their adoption to smoking habit, among medical students in the Nile Delta. From December 2014 to February 2015, a questionnaire-based cross-sectional study was conducted at the four faculties of medicine in the Nile Delta. A total of 1715 students were targeted from the 2nd to 6th academic years to represent different levels of knowledge, awareness, and the influence of medical education on their attitude towards smoking. 5.6 and 1.2% of the students reported being smokers and ex-smokers, respectively, with a higher prevalence among 6th-year students, 40% of them reported to be involved with substance abuse. In general, medical students had positive antismoking attitude. The prevalence of smoking among medicine students was not high. However, there is a need to address smoking cessation programs during their study.

Spontaneous Reformation of Imperforate Hymen after Repeated Hymenectomy.

BACKGROUND: Imperforate hymen prevents menstrual blood drainage, which causes cyclic lower abdominal pain and amenorrhea. Untreated patients might develop serious complications such as endometriosis and infertility. Hymenectomy represents the adequate treatment. CASE: In a 16-year-old female virgin presented with recurrent lower abdominal pain, urine retention, and secondary amenorrhea after 3 hymenectomy surgeries. The examination revealed imperforate hymen. A fourth hymenectomy was performed with continuous locked sutures over all of the edges. SUMMARY AND CONCLUSION: Recurrent imperforate hymen after hymenectomy should be suspected if symptoms recur. Diagnosis can be achieved through meticulous clinical examination and appropriate imaging techniques.

Successful Delivery of Twin Pregnancy in Class U3b/C2/V1 Uterus by Bilateral Caesarean Section after Spontaneous Conception.

A case of a 19-year-old female with class U3b/C2/V1 uterus conceived a twin pregnancy with a fetus in each horn after spontaneous conception. She referred to our department with presentation of premature rupture of membranes, with a history of cesarean delivery of a single full term living fetus a year and a half before this delivery. Examination revealed two completely separate uterine horns with a fetus in each horn, two distinct externally rounded cervices, and a single vagina with a short nonobstructing vaginal septum in the upper part of the vagina. And as the appropriate mode of delivery is still unclear, each case should be managed as the condition requires, and in our case urgent bilateral caesarean sections were performed.