Clinical and epidemiologic features of psoriasis patients in an Egyptian medical center.

BACKGROUND: Identification of epidemiologic and phenotypic variations of psoriasis among different ethnic groups can further our understanding of this perplexing disease, aiming at better management of patients worldwide. OBJECTIVE: To provide a descriptive analysis of psoriasis patients registered at Kasr Al-Ainy Psoriasis Unit Disease Registry. METHODS: This retrospective single-center registry study included patient records between November 2015 and November 2018 (2534 patients). Sociodemographic and phenotypic data were analyzed. RESULTS: The mean age of the registered patients was 39.3 years and 56.3% were men. Stress was the main precipitating factor (48.3%), whereas the most common symptom reported was itching (82.4%). The median body mass index was 27.5, and the median percentage of body surface area involved was 10.0. The mean Psoriasis Area Severity Index score was 8.7, and the mean Psoriasis Disability Index score was 13.0. Both parameters correlated positively, and both showed significantly higher means in smokers. LIMITATIONS: Despite that the study was performed at a highly specialized tertiary care center with a high flow of patients, this was still a single-center registry. CONCLUSIONS: This work shows that the characteristics of Egyptian patients with psoriasis are comparable to those of other studied ethnic groups, with minor differences.

Site-oriented depigmentation in vitiligo patients using Q-switched Nd:YAG laser (1,064/532 nm), cryotherapy and chemical peels: A comparative study.

Depigmentation emerges as a feasible solution for vitiligo universalis and refractory cases of vitiligo vulgaris that hinder patients' quality of life. A range of depigmenting modalities has previously been developed. However, each has its own limitations. Based on skin sensitivity, this study sets out to compare the efficacy and tolerability of "trichloroacetic acid (TCA) peels 25% and 50% and Qs Nd:YAG laser (1,064/532 nm)" for facial depigmentation and "cryotherapy, phenol 88% and Qs Nd:YAG (1,064/532 nm)" for extrafacial skin depigmentation. Forty vitiligo patients were examined and equally divided into facial & extrafacial groups. Regular sessions were performed. Patients' responses were assessed after 3 months or when excellent/complete depigmentation was attained through assessing "depigmentation grade", "extent of depigmented skin", "patient satisfaction" and "overall response". Patients were observed for a six-month follow-up period. In facial depigmentation, Qs Nd:YAG showed the highest significant response followed by TCA 50% and 25%. In extrafacial depigmentation cryotherapy, phenol 88% and Qs Nd:YAG laser displayed positive outcomes without significant difference. Among the modalities tested Qs Nd:YAG yielded superior results in facial residual pigmentation in vitiligo when compared to TCA 50% and 25%, whereas in extrafacial sites Qs Nd:YAG, cryotherapy and phenol were equally effective.

Is There a Relation between Vitamin D and Interleukin-17 in Vitiligo? A Cross-Sectional Study.

BACKGROUND: High interleukin (IL)-17 contributes to vitiligo pathogenesis. Vitamin D has been assessed in vitiligo, with no reports targeting its relation to IL-17. OBJECTIVE: To evaluate a possible regulatory effect of vitamin D on IL-17 and their relation to disease activity in vitiligo. METHODS: This study included 30 vitiligo patients and 40 controls evaluated for IL-17 and vitamin D serum levels by ELISA technique. RESULTS: IL-17 was significantly higher (p = 0.001) whereas vitamin D was found to be lower among the patients (p < 0.001). Multivariable regression was performed to evaluate the relationship between IL-17 and vitamin D levels with the demographic data on the patients, revealing a nonsignificant relationship (p > 0.05). A significant positive correlation was noted between vitamin D levels and disease duration. CONCLUSION: Vitamin D represents a potential player in the pathogenesis of vitiligo. Its possible regulatory relation to IL-17, together with its weight as a screening tool in vitiligo, needs further evaluation.

Effect of different types of therapeutic trauma on vitiligo lesions.

New treatment modalities for vitiligo acting by changing certain cytokines and metalloproteinases are newly emerging. The aim of this work is to To assess the efficacy of trichloroacetic acid (TCA) chemical peel, dermapen, and fractional CO2 laser in treatment of stable non-segmental vitiligo and to detect their effects on IL-17 and MMP-9 levels. Thirty patients with stable vitiligo were recruited in a randomized controlled study. They were randomly categorized into three equal groups. Group 1: TCA peel, Group 2: dermapen machine, and Group 3: Fractional CO2 laser. Skin biopsies were taken from treated areas and from control areas for which MMP-9 and IL-17 tissue levels were measured using ELISA. The 30 vitiligo patients had low basal tissue MMP-9 levels and high baseline IL-17 tissue levels. As regards the three different used modalities, all of them caused rise in MMP-9 as well as IL-17 levels and almost their levels were much more elevated with repetition of the previously mentioned traumatic procedures. TCA 25% peel proved to be the most effective modality both clinically and laboratory and it can be used prior or with other conventional therapies in the treatment of vitiligo.

