Analysis of factors influencing target PASI responses and side effects of methotrexate monotherapy in plaque psoriasis: a multicenter study of 1521 patients.

Methotrexate (MTX) is commonly used as first-line systemic treatment agent in psoriasis. We aimed to evaluate the clinical characteristics and treatment responses of patients with psoriasis undergoing MTX monotherapy. Data from adult patients with plaque psoriasis who received MTX monotherapy for at least 3 months between April 2012 and April 2022 were retrospectively evaluated in 19 tertiary care centers. Our study included 722 female and 799 male patients, a total of 1521 participants. The average age of the patients was 44.3 ± 15.5 years. Mode of treatment was oral in 20.4% of patients while in 79.4% it was subcutaneous. The median treatment duration was 8 months (IQR = 5-15). The median weekly dose was 15 mg (IQR = 11-15). 1448 (95.2%) patients were taking folic acid supplementation. At week 12, 16.3% of the patients achieved PASI (Psoriasis Area and Severity Index) 90 response while at week 24, 37.3% achieved it. Logistic regression analysis for week 12 identified the following independent factors affecting PASI 90 achievement positively: median weekly MTX dose ≤ 15 mg (P = 0.011), subcutaneous administration (P = 0.005), no prior systemic treatment (< 0.001) and folic acid use (0.021). In logistic regression analysis for week 24; median weekly MTX dose ≤ 15 mg (P = 0.001), baseline PASI ≥ 10 (P < 0.001), no prior systemic treatment (P < 0.004), folic acid use (P = 0.001) and absence of comorbidities (P = 0.009) were determined as independent factors affecting the achievement of PASI 90. Adverse effects were observed in 38.8% of the patients, with nausea/vomiting (23.9%) and transaminase elevation (13%) being the most common. The most common reasons for interruptions (15.3%) and discontinuations (27.1%) of the treatment were patient related individual factors. The use of MTX as the first systemic treatment agent, at doses ≤ 15 mg/week and concurrent folic acid application are positive predictive factors for achieving the target PASI response both at weeks 12 and 24. In our study, which is one of the most comprehensive studies on MTX treatment in psoriasis, we observed that MTX is an effective and safe treatment option.

Is there any Correlation between Red Cell Distribution Width, Mean Platelet Volume Neutrophil Count, Lymphocyte Count, and Psoriasis Area Severity Index in Patients Under Treatment for Psoriasis?

Psoriasis vulgaris is a well-known systemic inflammatory disease accompanied by many cardiac, renal, and metabolic manifestations. In recent years, hematological parameters have been studied in different systemic diseases as markers for inflammation. In this study, we investigated the possible association between the hematological parameters, namely neutrophil-to-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), red cell distribution width (RDW), and Psoriasis Area Severity Index (PASI) scores, in patients under treatment for psoriasis. Forty-five patients with moderate to severe psoriasis and PASI values of 7 or greater were included in the study. Patients with other inflammatory diseases were excluded. All the patients were treated according to the severity of the disease. Hematological parameters and PASI were examined at baseline and at month 3, 6, 9, and 12. Twenty-seven patients (60%) were women, and the mean age was 42.2 years. No statistically significant association was found between PASI values and NLR, PLR, or RDW at months 0 and 12. The mean platelet volumes increased only at month 3, and lymphocyte counts increased significantly at all months. However, platelet counts decreased significantly only at month 6, 9, and 12, while RDW decreased significantly only at month 3. All the remaining parameters such as: neutrophils count, lymphocyte count, and erythrocyte sedimentation rate decreased significantly. The decrease in RDW and the increase in the mean platelet volume accompanied by a decrease in PASI values may represent contributing prognostic hematologic parameters to predict clinical progress and treatment response of patients with moderate-severe psoriasis during the first 3 months of treatment.

Narrow-band UV-B phototherapy: an effective and reliable treatment alternative for extensive and recurrent pityriasis versicolor.

