Dermatoscopic Features of Early Erythema Chronicum Migrans.

Dear Editors, A 37-year-old man from a Lyme disease-endemic area presented with a one-week old rapidly expanding rash on his right calf. He lacked other comorbidities or symptoms such as fever, weakness, lack of appetite, or joint pain, but recalled removing a tick from the same region three weeks earlier. Inspection revealed a round, bluish-red erythematous patch with a central clearing (Figure 1). The patient experienced no discomfort, but the rash was warm and faded easily when palpated. Dermatoscopic inspection revealed collarette-shaped white scales encircling the punctum of the tick bite in the center (Figure 2, left inset). There were three distinct background zones towards the periphery: skin-colored, bluish-red, and bright red. The transitions between the zones were not fully discernable. Red purpuric dots and clods were randomly distributed over these backgrounds, gradually increasing towards the periphery (Figure 2). The rash was diagnosed as erythema chronicum migrans (ECM), and the patient was started on doxycycline 100 mg BID. The expansion of the rash was stopped, while the speed of central clearing was increased. Half of the rash had healed by the third day (Figure 1, left inset), and it had completely disappeared by the seventh (Figure 1, right inset). Anti-Borrelia burgdorferi antibodies were initially negative for IgM and positive for IgG, but both tested positive two weeks later. ECM is the hallmark of early-stage lyme disease, but it is not always present. In addition to the classically described bull's eye appearance, ECM may appear as homogenous erythematous patches, interrupted annular patches, or patches with hemorrhagic or purpuric components (1). It can manifest anywhere except in the palmoplantar region, but it is more common around large joints. Despite the morphological variations of ECM, the clinical presentation is often clear and distinct enough for dermatologists to correctly diagnose more than 90% of patients (1). Diagnostic procedures such as ELISA or Western blot are employed in cases when the ECM is absent or atypical. However, their reliability is low due to the lack of standardization, limited coverage of Borrelia spp., and significant false-positive and false-negative rates (1). Seropositivity owing to previous asymptomatic infection in individuals residing in endemic areas may result in incidental positive findings. Alternative methods, including isolating the pathogen or PCR testing from biopsy samples have similar drawbacks (1). Histopathological investigations are another practical method that yields supportive findings. ECM exhibits diffuse perivascular and interstitial inflammation, including lymphocytes, eosinophils, and plasma cells (2), which corresponds to background erythema in dermatoscopy. As the inflammation develops, the newly-developed regions are superficial and brilliant red, but the surface inflammation fades over time, leaving bluish erythema, which correlates to deeper inflammation (2,3) dermoscopy is gaining appreciation in assisting the diagnosis of nonneoplastic diseases, especially inflammatory dermatoses (inflammoscopy). Extravasated erythrocytes combined with perivascular inflammation (2) generate purpuric pinkish-red dots and clods. Given the greater efficacy of early treatment and the ambiguity surrounding diagnostic methods, clinical findings should be deemed adequate to commence therapy, particularly in endemic regions (1). Dermatoscopic examination of ECM offers a quick and low-cost alternative approach for supporting the diagnosis. However, as emphasized by Errichetti, dermatoscopic examination in non-neoplastic diseases should be regarded as the second step of a "2-step procedure", with differential diagnoses established first by history and clinical examination (3). A systematic investigation of early and late, typical and atypical lesions would improve the reliability and utility of this method.

Dermatopathological Correlation of Clinically Challenging Cutaneous Lesions: a Single Center Experience of 2184 Cases.

Introduction: Although a trained eye can easily identify typical skin lesions, histopathological examination and clinicopathological correlation are critical in challenging cases. Objectives: The primary objective is to organize the final diagnoses reached following clinicopathological consensus in clinically challenging cutaneous lesions, identifying the most common diagnostic scenarios encountered by dermatopathologists and discussing their diverse differentials submitted by clinicians. The secondary objective is to investigate how the case profile and clinician decision-making processes evolved during the COVID-19 pandemic. Methods: Skin and mucosa samples collected by the dermatology department between 2016 and 2020 were classified based on pathology reports. For frequent diagnoses, preliminary diagnoses stated by clinicians on pathology requisition forms were reviewed. The years preceding and following the first nationally reported COVID-19 case were compared to investigate the pandemic's impact on the distribution of dermatology and dermatopathology cases. Results: One thousand nine hundred and eighty-nine reports were classified into 4 major categories: inflammatory (49.8%), neoplastic (30.1%), other diseases (7.1%), and non-diagnostic (12.8%). We further classified inflammatory diseases based on major tissue reaction patterns and neoplasms based on cell origin. We analyzed the leading diagnoses in each category, discussed their differential diagnoses, and provided clinicians with clues to reduce errors in practice. Following the pandemic, the overall number of pathology reports and patient admissions dropped dramatically, with significant changes in case profiles. Conclusions: We presented and discussed the frequently encountered confounding cases to sketch the diagnostic landscape. In the authors' experience, clinicopathological correlation can increase the rate of reaching the diagnosis by up to 75.3%.

