Ersin Aydin

An unusual garlic burn occurring on an unexpected area

A 24-year-old otherwise healthy woman presented with an itchy, burning, erythematous lesion located over her neck. She had applied crushed raw garlic over her neck for about 5 h following a sore throat. On dermatological examination an erythematous demarcated area with eruption, patchy squamous and vesicular lesions were present over the submandibular region (figure 1). On the basis of history …

Arterial Stiffness Without Other Inflammatory Markers May Not Accurately Provide Information to Clinicians About the Severity of Psoriasis

We read the article ‘‘Aortic Arterial Stiffness is a Moderate Predictor of Cardiovascular Disease in Patient with Psoriasis Vulgaris’’ by Balta et al with interest. This well-presented study investigated the relationship between arterial stiffness and high-sensitivity CRP (hsCRP) in patients with psoriasis. The authors concluded that arterial stiffness correlated positively with age, sex, body mass index, diastolic blood pressure, and hsCRP level. These findings provide further evidence of a link between premature atherosclerosis and psoriasis. Arterial stiffness represents vascular damage and is a measure of the degree of atherosclerosis. Arterial stiffness has received increased attention because of its role as an independent predictor of cardiovascular disease and relationship to the metabolic syndrome. Increased arterial stiffness is a common indicator of atherosclerotic involvement of the vascular structure, indicating cardiovascular diseases, stroke and renal diseases, as well as total mortality. It can also be affected by atherosclerotic risk factors such as smoking, alcohol consumption, hypercholesterolemia, hypothyroidism, plasma homocysteine, and serum gamma-glutamyltransferase (GGT). Furthermore, in recent studies, plasma homocysteine concentrations were found to be significantly higher in patients with psoriasis. In this point of view, in the present study, the authors did not mention about some of the factors affecting arterial stiffness, including alcohol consumption, hypothyroidism, plasma homocysteine, and serum GGT levels. If the authors had described these factors, they would have obtained different results. More severe psoriasis was significantly associated with higher prevalence of concomitant disease, greater involvement (nails, scalp, palm soles), and poorer quality of life. Severe psoriasis is also associated with increased risk of cardiovascular mortality and morbidity due, in part, to shared immune–inflammatory mechanisms. In our opinion, it would have been better if the authors of the present study had included information about disease severity (mild, moderate, or severe), mean Psoriasis Area and Severity Index, and presence of psoriatic arthritis. In conclusion, arterial stiffness was shown as a noninvasive method to assess endothelial dysfunction in clinical practice, which is affected by many factors. Arterial stiffness itself without other inflammatory markers may not provide information to the clinicians about the endothelial inflammation on psoriasis. So we believe that it should be evaluated together with other serum biochemical markers.

Could aluminum be a new hidden allergen in type 1 hypersensitivity reactions when used as a drug additive

Medications usually contain numerous additives and preservatives. Some of these agents have been reported as causative factors in adverse drug reactions, including asthma attacks, urticaria and/or angioedema, and even severe systemic anaphylaxis. Moreover, allergens such as additives and preservatives may be hidden as they are not easily identified during etiological investigations.

Efficacy of Omalizumab in a Patient with Angioedema Clinically Resembling a Hereditary Angioedema.

Dear Editor: A 20-year-old man was referred to our allergy and immunology department with complaints of recurring angioedema attacks, lasting 48~96 h, on his lips, eyes, and face, as well as swelling of the extremities and testicles during the last 1 year. Regular use of antihistamine and steroid drugs was generally ineffective against the frequency and severity of the angioedema attacks. He experienced recurrent abdominal pain attacks during the evaluation period. He was hospitalized in another center with a prediagnosis of familial Mediterranean fever; however, that diagnosis was excluded later. Urticarial lesions were not observed during the angioedema attacks. He did not have a history of drug or food allergy, and no specific family history for angioedema was reported. A detailed evaluation for arthritis and rheumatologic disorder was done but no specific findings were found. Furthermore, rheumatologic markers were negative (IRB No. 1491-21-16/1539). Routine laboratory tests for the management of chronic urticaria-angioedema and for anti-nuclear antibody, rheumatoid factor, anti-cyclic citrullinated peptide antibodies, C3, and C4 were within the reference limits. The total immunoglobulin E (IgE) value was 213 IU/ml, and the C4 levels during the attacks were normal. However, C1 esterase inhibitor was measured to be 28.3 mg/dl (reference, 32~39 mg/dl), and hereditary angioedema (HAE) was clinically considered. Danazol treatment up to 400~600 mg/day was started; however, no significant benefit was observed. As the 1,000 U C1 esterase inhibitor administered during the attacks (Cetor, 500 U; Sanquin, Amsterdam, The Netherlands) was ineffective, the diagnosis of HAE was excluded. Because the urticarial complaints started in addition to the angioedema complaints, our patient received 300 mg omalizumab (Xolair 150 mg; Novartis Pharmaceuticals, Basel, Switzerland) subcutaneously every 4 weeks according to conventional asthma treatment protocols. He was treated with omalizumab for 6 months. His angioedema attacks ceased completely within 2 weeks after the start of this treatment. Except for the very short period for the formal procedures required for the procurement of the drug, he had no other complaints during the 6 months follow-up. In randomized, placebo-controlled trials, omalizumab was shown to have excellent efficacy in chronic spontaneous urticaria1. A growing number of case reports and series suggest that anti-IgE treatment may also be beneficial for patients with physical urticarias and chronic angioedema. Recently, omalizumab treatment for inducing and maintaining long-term remission in patients with severe chronic urticaria has been demonstrated2. Unfortunately, for such disorders with complex and unclear etiology, no randomized placebo-controlled trial has been performed yet3. The mechanism of omalizumab activity in angioedema is currently not well defined. However, several mechanism may be considered. Even if the pathogenesis of angioedema in the present case may not be directly mediated by IgE, omalizumab may be effective through an unidentified and indirect anti-inflammatory manner. Sayama et al.4 reported that the stimulation of high-affinity IgE receptor (FceRI) in human umbilical cord mast cells causes substantial change in the expression of many genes, including Interleukin-11 (IL-11), and at least 30 other cytokines and chemokines and several adhesion molecules involved in potential interactions with T cells, B cells, or dendritic cells. Another work, in which the anti-inflammatory activity of omalizumab was mediated, has provided evidence showing the efficacy of this drug in idiopathic angioedema through eosinophil apoptosis induction and downregulation of the inflammatory cytokines IL-2 and IL-135. In conclusion, it seems that therapeutic efficacy spectrum of anti-IgE treatment comprises many allergic disorders with unknown etiology, including angioedema.