PURPOSE: In the previous studies, positive effect of sunlight on seborrheic dermatitis may well be explained by the direct influence of UV-light on the yeasts. Narrow-band ultraviolet-B phototherapy appears to be a very effective and safe treatment option for patients with severe seborrheic dermatitis. We aimed to investigate the efficacy of narrow-band ultraviolet-B phototherapy as an alternative treatment for pityriasis versicolor. MATERIAL AND METHODS: A total of 38 patients diagnosed with disseminated pityriasis versicolor having more than four relapsing episodes within 12 months were treated with narrow-band ultraviolet-B phototherapy given three times weekly. Clinical assessment on the basis of the severity of pruritus, erythema/hyperpigmentation and scaling and mycological examination were made at Weeks 0, 4, 8, 12 and 16. RESULTS: Of the remaining 30 patients, 20 (66.7%) achieved excellent results and four patients (14%) had mild residual disease. The decrease in the clinical scores calculated at 4th week, 8th week, 12th week and 16th week were statistically significant. CONCLUSION: Narrow-band ultraviolet-B presumably may have an immunomodulatory and inhibitory effect on Malassezia growth. Narrowband ultraviolet-B is an effective and safe alternative tool for the management of extensive and recurrent pityriasis versicolor for patients who are unresponsive to conventional treatments.

A split-face, investigator-blinded comparative study on the efficacy and safety of Q-switched Nd:YAG laser plus microneedling with vitamin C versus Q-switched Nd:YAG laser for the treatment of recalcitrant melasma.

BACKGROUND: High recurrence has previously been reported in the treatment of melasma with low-fluence 1,064-nm Q-switched neodymium-doped yttrium aluminium garnet (QS-Nd:YAG) laser. On the other hand, the efficacy and safety of the QS-Nd:YAG laser plus microneedling with vitamin C have not been evaluated in patients with mixed-type melasma. MATERIAL AND METHODS: Sixteen patients with recalcitrant dermal- or mixed-type melasma were included in the study. One side of patients' face was treated with QS-Nd:YAG laser plus microneedling with vitamin C (Group A) and the other side with QS-Nd:YAG laser alone (Group B) for four sessions at four-week intervals. Melasma Area Severity Index (MASI) scores and clinician's evaluation of clinical response were assessed monthly. RESULTS: Group A had a significantly lower mean MASI score and better treatment response than Group B according to clinician's evaluation. According to MASI scores, in Group B, two patients had a good response while 12 were unresponsive to treatment. Good or very good improvement was reported by 10 patients in Group A and three patients in Group B. Adverse effects and recurrence rates were similar in Groups A and B (31.3 and 43.8%, respectively). DISCUSSION: QS-Nd:YAG increases the blood circulation in the dermis, thereby enhancing the mechanical effect of microneedling to promote the penetration of vitamin C. CONCLUSION: Vitamin C application with microneedling immediately after treatment with QS-Nd:YAG laser is a promising adjunctive method for the treatment of recalcitrant melasma.

Best dilution of the best corticosteroid for intralesional injection in the treatment of localized alopecia areata in adults.

PURPOSE: To evaluate and compare the clinical efficacy, dermoscopic results and safety of triamcinolone acetonide (TA) and betamethasone dipropionate (BD) injections at different concentrations in localized scalp and beard alopecia. METHODS: Intralesional injection of BD or TA in three different dilutions; 1/4, 1/8, 1/12 (BD1, BD2, BD3, TA1, TA2, TA3) and Saline (control) was randomly applied to a total of 231 alopecia patches in 83 patients every four weeks in a maximum of six sessions until a hair regrowth score of 4 was achieved. The number of required sessions, sixth-month hair regrowth scores, treatment success rates and dermoscopic data were investigated. RESULTS: The mean number of required sessions were similar and significantly lower in BD1 and TA1 being 4.21 ± 1.12 and 3.74 ± 0.99, respectively. Dermoscopic examinations revealed similar terminal hair growth rations in Saline (30.3%), BD1 (44.4%) and TA1 (42.9%). However, sixth-month hair regrowth scores, overall treatment success rates and percentage of terminal hair regrowth were similar in BD1 and TA1. However, adverse effects were more common in TA groups (24.3%) than in BD groups (10.6%) at the sixth month. CONCLUSIONS: BD » dilution (1.25 mg/dL) seems best corticosteroid for intralesional injection in the treatment of localized alopecia areata in adults.

Salicylic acid peeling combined with vitamin C mesotherapy versus salicylic acid peeling alone in the treatment of mixed type melasma: A comparative study.

INTRODUCTION: Melasma is a distressing condition for both dermatologists and patients. We evaluated the effectiveness of salicylic acid (SA) peel and vitamin C mesotherapy in the treatment of melasma. MATERIALS AND METHODS: Fifty female patients were divided into two groups. All patients were treated with 30% SA peel every two weeks for two months. In addition, after SA peeling Group A was intradermally administered 10 vitamin C on the melasma lesion at 1-cm intervals. All patients were followed up for 6 months, during which the recurrence rates were evaluated. Digital photographs of the melasma site were taken and patients' Melasma Area and Severity Index (MASI) scores were assessed. After the treatment, the patients were asked to complete the melasma quality of life questionnaire (MelasQoL) to evaluate their satisfaction with the treatment. All the adverse effects were noted. RESULTS: The MelasQoL and MASI scores of patients in both groups significantly decreased after the treatment. Apart from a burning sensation, no adverse event was observed and all patients tolerated the treatment well. DISCUSSION: SA peel combined with vitamin C mesotherapy is a safe and effective alternative for the treatment of melasma with no significant side effects and minimal downtime.