The role of systemic steroids and phototherapy in the treatment of stable vitiligo: a randomized controlled trial.

Pathogenesis of vitiligo is believed to be multifactorial disease with a wide variety of therapeutic modalities. The aim of this work is to assess the efficacy of oral mini-pulse steroids (OMP) plus Nb-U.V.B in comparison to OMP alone and Nb-U.V.B alone in treating stable vitiligo. A prospective randomized controlled study including 45 patients categorized into three groups receiving therapy for 3 months; Group A received Nb-U.V.B plus OMP, Group B received OMP alone while Group C received Nb-U.V.B alone. Clinical assessment and PCR evaluation of bFGF, ICAM1, and ELISA for AMA were done. Patients receiving Nb-U.V.B plus OMP and using Nb-U.V.B alone gave statistically significant clinical response than those treated with OMP alone. Statistically significant rise of BFGF was noticed after treatment with Nb-U.V.B plus OMP and with Nb-U.V.B alone. Patients treated with OMP alone and with Nb-U.V.B alone showed statistically significant drop of ICAM-1 after therapy. NB-U.V.B plus OMP and Nb-U.V.B alone were found to be clinically superior over OMP alone in treating stable vitiligo patients, hence suggesting that adding OMP to Nb-U.V.B can maintain clinical and laboratory success for a longer period of time and with less relapse.

Phototherapeutic modalities pose no significantly increased risk of oxidative damage to DNA in dark skinned individuals.

BACKGROUND: 8-oxoguanine, a major product of DNA oxidation, is considered a key parameter in measuring the carcinogenic effects of ultraviolet radiation. OBJECTIVE: To assess and compare the carcinogenic potential of different photo (chemo) therapeutic modalities in photoresponsive skin diseases by measuring the levels of 8-oxoguanine in dark-skinned individuals before and after photo (chemo) therapy. METHODS: A prospective, randomized controlled pilot study was conducted in 63 patients of skin types III-V with photo-responsive dermatoses including vitiligo, psoriasis and mycosis fungoides. Patients were divided into three groups; Group 1 (received narrowband ultraviolet-B), Group 2 (received psoralen plus ultraviolet-A) and Group 3 (received broadband ultraviolet-A). Biopsies were taken before and after phototherapy to measure 8-oxoguanine levels using enzyme-linked immunosorbent assay. Biopsies were also taken from the sun-protected skin in 21 controls subjects who had no dermatological disease. RESULTS: Regardless of the disease, a significantly higher level of 8-oxoguanine was found after treatment when compared to the pre-treatment baseline levels; however, these levels were comparable to those in control subjects. A weakly significant positive correlation was found between cumulative dose and 8-oxoguanine levels following psoralen plus ultraviolet-A therapy. In controls, comparing the 8-oxoguanine levels between skin types III and IV showed significantly lower 8-oxoguanine in skin type IV. CONCLUSION: Therapeutic doses of ultraviolet radiation are relatively safe in dark skinned patients; however, minimizing the cumulative dose of phototherapeutic modalities (particularly psoralen plus ultraviolet-A) is recommended.

Evaluation of the correlation between serum levels of vitamin D and vitamin D receptor gene polymorphisms in an Egyptian population.

BACKGROUND: Vitiligo is an autoimmune depigmentation disorder. Polymorphisms in the vitamin D receptor (VDR) have been found to be associated with vitiligo. OBJECTIVES: To evaluate the potential association between VDR gene polymorphisms (ApaI, TaqI, and FokI) and vitiligo susceptibility, and to detect if there is correlation between serum 25-hydroxyvitamin D [25(OH)D] levels and vitiligo and between VDR gene polymorphisms and 25(OH)D levels in vitiligo. MATERIALS AND METHODS: Seventy-five patients with vitiligo and 75 age and sex-matched controls were subjected to detailed history taking and dermatological examination to determine the extent and clinical type of vitiligo. A blood sample (5 ml) was retrieved to investigate VDR gene polymorphisms and serum 25(OH)D level. RESULTS: Our results showed that the serum level of vitamin D is statistically significantly lower in patients than controls. The frequency of the ApaI variant a allele, the variant genotype (aa), and the variant genotype (tt) were significantly higher among the vitiligo cases than among controls. Our study also showed that the serum 25(OH)D levels were not significantly different among the different ApaI, TaqI, and FokI genotypes. CONCLUSION: The present study showed that serum level of 25(OH)D is statistically significantly lower in patients than controls, so screening for vitamin D deficiency seems of value in patients with vitiligo for the possibility of vitamin D supplementation. We also report that VDR gene polymorphisms may be a risk for the development of vitiligo in an Egyptian population.