Therapeutic efficacy and safety of three different modalities in pediatric patients with plantar warts.

Human papillomavirus infection is relatively common in communities. Thus, determining an effective and painless treatment method, especially in pediatric patients is of utmost importance. This study aimed to compare the outcomes of three different methods of treating plantar warts in pediatric patients. Children with verruca plantaris treated with a salicylic acid-lactic acid combination once daily (SA/LA 1), a salicylic acid-lactic acid combination applied in three to seven layers under occlusion every 3 days (SA/LA 2), or a combination of 5-fluorouracil (0.5%) and salicylic acid (10%) (SA/5-FU) were evaluated retrospectively. Treatment responses and recurrence rates were also evaluated after a minimum of 4 months. Among the 98 children with verruca plantaris, 19 were treated with SA/LA 1, 53 were treated with SA/LA 2, and 18 were treated with SA/5-FU; the eight patients who received cryotherapy were excluded. The mean treatment duration was significantly shorter in the SA/LA 2 group than in the SA/LA 1 group and the SA/5-FU group. (p = 0.000 for both) Application of a salicylic acid-lactic acid combination in multiple layers under occlusion is a safe, painless, and effective treatment method for plantar warts in children.

Treatment of three hereditary leiomyomatosis patients with cryotherapy.

Hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome is an autosomal dominant disorder characterized by cutaneous leiomyomas (CLM), uterine leiomyomas, and the increased risk of renal cell carcinoma. Piloleiomyomas develop from the arrectorpili muscle and are usually painful. For 22% of the affected patients, the pain is reported to impair their life quality. Since there are few case reports about cryotherapy for cutaneous leiomyomas in the literature, we have decided to present three patients who had painful cutaneous leiomyomas treated with cryotherapy.

Persistent Reaction to Bacitracin after Patch Testing with Thin Layer Rapid Use Epicutaneous Test.

Long-lasting allergic patch test reactions (LLAPTR) are reactions that remain positive for two weeks or more after the application of the allergen. LLAPTR of longer than 6 weeks duration is rarely seen. Here we present a 54-year-old female patient who had a positive allergic reaction to bacitracin with the thin layer rapid use epicutaneous test (TRUE test), which lasted for about 11 weeks duration. To our knowledge this is the first reported case of LLAPTR related to the bacitracin.

Effects of isotretinoin on the thyroid gland and thyroid function tests in acne patients: A preliminary study.

BACKGROUND: Isotretinoin is widely used in the treatment of acne. AIMS: We investigated the effects of isotretinoin on thyroid function tests and thyroid volume in acne patients. METHODS: In this prospective study, a total of 104 acne patients were included. Sixty-six patients were treated with isotretinoin for at least 4 months. Thirty eight patients were included in the control group. The levels of thyroid stimulating hormone, free triiodothyronine, free thyroxine, antithyroglobulin and antithyroid peroxidase antibodies were measured and a thyroid ultrasound was performed in all the subjects before treatment and 4 months after treatment. A "p" value of < 0.05 was considered significant. RESULTS: In the isotretinoin-treated group, thyroid stimulating hormone levels increased significantly during isotretinoin treatment (P = 0.018). Free triiodothyronine, free thyroxine, anti-thyroid peroxidase levels and thyroid volume decreased significantly during treatment (P = 0.016, P= 0.012, P= 0.006, P = 0.020 respectively). LIMITATIONS: The major limitation of this study is the lack of follow-up data after the cessation of isotretinoin therapy in acne patients. CONCLUSION: Patients treated with isotretinoin should be monitored with thyroid function tests.

Relationship Between Serum Fetuin-A Levels and Carotid Intima-media Thickness in Turkish Patients with Mild to Moderate Psoriasis. A Case-control Study.

