Bullous Pemphigoid and Scabies: Is There an Association?

BACKGROUND: Bullous Pemphigoid (BP) is an autoimmune subepithelial bullous disease. Several reports suggested an association between BP and scabies. OBJECTIVE: We aimed to evaluate whether an association between BP and scabies exists. METHODS: This is a retrospective matched case-control study. We retrospectively identified BP patients treated in our clinic between January 1, 2009, and December 31, 2016. Each patient was assigned to 3 control subjects (matched by age and sex) treated in our clinic, not due to BP. The study group was examined for a scabies diagnosis within the 3 years prior to BP diagnosis; the control group was examined for a scabies diagnosis 3 years prior to its first visit in our clinic. RESULTS: Fifteen out of the 87 (17.2%) BP patients were diagnosed with scabies within the 3 years prior to their initial BP diagnosis, compared to only 4.2% (11 out of 261) among the control group. The odds ratio of scabies history was 4 times higher among BP patients compared to the control group (OR=4.23; 95% CI: 1.50–11.91, P=0.007). LIMITATIONS: A retrospective study design. CONCLUSIONS: An association between scabies diagnosis and BP is demonstrated in our study. J Drugs Dermatol. 2022;21(9):1009-1011. doi:10.36849/JDD.4900.

CRP Levels as a Prognostic Factor in Mycosis Fungoides.

Mycosis Fungoides (MF) and Sézary syndrome (SS) are the most common forms of cutaneous T-cell lymphomas. Few validated prognostic factors have been reported in MF/SS, especially when compared with non-cutaneous lymphomas. Increased C-reactive protein (CRP) levels have recently been associated with poor clinical outcome in various malignancies. The aim of this study was to evaluate the prognostic significance of serum CRP levels at diagnosis in patients with MF/SS. This retrospective study included 76 patients with MF/SS. Stage was assigned according to the ISCL/EORTC guidelines. The follow-up period was 24 months or more. Disease course and response to treatment were determined using quantitative scales. Wilcoxon's rank test and multivariate regression analysis were used to analyze the data. Increased CRP levels correlated significantly with advanced stages (Wilcoxon's test, P>0.0001). Furthermore, increased CRP levels were associated with a lower treatment response rate (Wilcoxon's test, P=0.0012). Multivariate regression analysis showed that CRP is an independent predictor of advanced clinical stage at diagnosis.The present data suggest that elevated CRP levels could serve as a useful prognostic factor in MF/SS and may assist in guiding treatment choices.

FOXP3 Predicts Response to Treatment in Mycosis Fungoides.

BACKGROUND: The role of the T-regulatory cells (Tregs) marker forkhead box Protein 3 (FOXP3) in mycoses fungoides (MF) pathogenesis is unclear and the results of previous studies are inconclusive. OBJECTIVE: We aimed at ascertaining the possibility that FOXP3 expression may serve to predict MF stage and response to therapy. PATIENTS AND METHODS: Immunohistochemistry staining for FOXP3 was performed on 30 skin biopsies from patients with MF, and FOXP3 expression level was quantitatively graded. Disease stage, progression, and response to treatment were determined based on clinical and imaging evidence, and association with FOXP3 expression was assessed. RESULTS: FOXP3 expression in the dermis correlated with poor response to treatment (P=0.047). A negative non-significant relationship between epidermal FOXP3 expression and clinical stage severity was observed (P=0.17). CONCLUSIONS: Dermal FOXP3 expression in MF lesions could be used to predict response to treatment in patients with MF.

1064-nm Q-switched fractional Nd:YAG laser is safe and effective for the treatment of post-surgical facial scars.

Post-surgical facial scars are often associated with unaesthetic outcome. Treatment of these scars using various lasers could be beneficial; however, the use of the Q-switched fractional (QSF) 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser has yet to be evaluated for this indication. Our objective was to determine the safety and efficacy of a QSF-Nd:YAG laser for the treatment of post-surgical facial scars. Eleven (5 male, 6 female) patients who underwent facial surgery with significant scarring were treated using the QSF-Nd:YAG laser. Scars were exposed to 600-1200 mJ/stacked pulses (12-24 mJ per pixel), emitted at a rate of 10 Hz for up to 2 passes per treatment session, receiving overall 3-6 treatments. Patient follow-up was 3 months. Scars' photographs were blindly assessed by two dermatologists, who graded them on a scale of scar severity from 1 to 5 (1 = least severe, 5 = most severe) before and after treatment. A blinded before/after recognition of these photographs was also performed. Patient satisfaction was assessed 3 months post-treatment and graded on a scale of 1-5 (1 = not satisfied, 5 = very satisfied). Pain perception and adverse effects were also evaluated. Patients demonstrated a decrease in scar severity score by a mean of 1.57 points (p = 0.0005). A blinded before/after recognition was correct in 86.5% of the cases. Pain and adverse effects were mild and transient. Patient satisfaction was high (4.2). QSF-Nd:YAG laser is a safe and effective modality for the treatment of post-surgical facial scars.