Use of Er:YAG for the treatment of recalcitrant facial verruca plana.

BACKGROUND: Recalcitrant facial verruca plana (FVP) may persist for years and full remission is not always achieved with conventional therapies. The clinical success rates reported for different lasers are highly variable and only one study evaluated the Er:YAG laser for the treatment of FVP. OBJECTIVE: To determine whether Er:YAG is safe and effective for the treatment of recalcitrant FVP. METHODS: Forty-six patients with recalcitrant FVP were treated by Er:YAG at four-week intervals. The patients' clinical response, adverse effects such as scarring and pigment change, recurrence and patient satisfaction were assessed. Patients were clinically evaluated after each session over a six-month follow-up. RESULTS: A total of 550 lesions of 46 participants were treated with 1-3 passes. The patients received 1-4 laser sessions with one session on average. Thirty-two patients (62.5%) achieved a complete response with 458 lesions (83.3%) being completely and 30 (5.5%) being partially healed. The post-treatment side effects were post-inflammatory hyperpigmentation and mild scar formation. FVP recurred in 12 patients (26.0%). Twenty-six patients (56.5%) were completely satisfied and nine (19.5%) were mostly satisfied with the treatment. CONCLUSIONS: Er:YAG laser is a good treatment option in patients with recalcitrant FVP, particularly for cosmetically sensitive areas.

Erbium:yttrium aluminum garnet laser versus Q-switched neodymium:yttrium aluminum garnet laser for the treatment of xanthelasma palpebrarum.

BACKGROUND: Several lasers have been used for the treatment of xanthelasma palpebrarum (XP), such as Q-switched neodymium:yttrium aluminum garnet (QSNd:YAG) and erbium:yttrium aluminum garnet (Er:YAG) laser. Up to now, a comparative study among these laser options in the treatment of XP has not been reported. OBJECTIVE: The aim of this study was to compare the clinical efficacy and response rates of QSNd:YAG and Er:YAG in the treatment of XP. METHODS: Sixty patients with a total of 102 XP lesions were randomly and equally divided into two groups. The first group was treated with QSNd:YAG at a fluence of 10 joule/cm2, 10 Hz and 2 mm spot size, and the second group was treated with Er:YAG at 200-300 millijoule, 4 Hz and 2 mm spot size. RESULTS: In the Er:YAG group, the percentage of patients who required 3 or 4 sessions and wound healing time were higher compared to those of the QSNd:YAG group. Furthermore, the percentage of patients who had an improvement score of 4 was higher in the Er:YAG than that in the QSNd:YAG group. CONCLUSION: Er:YAG is an efficient, successful and minimally invasive method without long-lasting adverse effects.

Efficacy and safety of mascara dyeing as an adjunct to Alexandrite and Nd:YAG laser applications for removing thin and white-colored facial and axillary hair.

INTRODUCTION: There is no satisfactory and efficient method for long-term removal of white-colored and thin hair. METHODS: We conducted a randomised clinical trial of hirsute patients with excessive white and/or thin hair on the face and/or axilla. In Group I (n: 16), the facial hair on one side of the face was painted with a black eyelash mascara immediately before Nd:YAG laser and the other half was only treated by Nd:YAG. In Group II (n: 20), the axillary hair on one side was painted with the mascara before the Alexandrite laser with the other side being only treated by Alexandrite. RESULTS: The terminal hair counts on the painted facial and axillary sides were significantly lower than those on the control sides throughout the study except for the first month. The decrease in the terminal hair count was significant from the beginning of treatment to the second and sixth months on the painted and control facial sides and to the first and sixth months on the axillary sides. CONCLUSION: Hair coloring with black eyelash mascara is a simple, efficient and safe adjunct to Alexandrite and Nd:YAG laser applications to enhance their clinical efficacy in eliminating white and thin facial or axillary hair.

The Role of p16, p21, p27, p53 and Ki-67 Expression in the Differential Diagnosis of Cutaneous Squamous Cell Carcinomas and Keratoacanthomas: An Immunohistochemical Study.