Acute compartment syndrome of the forearm as a rare complication of toxic epidermal necrolysis: a case report.

INTRODUCTION: Toxic epidermal necrolysis lies within the spectrum of severe cutaneous adverse reactions induced by drugs, affecting skin and mucous membranes. Toxic epidermal necrolysis is considered a medical emergency as it is considered to be potentially fatal and carries a high mortality rate. To the best of our knowledge the association of toxic epidermal necrolysis and compartment syndrome has been rarely mentioned in the literature. In this case we treated the compartment syndrome promptly despite the poor general condition and skin status of our patient. Despite the poor skin condition, wound healing was uneventful with no complications. CASE PRESENTATION: A 62-year-old Caucasian man with a generalized macular-vesicular rash involving 90% of his body surface area and mucous membranes, as well as impaired renal and hepatic functions following ingestion of allopurinol for treatment of gout, was admitted to our hospital. Skin biopsies were taken and he was started on a steroid infusion. Within hours of admission, he developed acute compartment syndrome of the dominant forearm and hand. CONCLUSIONS: Despite its rare incidence, toxic epidermal necrolysis is a condition with a high incidence of complications and mortality. Patients with severe conditions affecting a large degree of the skin surface area should be treated as promptly and effectively as patients with burns, with close monitoring and the anticipation that rare musculoskeletal complications might arise. The association of compartment syndrome and toxic epidermal necrolysis might lead to a rapid deterioration and fatal systemic involvement and multiple organ failures.

Comparative study of the effect of a daily steroid regimen versus a weekly oral pulse steroid regimen on morphological changes, blood sugar, bone mineral density and suprarenal gland activity.

BACKGROUND: The most serious side effects of systemic steroids include osteoporosis and suprarenal suppression. Many steroid regimens have been suggested to minimize these side effects; one of them is oral steroid pulse therapy. OBJECTIVE: To compare the side effects of a daily oral steroid regimen versus a weekly oral steroid pulse regimen on bone mineral density and suprarenal suppression. METHODS: Thirty patients with different skin diseases were divided into two groups: 15 for oral daily steroids (ODS) (group 1) and 15 for weekly oral pulse steroids (WOPS) (group 2). They were evaluated for bone mineral density (measured by DEXA) and suprarenal suppression (measured by serum cortisol level), morphological changes and blood sugar. Treatment was continued for 6 months to 3 years. RESULTS: Cushingoid features in group 1 were observed in 73%, yet they were not detectable in group 2. Disturbed blood sugar in group 1 was 33% and 0% in group 2. The serum cortisol level was lower in patients on ODS than those on WOPS. The effect of WOPS on bone mineral density was very limited in comparison with the ODS. CONCLUSION: Weekly oral steroid pulse therapy induces no significant bone loss and no suprarenal suppression and can be an alternative option in the treatment of chronic disorders requiring long-term oral steroid therapy.

Leukocytoclastic vasculitis and necrolytic acral erythema in patients with hepatitis C infection: do viral load and viral genotype play a role?

BACKGROUND: Leukocytoclastic vasculitis (LCV) and necrolytic acral erythema (NAE) are skin disorders associated with hepatitis C virus (HCV) infection. However, they have not been found to occur simultaneously in the same patient. OBJECTIVE: We sought to analyze the role of serum HCV-RNA levels and HCV genotype in the pathogenesis of both LCV and NAE in an attempt to assess whether these two parameters play a role in mutual exclusivity of LCV and NAE in the same patient. METHODS: The study included 11 patients with LCV and 13 with NAE, all of whom were infected with HCV. All 24 patients were evaluated for the quantitative levels of HCV-RNA, using real-time polymerase chain reaction. HCV genotyping was performed on 10 patients in each group (N = 20). RESULTS: Patients with LCV had a higher prevalence of moderate and high levels of HCV-RNA viremia (P = .038) than those with NAE. However, there was no significant difference in HCV genotype between LCV and NAE groups (P = .211). LIMITATIONS: Small number of cases is a limitation. CONCLUSION: Viral load seems to play a role in determining the response of the skin to HCV infection. High levels of HCV viremia were found to be significantly associated with LCV but not with NAE. HCV viremia may play a role in the development of LCV in HCV-infected patients.

Topical calcineurin inhibitors in atopic dermatitis: a systematic review and meta-analysis.

