The role of long-wavelength ultraviolet A1 (UVA1) in acral vitiligo.

INTRODUCTION: Acral vitiligo is a resistant subtype of vitiligo that does not respond easily to any treatment modality. Ultraviolet A1 (UVA1) (340-400 nm) therapy can penetrate the deep dermis of the skin and is relatively free of adverse effects associated with different phototherapeutic modalities. This study's objective was to evaluate the effect of medium-dose long-wavelength UVA1 (40-70 J) in acral vitiligo treatment and compare it with topical psoralen plus ultraviolet A (topical PUVA). METHODS: Patients in this randomized-controlled comparative clinical trial were divided into two groups, medium-dose UVA1 group and topical PUVA group (10 acral vitiligo patients each). Patients received 36 sessions of phototherapy over a period of 12 weeks. Every patient was clinically evaluated monthly as regards the appearance of new lesions or increase in diameter of the current lesion according to point counting and vitiligo area severity index. RESULTS: No statistically significant clinical difference was found between patients in UVA1 and topical PUVA groups regarding response and pattern of response (P > 0.05). CONCLUSION: Ultraviolet A1 seems to be of limited use as a monotherapy in acral vitiligo treatment. However, more studies combining it with other treatment modalities as systemic steroids and/or using higher UVA1 doses may prove beneficial.

Rituximab treatment in pemphigus vulgaris: effect on circulating Tregs.

Rituximab (RTX) has been used successfully to treat refractory pemphigus. We aimed to assess the response of pemphigus vulgaris (PV) cases to RTX therapy and its effect on CD4+CD25+ (T regulatory) cells level. Sixteen PV patients were included in this study, each received one cycle of two RTX infusions (1000 mg on days 1 and 15). Five PV patients served as controls. All cases were on prednisolone ± adjuvant therapy. Pemphigus disease area index (PDAI), autoimmune bullous skin intensity score (ABSIS), anti-desmoglein antibodies, CD4, CD8, CD20 and CD4+CD25+ levels were assessed at baseline, 3, 6 and 12 months after therapy. Fourteen patients were followed up for a mean duration of 17 while two were lost to follow up 6 months after RTX therapy. A significant decrease in PDAI, ABSIS, Dsg3 (p < 0.0001) was found. The depletion of B cells lasted for 12 months in 11 (69%) patients and for 24 months in 3 (21.4%) patients. There was significant decrease in CD20+ and CD4+CD25+ cells after 12 months of RTX, p values were 0.005 and 0.02, respectively. While no similar change in CD8 and CD4 was found (p = 0.2 for both), no significant change of CD20 and CD4+CD25+ cells were detected in the control group. In conclusion RTX is safe and effective as an adjuvant therapy in refractory cases of PV. In addition to B cell depletion a significant reduction of T regulatory cells occurs in treated cases which may be due to increased skin homing of these cells.

Effect of Procedural-Related Variables on Melanocyte-Keratinocyte Suspension Transplantation in Nonsegmental Stable Vitiligo: A Clinical and Immunocytochemical Study.

BACKGROUND: Melanocyte-keratinocyte suspension (M-K susp) is gaining popularity for vitiligo treatment. Few studies have addressed procedure-related variables. OBJECTIVE: To assess the effect of different M-K susp procedure-related variables on the clinical outcome in stable vitiligo. METHODS: This prospective multicenter comparative study included 40 cases with nonsegmental stable vitiligo. Donor site was either a skin graft in noncultured epidermal cell suspension (NCECS) or hair follicle units in outer root sheath hair follicle suspension (ORSHFS). Recipient site was prepared by either cryoblebbing or CO2 laser resurfacing. Cell counts and viability were recorded in the cell suspensions. Tissue melanocytes and keratinocytes were examined by melan-A and cytokeratin, respectively. Assessment of repigmentation was performed 18 months after the procedure. RESULTS: Thirty-seven subjects completed the study. Cell count was significantly lower in the ORSHFS compared with NCECS with no significant difference in the repigmentation outcome. On comparing techniques of recipient site preparation, homogenicity was better in the CO2 group. Elbows and knees responded better to CO2 resurfacing, whereas distal fingers responded better to combination of cryoblebbing with NCECS. CONCLUSION: Using different techniques in M-K susp produces comparable results. However, the distal fingers showed better results using combination of donor NCECS and recipient cryoblebs.

Ablative CO2 fractional resurfacing in treatment of thermal burn scars: an open-label controlled clinical and histopathological study.

INTRODUCTION: Burn scars can cause permanent disfiguring problems with limited treatments available. OBJECTIVES: To assess and correlate the clinical and histopathological effects of fractional CO2 laser on thermal burns in a controlled study. METHODS: Fifteen patients 11 with hypertrophic and four with keloidal scars received three CO2 fractional laser sessions every 4-6 weeks. Half of the scar was untreated as a control. Clinical evaluation by Vancouver, PSOAS scores, and photography before, monthly, and 3 months after the last laser session was performed. Ten patients were evaluated histopathologically by standard H&E, Masson trichrome, and Elastica von Gieson special stains. RESULTS: Hypertrophic scars (HTSs) showed textural improvement and a significant decrease of Vancouver, POSAS observer, and patient scores by the end of follow-up period in the laser-treated area (P = 0.011, 0.017 and 0.018, respectively) unlike keloidal scars. Histopathology revealed significant decrease in scar thickness in HTSs only (P < 0.001) as well as a significant decrease in collagen bundle thickness and density in the upper dermis in both types of scars. CONCLUSIONS: Fractional CO2 laser is a possible safe and effective modality for the treatment of hypertrophic burn scars with improvement achieved both clinically and histopathologically.