BACKGROUND: Distinguishing squamous cell carcinoma (SCC) from keratoacanthoma (KA) by histopathological features may not be sufficient for a differential diagnosis, as KAs may, in some cases, imitate well-differentiated SCCs. AIMS: In this study, we investigated whether the expression of the p16, p21, p27, p53 genes and a Ki-67 proliferation index are useful in distinguishing between these two tumors. STUDY DESIGN: Cross-sectional study. METHODS: Immunohistochemistry was used to investigate the expression of the p16, p21, p27, p53 genes and the Ki-67 proliferation index was investigated in well-differentiated SCC with KA-like features (n=40) and KA (n=30). RESULTS: The results of all of the examined markers, except for p27 (p16, p21, p53, and Ki-67) were found to be significantly different between the SCC and KA samples (p<0.05). CONCLUSION: In well-differentiated SCC with KA-like features and KA cases where the differential diagnosis is difficult from a histopathological perspective, the use of p16, p21, p53 expression and a Ki-67 proliferation index can be useful for the differential diagnosis of SCCs and KAs.

Chondroid syringomas: an immunohistopatological analysis.

BACKGROUND: Chondroid syringoma is a rare benign skin adnexal tumor composed of both epithelial and mesenchymal components, and is known as a cutaneous mixed tumor. Its clinical diagnosis is generally incorrect, and an exact diagnosis can only be made with histopathological investigations. The aim of this study was to determine the clinicopathological findings of the cases diagnosed with chondroid syringoma. METHODS: In this study, over the period from January 2008 to March 2014, a total of 2661 excised skin lesions were evaluated for the clinicopathological findings, and fifteen cases were diagnosed with chondroid syringoma. Various parameters such as gender, mean age, tumor localization and immunohistochemical markers (pan-cytokeratin, vimentin, S-100 protein, CEA-(M) and p53 were examined. RESULTS: Of the15 cases diagnosed with chondroid syringoma, 10 (67%) were male and 5 (33%) were female. The mean age of the patients was 46 (range 11-80 years). The chondroid syringomas were positive for pan-cytokeratin (87%), vimentin (100%), S-100 protein (100%), CEA-M (53%) and p53 (80%). CONCLUSIONS: Chondroid syringomas should be included in the differential diagnosis of a slowly growing, nodular mass in the dermis. Definitive diagnosis of the tumor is made by histopathological examination. Difficult cases may benefit from immunohistochemical examination.

The importance of cytokeratin 19 expression in the differentiation of Basal cell carcinoma and trichoepithelioma.

INTRODUCTION: Basal cell carcinoma (BCC) is the most common skin neoplasm reported in human. On the other hand, trichoepithelioma (TE) is a rare, benign tumour of skin adnexa. The differentiation of BCC and TE may be difficult since their morphological findings are similar. In a few studies, it has been determined that undifferentiated basaloid cells are highly positively stained with cytokeratin 19. AIM: The aim of this study was the comparison of cytokeratin 19 expression in cases of BCC and TE. MATERIALS AND METHODS: Sections of skin tissues of 17 TE, 25 BCC and 12 non-neoplastic cases were used for cytokeratin 19 (CK19) immunohistochemical staining. RESULTS: Staining with CK19 of the BCC cases gave 15(60%) diffuse, 7 (28%) focal and 3 (12%) negative staining. On the other hand, among TE cases, 2 (12%) gave diffuse, 5 (29%) focal and 10 (59%) negative staining with CK19. In the non-neoplastic skin tissue samples, while positive staining with cytokeratin 19 in the outer root sheath of hair follicles and sweat glands were observed, there was no staining in basal layers. CONCLUSION: CK19 expression may be helpful in the differential diagnosis of BCC and TE especially in small skin biopsy samples in which morphologic differentiation is difficult.

Labial adhesion with acute urinary retention secondary to vaginitis.

Labial adhesion occurs most often in infants and girls and is usually associated with low estrogen levels. Labial adhesion in the reproductive age group is extremely rare due to abundance of estrogen. Herein we present a case of almost complete labial adhesion with acute urinary retention in a 21-year-old virgin woman secondary to a probable untreated severe vaginitis.

Angioedema due to Systemic Isotretinoin Therapy.

Angioedema is the swelling of the mucosal membranes as a variant of urticaria induced by hereditary C1 esterase inhibitor enzyme deficiency, certain foods, or drugs. Herein, we report the case of a 23-year-old woman, with mild-moderate acne presenting with widespread facial angioedema on the 2nd day of systemic isotretinoin treatment. The patient had taken no drugs other than isotretinoin in the preceding days and had no known food allergy. Her angioedema was resolved after the isotretinoin was discontinued. We want to draw the attention of dermatologists to this rare adverse allergic effect of isotretinoin which is frequently used in the treatment of acne vulgaris.