OBJECTIVES: To build a critical appraisal of the available literature to evaluate the effectiveness of topical calcineurin inhibitors in treatment of atopic dermatitis (AD), in comparison to topical corticosteroids (TCs) and/or placebo. DESIGN: systematic review and meta-analysis. DATA SOURCES: electronic search of MEDLINE Pubmed along the last 10 years (1997-2006). STUDY SELECTION: randomized control trials of TCIs reporting efficacy outcomes, in comparison to TCs or vehicle (placebo) or both. DATA SYNTHESIS: of 210 articles, 19 studies were included, 10 for tacrolimus and 9 for pimecrolimus, involving 7378 patients of whom 2771 applied tacrolimus, 1783 applied pimecrolimus, and 2824 were controls. Both drugs were significantly more effective than a vehicle. However, two long-term trials comparing demonstrated the value of pimecrolimus in reduction of flares and steroid-sparing effect after 6 months. Compared to TCs, both 0.1% and 0.03% tacrolimus ointments were as effective as moderate potency TCs, and more effective than a combined steroid regimen. Tacrolimus was more effective than mild TCs. CONCLUSIONS: TCIs in AD are more effective than placebo. Although less effective than TCs, pimecrolimus has its value in long-term maintenance and as a steroid-sparing agent in AD, whenever used early enough, at first appearance of erythema and/or itching. In treatment of moderate to severe AD, topical tacrolimus is as effective as moderately potent TCs, and more effective than mild preparations. Chronic AD lesions of the face and flexures are the most justified indication for topical calcineurin inhibitors.

Different narrowband UVB dosage regimens in dark skinned psoriatics: a preliminary study.

BACKGROUND: Psoriasis is a common and relapsing disease, which is both physically and psychologically disabling. Narrowband UVB (NB-UVB) is used in fair-skinned population in suberythemogenic doses with good results; however, in the darker skin population (skin types III, IV, V) erythemogenic doses have not been thoroughly investigated. AIM: A left-right bilateral comparative trial was carried out to compare the suberythemogenic dose of NB-UVB vs. erythemogenic dose in the treatment of dark-skinned psoriatic patients. PATIENTS AND METHODS: The study was conducted on 20 patients with chronic plaque psoriasis. The left side was treated with the dose causing minimal erythema [100% of minimal erythema dose (MED)] while the right side received 70% of this MED (suberythemogenic side). RESULTS: Our results revealed no statistically significant difference in PASI final and in the percentage of reduction of PASI score between both sides as well as the total number of sessions (P-value>0.05), while the total cumulative UVB dose on the suberythemogenic side was significantly lower (P-value<0.001). CONCLUSION: Our study recommends reducing the dose regimen of NB-UVB and consequently the cumulative UVB dose by using the suberythemogenic dosing schedule even in dark skin population.

A comparative study of different treatment frequencies of psoralen and ultraviolet A in psoriatic patients with darker skin types (randomized-controlled study).

BACKGROUND: Photochemotherapy psoralen and ultraviolet A (PUVA) is a viable option for treatment of psoriasis. However, concerns about its side effects have raised the need to change current PUVA protocols. The aim of this study is to determine whether reducing the treatment frequency of PUVA to twice/week instead of three times/week would affect the efficacy of PUVA therapy. PATIENTS AND METHODS: The study included 20 psoriatic patients, randomized into two groups, 10 patients in each group. The first group received two weekly sessions, the second group received three. The study lasted until complete clearance or for 12 weeks (endpoint). Psoriasis area and severity index (PASI) score was done prior to therapy, at mid therapy and at end of therapy (PASI final). RESULTS: No significant different in PASI final and in the percentage of reduction of PASI score between both groups (P value >0.05) was found. However, a significant difference in the total number of sessions and the total cumulative UVA doses between both groups was found (P value <0.001). CONCLUSION: Our study suggests reducing PUVA frequency and the cumulative UVA dose does not compromise the efficacy of PUVA, but it may improve its benefit/risk ratio. RESTRICTIONS: Few number of cases.

Detection of herpes simplex virus DNA in serum and oral secretions during acute recurrent herpes labialis.

Although herpes simplex virus (HSV) has been detected in the peripheral blood of immunocompromised patients and in neonates with disseminated disease, the extent to which the virus may be present in the blood during a localized infection in otherwise healthy patients is still unknown. Literature on patterns of HSV shedding into the oral cavity at the prodromal stage of the disease, during recurrences, and also during asymptomatic periods is still lacking. The present study aims at the detection of HSV DNA in the serum and oral secretions during acute herpes labialis using a highly sensitive technique, the polymerase chain reaction (PCR). The study included 10 patients with acute herpes labialis and five healthy controls. Using PCR, herpes simplex virus DNA was detected in the serum of seven patients (70%) and in the saliva of nine patients (90%). One of the control cases showed positive HSV DNA in the saliva (20%). There was good statistical agreement between the presence of HSV DNA in the serum and saliva. Frequency of attacks, patient's age, and gender had no statistically significant effect on the presence of the virus in serum or in saliva. It is concluded that HSV viremia during attacks of recurrent herpes simplex is more frequent than previously appreciated.