[PIGMENTED BASAL CELL CARCINOMA AND IONIZING RADIATION].

AIMS: This study aimed at demonstrating whether the histological and clinical manifestations of pigmented basal cell carcinoma are different among those who were previously treated with ionizing radiation for ringworm infection. BACKGROUND: Ionizing radiation is known to cause increased morbidity among those who are chronically exposed. Basal cell carcinoma in known to be related to ionizing radiation however, the characteristics of pigmented BCC in relation to ionizing radiation are poorly described. METHODS: The study included the demographics and characteristics of 23 patients with pigmented BCC who were treated for ringworm with ionization radiation and a control group of 21 patients that had not been treated with ionizing radiation. All the cases treated between the years 2005-2015 were included in the study. The data was analyzed with a SPSS program. RESULTS: Among the patients who were treated with ionizing radiation the percentage of the tumors that were well differentiated was 34.8%, much higher than those who were not treated with ionizing radiation - 14.3%. In addition, the average age for those who were treated with ionizing radiation was 66 compared to 73 in the group that weren't treated with radiation. DISCUSSION: Pigmented basal cell carcinoma is a rare variant of BCC and it has characteristics that are quite dissimilar among patients treated with ionizing radiation. However, more studies are needed in order to strengthen the results.

[SYSTEMIC REVIEW OF EOSINOPHILIC DERMATOSES PATIENTS TREATED WITH TNF-Α INHIBITORS AND USTEKINUMAB].

AIMS: This study aims to critically review the pros and cons of biological drugs as treatments and triggers of eosinophilic dermatoses. BACKGROUND: Eosinophilic dermatoses syndromes are rare diseases with a prominent eosinophilic infiltration mechanism. These syndromes have several known treatments with limited success. Several physicians worldwide suggested possible advantages of using specific biological drugs, which are different from eosinophil targeted biotherapies as treatments for eosinophilic dermatoses syndromes. Others considered these drugs as possible triggers. METHODS: Articles published in the last 30 years containing relevant key words were reviewed using PubMed and Medline. Associations between Infliximab, Adalimumab, Etanercept, TNF alpha inhibitors and Ustekinumab to Eosinophilic Dermatoses syndromes were reviewed. RESULTS: Our search revealed an association between 17 eosinophilic dermatoses patients and the drugs of interest. Out of 5 Wells' syndrome cases, four patients had an outbreak of the disease following treatment and one improved by the treatment. Six cases of Eosinophilic Fasciitis mostly had a positive reaction to the treatment. More associations were found among 4 cases of Churg-Strauss syndrome, one case of Granuloma Faciale and 1 case of Eosinophilic Pustular Folliculitis. CONCLUSIONS: TNF alpha inhibitors and Ustekinumab may have a role in the treatment of eosinophilic dermatosis syndromes. These drugs may act as triggers among Wells' syndrome patients. Further investigation is needed.

The Role of Desmoglein 1 in Gap Junction Turnover Revealed through the Study of SAM Syndrome.

An effective epidermal barrier requires structural and functional integration of adherens junctions, tight junctions, gap junctions (GJ), and desmosomes. Desmosomes govern epidermal integrity while GJs facilitate small molecule transfer across cell membranes. Some patients with severe dermatitis, multiple allergies, and metabolic wasting (SAM) syndrome, caused by biallelic desmoglein 1 (DSG1) mutations, exhibit skin lesions reminiscent of erythrokeratodermia variabilis, caused by mutations in connexin (Cx) genes. We, therefore, examined whether SAM syndrome-causing DSG1 mutations interfere with Cx expression and GJ function. Lesional skin biopsies from SAM syndrome patients (n = 7) revealed decreased Dsg1 and Cx43 plasma membrane localization compared with control and nonlesional skin. Cultured keratinocytes and organotypic skin equivalents depleted of Dsg1 exhibited reduced Cx43 expression, rescued upon re-introduction of wild-type Dsg1, but not Dsg1 constructs modeling SAM syndrome-causing mutations. Ectopic Dsg1 expression increased cell-cell dye transfer, which Cx43 silencing inhibited, suggesting that Dsg1 promotes GJ function through Cx43. As GJA1 gene expression was not decreased upon Dsg1 loss, we hypothesized that Cx43 reduction was due to enhanced protein degradation. Supporting this, PKC-dependent Cx43 S368 phosphorylation, which signals Cx43 turnover, increased after Dsg1 depletion, while lysosomal inhibition restored Cx43 levels. These data reveal a role for Dsg1 in regulating epidermal Cx43 turnover.