Previous studies have associated severe psoriasis and psoriatic arthritis with an increased risk of atherosclerosis. However, the association between patients with mild-to-moderate plaque-type psoriasis and atherosclerosis has yet to be studied in depth. This study investigates a) possible correlations between carotid intima-media thickness (CIMT) and serum fetuin-A levels in patients with mild-to-moderate psoriasis and b) correlations between psoriasis severity index (PASI) and fetuin-A levels. The latter correlation was recently reported to be important for wound healing and vascular calcification. In this prospective study, a total of 70 patients with mild-to-moderate psoriasis and 66 control participants were included. PASI, CIMT, and serum fetuin-A levels were examined in all patients. Although the difference in fetuin-A values was not statistically significant between patients with mild-to-moderate plaque-type psoriasis and control groups (P=0.401), the CIMT levels in the psoriasis group were significantly higher than the control group (P=0.002). There were no correlations among fetuin-A levels, CIMT, and PASI. This study establishes an association between mild to moderate psoriasis and atherosclerosis. This study also concludes that, similarly to patients with severe psoriasis, CIMT levels are a better indicator of cardiovascular risk than serum fetuin-A levels in patients diagnosed with mild-to-moderate plaque-type psoriasis.

Is there a role for DWI in the diagnosis of sacroiliitis based on ASAS criteria?

PURPOSE: Sacroiliitis based on MRI is one of the main diagnostic criteria of axial spondyloarthritis (SpA). Our purpose was to assess (a) whether apparent diffusion coefficient (ADC) values on diffusion-weighted imaging (DWI) differ between regions of bone marrow edema (BME) and subchondral normal-appearing bone marrow (NABM) in active sacroiliitis, (b) whether ADC values can differentiate early SpA and chronic SpA, both in the active and inactive phase, and (c) whether ADC values are related to laboratory findings. MATERIALS AND METHODS: 47 patients (24 female, 23 male, mean age: 38.53 years) with the diagnosis of SpA were included in this retrospective study. 20 age- and sex-matched subjects without SpA constituted the control group. ADC measurements were taken from all lesions and NABM of each sacroiliac joint. RESULTS: A total number of 120 subchondral BME lesions (acute: 17, chronic active: 103) were noted. The mean ADC values of the BME lesions (1.30 ± 0.18 × 10(-3) mm(2)/s) were significantly higher than the ADC values in the NABM regions (0.55 ± 0.08 × 10(-3) mm(2)/s) as well as in both the control group (0.56 ± 0.05 × 10(-3) mm(2)/s) and the chronic inactive group (0.54 ± 0.03 × 10(-3) mm(2)/s). There were more BME regions in patients with chronic active sacroiliitis than early SpA patients. Correlation was found between the CRP values and ADC values. CONCLUSION: DWI with ADC values may be complementary to FS T2-weighted or STIR MR images for accurately diagnosing inflammatory sacroiliitis. The value of DWI versus dynamic contrast-enhanced imaging in the follow-up needs to be clarified.

CXCR-4 and COX-2 expression in basal cell carcinomas and well-differentiated squamous cell carcinomas of the skin; their relationship with tumor invasiveness and histological subtype.

OBJECTIVE: Both CXCR-4 and COX-2 are biological markers that play a significant role in several neoplastic processes. We explored the differences in expression of these markers in certain subtypes of basal cell carcinoma, and squamous cell carcinomas in general. MATERIAL AND METHOD: In this study, we investigated the differences between 38 patients with basal cell carcinoma (nodular, infiltrative and micro-nodular subtypes) and 24 patients with well-differentiated squamous cell carcinomas with respect to their depth of invasion, tumor location, age, and CXCR-4 and COX-2 expression. RESULTS: Statistically, we found no significant difference between squamous cell carcinomas and basal cell carcinoma in terms of CXCR-4 and COX-2 expression; however, the degree of marker expression became stronger with increasing depth of invasion in both tumors. The expression of both markers was also higher in infiltrative type basal cell carcinoma compared to all the other subtypes. The results were statistically significant (p<0.05). Additionally, a significantly positive correlation also existed between COX2 and CXCR4 expression (p < 0.05). CONCLUSION: The degree of expression of CXCR-4 and COX-2 is related to invasiveness in both malignancies; thus, infiltrative type of basal cell carcinoma displays the highest degree of CXCR-4 and COX-2 expression among all the subtypes. Furthermore, our results indicate that these two biological markers may both be involved in the process of carcinogenesis and require investigation with further molecular and genetic studies in larger series.

Evaluation of Arterial Stiffness in Patients with Behçet's Disease by Using Noninvasive Radiological Methods such as Intima-Media Thickness of the Carotid, Ankle-Brachial Pressure Index, Coronary Artery Calcium Scoring, and Their Relation to Serum Fetuin-A Levels: A Case-Control Study.