Coexistence of aplasia cutis congenita, faun tail nevus and fetus papyraceus.

BACKGROUND: Aplasia cutis congenita is a disorder of the skin embryonic development characterized by a defect of localized or widespread areas of skin at birth. The lesions are mostly oval, 1-3 cm in diameter, with localization on the parietal part of scalp (60%) and rarely on the face and extremities. MAIN OBSERVATIONS: Herein, we reported a case of aplasia cutis congenita termly born at 39 weeks of gestation to a 30-year-old mother with bronchial asthma attacks. She was referred for 3 punched-out punctate depressed defective lesions in 0.4 cm's diameter on the vertex covered with necrotic and hemorrhagic crusts. There was a hypertrichotic area consisting of tufts of terminal hair on the lumbosacral area over a sinus tract. Maternal perinatal drugs included aerosol salbutamol sulfate, ipratropium bromide and oral montelukast sodium for bronchial asthma. The pregnancy was firstly started as a di-chorionic, di-amniotic twin gestation, but deteriorated after the fetal resorption of the co-twin in the 20th gestational week resulting in fetus papyraceus. CONCLUSION: In multi-gestational pregnancies, the presence of the fetus papyraceus or the death of the co-twins should make the neonatologists and dermatologists be aware of the possible cutaneous defects like aplasia cutis congenita. We emphasize that the possibility of this rare entity should be kept in mind in the presence of fetus papyraceus, perinatal drug use, maternal cigarette smoke, or maternal diseases like bronchial asthma in multiple gestations.

Clinical and histopathologic differential diagnosis of venous malformation of the uterine cervix.

OBJECTIVE: Venous malformations of the uterine cervix are extremely rare. Most lesions are asymptomatic and incidental, but sometimes, they may present with abnormal and/or intractable vaginal bleeding. The study aimed to describe a case of venous malformation of the uterine cervix and discuss the clinical and histopathologic differential diagnosis of this entity. CASE: A 50-year-old woman attended to the gynecology clinic for postcoital spotting and postmenopausal bleeding. Gynecologic examination revealed polypoid, lobulated, bluish, vascular nodular lesions 4 to 1 cm in size surrounding the cervical introitus. The lesions were completely excised via loop electrosurgical excision procedure method. Pathologic diagnosis revealed venous malformations of the uterine cervix. CONCLUSIONS: Venous malformations of the uterine cervix should be considered in the differential diagnosis of patients with cervical mass and vaginal bleeding. Pathologic examination is necessary in such a case to exclude the possibility of malignant vascular tumor or cervical neoplasm.

Eosinophilic panniculitis presenting with Kaposi's sarcoma-like plaques in a patient who is human immunodeficiency virus positive: a case report.

INTRODUCTION: Eosinophilic panniculitis is an unusual type of panniculitis characterized by a prominent infiltration of subcutaneous fat with eosinophils without an exact etiopathogenesis. To the best of our knowledge, up to now eosinophilic panniculitis has been described in only one previous case with human immunodeficiency virus disease in the literature. CASE PRESENTATION: Here we report the case of a 44-year-old Caucasian man, who is human immunodeficiency virus positive, diagnosed with eosinophilic panniculitis. A dermatological examination revealed multiple, confluent Kaposi's sarcoma-like purple colored, deep plaques and nodules on his right gluteal area and right thigh. The presence of the mixed inflammatory infiltrate of lymphocytes, macrophages, and numerous eosinophils involving both septa and lobules of the subcutis were noted on the histopathological examination. On the basis of all these clinical and histopathological findings the patient was diagnosed with eosinophilic panniculitis. He was given intravenous 60mg/day methylprednisolone for 3 consecutive days a week for 6 months. The lesions resolved almost completely after 6 months. CONCLUSION: The predominance of T helper-2 subset of T helper cells and the consequential increase in interleukin-5 cytokines accompanying peripheral eosinophilia and high serum immunoglobulin E levels may all be blamed for the development of eosinophilic panniculitis in our case study. As a result, we aim to emphasize that eosinophilic panniculitis should be kept in mind in the differential diagnosis of subcutaneous nodular lesions in patients who are human immunodeficiency virus positive. We also focus on the requirement of histopathological examination for the definitive diagnosis because the clinical features of eosinophilic panniculitis may easily be confused with Kaposi's sarcoma.