Kerion of the pubis and vulva with bacterial superinfection: a rare occurrence.

Kerion is a severe hypersensitivity reaction to fungal infection that is rarely seen in the groin. Frequent shaving of pubic hair and religious conservatism surrounding genital hygiene are common among Bedouin women in the Negev Desert, and may predispose to kerion. This case highlights the clinical course of a 20-year-old Bedouin woman who presented with severe kerion celsi of the pubis and vulva with secondary bacterial infection. The patient was successfully treated with intravenous antibiotics, oral antifungal medication and wet topical dressings. The case outlines the risk factors and treatment for severe kerion celsi of the groin, as well as possible preventive measures that may reduce its incidence.

Acetic acid treatment for toe web infection caused by Pseudomonas Aeruginosa combined with fungal infection: A case series of ten patients.

Gram-negative bacterial toe web infection (GNBTWI) caused by Pseudomonas Aeruginosa combined with fungal infection has variety of treatments. However, these treatments have been poorly described in the literature. Our retrospective study describes patients that had been treated in our medical center with acetic acid combined with local antifungal treatment, to evaluate evidences for the appropriateness of this treatment. Ten patients with evidence of GNBTWI caused by Pseudomonas Aeruginosa combined with local fungal infection which have been treated with acetic acid in Emek Medical Center were identified. Eight patients (80%) had a complete response while two patients (20%) showed only a partial response. Side effects were minimal and included temporary stinging sensation. Acetic acid is a relatively cheap ingredient with minimal side effect profile and highly effective outcomes as a treatment for GNBTWI caused by Pseudomonas Aeruginosa and should be considered as an adjuvant treatment.

Mortality and risk factors among Israeli bullous pemphigoid patients.

There are differences concerning reported mortality rates and prognostic factors of bullous pemphigoid (BP) patients in different studies. Our objectives were to evaluate the mortality rates and prognostic factors among Israeli BP patients compared to matched control subjects. Three age- and sex-matched patients without BP (n = 261) who were treated in our clinic were selected and compared to BP patients (n = 87). Mean survival period of the BP group was 4.1 years (95% CI: 3.3-4.8 years) and 5.9 years among the non-BP group (95% CI: 5.6-6.3 years). The 1-year mortality rate was 24.1% for the BP group and 6.5% for the control group. In multivariate analysis, age above 80 was a significant risk factor for mortality [HR 3.22 (95% CI, 1.15-8.96), p = 0.03], while statins intake had a protective role [HR 0.36 (95% CI, 0.15-0.88), p = 0.03]. In univariant analysis, dementia [HR 2.44 (95% CI, 1.02-5.99), p = 0.04] was a risk factor. In conclusion, BP patients' mortality is correlated to increasing age at diagnosis, dementia, and statins use. Statins' protective role is newly discussed in the literature.

Subungual and ungual scabies: avoiding severe presentation in high-risk patients.

Scabies is a pruritic disorder caused by Sarcoptes scabiei var. hominis infestation of the skin. Transferred by close body contact, scabies is endemic within nursing homes and among poor and overcrowded populations. Crusted scabies is a severe form of disease, characterised by a large, thick, crusted eruption with significant mite infestation. We report a patient hospitalised with crusted scabies that had massive nail involvement. A 79-year-old female patient with multiple comorbidities and several recent prior scabies diagnoses presented with agitation and dystrophic fingernails; scabies mites were found embedded in and below the nail keratin. Aggressive treatment resulted in complete resolution, with notable improvements in mental status. Crusted scabies with nail involvement is extremely rare and may be more likely to develop from initially subclinical infestation sites. It is important to consider this potential presentation, as standard topical treatments may prove ineffective when there is deep nail involvement.