BACKGROUND: Behçet's disease (BD) is a chronic, recurrent inflammatory systemic vasculitis. Evidence for increased atherosclerosis in BD has been observed. The relation between cardiovascular risk factors and increased atherosclerosis in patients with BD is still controversial. OBJECTIVE: We performed this study to evaluate arterial stiffness in patients with BD by using noninvasive radiological methods such as carotid artery intima-media thickness (CIMT), ankle-brachial pressure index (ABPI), coronary artery calcium score (CACaS), and their relation to serum fetuin-A levels, which was recently found to be important in vascular calcification. METHODS: This prospective study included 26 patients with BD and 25 control subjects. In all patients, the CIMT, ABPI, CACaS, and serum fetuin-A levels were examined. RESULTS: The CIMT and CACaS were statistically higher and the ABPI was statistically lower in BD patients than in the control group. All p-values were <0.001. Positive correlations were found between the CACaS and CIMT, and negative correlations were found between the CACaS and ABPI. Although the values of fetuin-A were higher in BD, the difference was not statistically significant (p=0.064). However, the correlations found between fetuin-A levels and CIMT and between fetuin-A levels and CACaS were significant. CONCLUSION: The CIMT, CACaS, and ABPI are all useful in detecting structural and functional vascular damage in BD.

Aquagenic syringeal acrokeratoderma.

Aquagenic syringeal acrokeratoderma is a rare, transient, and usually bilaterally symmetric, palmoplantar keratoderma. Patients complain of tingling and pain in the hands starting a few minutes after exposure to water and lasting for 20-30 minutes after removal. Clinically, there is marked wrinkling with edematous white papules on the palms or, less often, the soles. We present the case of a 21-year-old woman who used spironolactone for polycystic ovary syndrome and had similar clinical features 2 weeks later, after withdrawing the drug.

Histological investigation of the effect of soybean (Glycine max) extracts on the collagen layer and estrogen receptors in the skin of female rats.

OBJECTIVES: The purpose of this study was to analyze the effects of soybean extracts obtained using different extraction methods on the skin of female rats. METHOD: A total of 64 female Sprague-Dawley rats were divided into 8 equal groups. Various extracts were administered to the female rats by oral gavage for one month. The groups comprised carboxymethyl cellulose-free control, carboxymethyl cellulose-plus control, 100-mg/kg n-hexane extract, 200-mg/kg n-hexane extract, 100-mg/kg ethyl acetate extract, 200-mg/kg ethyl acetate extract, 100-mg/kg ethanol extract and 200-mg/kg ethanol extract groups. The thickness of the collagen layer and the number of estrogen receptor-positive cells were evaluated. RESULTS: All the extract-treated groups showed a statistically significant decrease in the number of estrogen receptor-positive cells compared with the control groups. Regarding the thickness of the collagen layer, only the 200-mg/kg ethyl acetate extract-treated group showed a significant increase compared with the control groups (p<0.05). CONCLUSIONS: Our data suggest that oral intake of three different total soybean extracts might have positive estrogenic effects on the skin and that only a high-dose ethyl acetate extract can increase the expression of collagen, which may prove to be beneficial for postmenopausal facial skin.

Histological investigation of the effect of soybean (Glycine max) extracts on the collagen layer and estrogen receptors in the skin of female rats

OBJECTIVES: The purpose of this study was to analyze the effects of soybean extracts obtained using different extraction methods on the skin of female rats. METHOD: A total of 64 female Sprague-Dawley rats were divided into 8 equal groups. Various extracts were administered to the female rats by oral gavage for one month. The groups comprised carboxymethyl cellulose-free control, carboxymethyl cellulose-plus control, 100-mg/kg n-hexane extract, 200-mg/kg n-hexane extract, 100-mg/kg ethyl acetate extract, 200-mg/kg ethyl acetate extract, 100-mg/kg ethanol extract and 200-mg/kg ethanol extract groups. The thickness of the collagen layer and the number of estrogen receptor-positive cells were evaluated. RESULTS: All the extract-treated groups showed a statistically significant decrease in the number of estrogen receptor-positive cells compared with the control groups. Regarding the thickness of the collagen layer, only the 200-mg/kg ethyl acetate extract-treated group showed a significant increase compared with the control groups (p<0.05). CONCLUSIONS: Our data suggest that oral intake of three different total soybean extracts might have positive estrogenic effects on the skin and that only a high-dose ethyl acetate extract can increase the expression of collagen, which may prove to be beneficial for postmenopausal facial skin. ...