In vivo visualization of hair follicles by ultrasound biomicroscopy in alopecia areata and its correlation with histopathology.

Ultrasound biomicroscopy (UBM) is a non-invasive imaging technique used in examination of several skin diseases but never in imaging hair and scalp diseases. Main objective of this investigation was assessment of the efficacy of UBM for in vivo visualization of hair follicles in cases of alopecia areata (AA) and correlation of findings with histopathological findings. This study included 30 patients with AA. Two areas, one with AA and a control area, were marked, examined by UBM and then biopsied for histopathological examination. In patients with alopecia totalis (AT) or universalis (AU) only an AA area was examined. Non-echogenic conical shadows reaching the epidermal entrance echo (probably corresponding to the hair follicles) were seen and were wider and fewer in number in areas of AA than in normal control areas. No significant difference was found regarding number and width of hair follicles between UBM and histopathological examination. However, a significant increase in length of follicles in histopathology was detected, indicating that the UBM image was probably unable to reach the deepest part of the follicle. Main limitation of the study is small number of cases. No significant difference was found between UBM and histological measurements of hair follicle number and width in patients with AA, making UBM a useful tool for in vivo visualization of hair follicles.

Efficacy and safety of fractional carbon dioxide laser for treatment of unwanted facial freckles in phototypes II-IV: a pilot study.

Facial freckles are a cosmetic concern to Egyptians, particularly young females. Several therapeutic lines exist with variable response rates and limitations. Fractional carbon dioxide (FCO2) laser provides minimal ablation and therefore less down time and less side effects. The efficacy and safety of this laser technology have still not been studied in freckles. The aim of this study is to assess the efficacy and safety of FCO2 laser in the treatment of unwanted facial freckles in Egyptians. Twenty patients undergone a single session of FCO2 laser and then were followed up clinically a month later. Photographs were taken before treatment and at follow-up visit and were assessed by three blinded investigators. Percent of global improvement was measured on a 4-point grading scale. Patient's satisfaction and adverse events were recorded. Two patients (10 %) showed grade 1 improvement, while eight patients (40 %) showed grade 2 improvement. Nine patients (45 %) showed grade 3 improvement, and only one patient (5 %) showed grade 4 improvement. FCO2 laser resurfacing is effective and safe in treatment of facial freckles in skin phototypes II-IV. It can offer a more practical alternative to topical treatments, and a cheaper alternative to Q-switched lasers.

PTPN22 gene polymorphism in Egyptian alopecia areata patients and its impact on response to diphencyprone immunotherapy.

PTPN22 1858C>T gene polymorphism has been associated with several autoimmune disorders including alopecia areata. The aim of the current study was to investigate the effect of the inherited genetic polymorphism 1858C>T of PTPN22 gene on the predisposition to severe forms of alopecia areata and its effect on the response to DPC treatment. To achieve our aim, PTPN22 1858C>T genotyping was performed by PCR-based restricted fragment length polymorphism (PCR-RFLP) analysis. The study included 103 Egyptian patients with extensive alopecia areata treated by DPC. Hundred healthy age and sex matched blood donors were included in the current study as a control group. Results of genotyping showed that PTPN22 CT and TT mutant genotypes were significantly higher in AA patients compared to controls and conferred increase risk of AA (OR=2.601, 95% CI=1.081-6.255). Statistical comparison between AA patients with wild and mutant genotypes revealed that the duration of the illness was significantly longer in those harboring the mutant genotypes. Moreover, the association of other autoimmune diseases as atopy and diabetes mellitus was higher in patients with mutant genotypes. Furthermore, PTPN22 1858C>T genetic polymorphism did not affect the patients' response to DPC immunotherapy.

A comparative study on efficacy of UVA1 vs. narrow-band UVB phototherapy in the treatment of vitiligo.

BACKGROUND/PURPOSE: Narrow-band ultraviolet B (NB-UVB) is considered the most effective and safe initial treatment for moderate-to-severe vitiligo but phototoxicity and possible carcinogenicity are the reported side effects. Ultraviolet A1 (UVA1) phototherapy has overlapping biological effects to NB-UVB and is relatively free of side effects associated with other phototherapy regimens. METHODS: Forty patients with vitiligo were included in this prospective, randomized controlled comparative clinical trial. Twenty patients received NB-UVB and 20 received UVA1 three times weekly for 12 weeks. The UVA1 group was divided into two subgroups. Ten patients received moderate and 10 received low dose of UVA1. Serum samples were collected before and after 36 sessions to assess soluble interleukin 2 receptor level. Patients were clinically evaluated before therapy then monthly according to Vitiligo Area Scoring Index (VASI) and Vitiligo European Task Force (VETF) scores. In addition, extent of response was determined by a blinded dermatologist comparing before and after therapy photographs. Pattern of response and side effects were recorded. RESULTS: NB-UVB was superior to UVA1 with a significant difference in blinded dermatological assessment (P<0.001), percentage change in VASI score (P<0.001) and percentage change in VETF area score (P=0.001). No significant difference in side effects was observed between both groups. Comparing UVA1 subgroups, better response in moderate-dose group was found as regard to percentage change in VASI (P<0.001) and percentage change in VETF area score (P=0.001), while no significant difference was found in blinded dermatological assessment (P=0.121). CONCLUSION: NB-UVB phototherapy remains to be an effective and safe therapeutic option in vitiligo. Response to UVA1 in vitiligo seems to be dose dependent and seems to be of limited value in treatment of vitiligo as a monotherapy. Further studies combining it with other lines of therapy such as systemic steroids may prove beneficial.