Identification of anger and self-esteem in psoriasis patients in a consultation-liaison psychiatry setting: a case control study

ABSTRACT Objective: Psoriasis is one of the most common chronic skin diseases, which has a negative impact on the interpersonal relationship and psychosocial well-being. Therefore, psoriasis may lead to a decrease in the self-esteem of the patients. Increased level of anger often accompanies patients with psoriasis. Our aim is to investigate the relationship of anger, anger expression style and level of self-esteem in patients with psoriasis and to determine whether duration and severity of disease affects anger, anger expression style and level of self-esteem. In addition, we aimed to compare the level of self-esteem in patients with early and late onset of psoriasis. Methods: Eighty-five patients with psoriasis and 86 healthy controls were included in the study. Severity of disease was calculated with Psoriasis Area and Severity Index (PASI). The patients were classified as early-onset (age < 20 years) and late-onset psoriasis (age ≥ 20 years). Duration of disease and socio-demographic characteristics were recorded. State-Trait Expression Inventory for Anger (STAXI) and Roserberg Self-esteem Scale (RSES) were used for determining anger, anger expression style and self-esteem. Results: Trait anger, state anger and anger-in scores were statistically significantly higher in patients with psoriasis (p < .05). Anger-out and anger-control scores were similar in both groups. RSES scores were statistically significantly higher in the psoriasis group (p < .05). There was a negative weak statistically significant correlation between RSES and anger-control scores (r = −0.246, p = .027). A positive, weak, statistically significant correlation was found between RSES scores and anger-out scores (r = 0.224, p = .045). A positive, mild, statistically significant correlation between duration of the disease and anger-in scores (r = 0.277, p = .027) was detected in patients with psoriasis whereas no statistically significant correlation between the other parameters and duration and severity of the disease was detected. No significant difference was detected when patients with early- and late-onset psoriasis were compared in terms of self-esteem (p = .722). A positive, mild, statistically significant correlation between duration of the disease and anger-in scores (r = 0.277, p = .027) was detected in patients with psoriasis whereas no statistically significant correlation between the other parameters and duration and severity of the disease was detected. Conclusion: Reduced self-esteem and increased anger levels are remarkable in psoriasis patients. While evaluating and arranging treatment of psoriasis patients, it should be considered that psoriasis is not only a dermatological disease, but also a disease resulting in reduced self-esteem and increased anger level; therefore dermatologic and psychiatric approaches should be taken with the patients.

A case of overlapping of Sturge Weber syndrome-Klippel Trenaunay syndrome and ophthalmological findings

Yazışma Adresi/Address for Correspondence: Dr. Yakup Aksoy, Gülhane Askeri Tıp Akademisi Haydarpaşa Eğitim ve Araştırma Hastanesi, Göz Hastalıkları Kliniği, İstanbul, Türkiye Tel.: +90 553 594 35 36 E-posta: dryakupaksoy@gmail.com Geliş Tarihi/Received: 15.10.2015 Kabul Tarihi/Accepted: 19.02.2016 Öz Gülhane Askeri Tıp Akademisi Haydarpaşa Eğitim ve Araştırma Hastanesi, Deri ve Zührevi Hastalıklar Kliniği, *Göz Hastalıkları Kliniği, **Radyoloji Kliniği, İstanbul, Türkiye Ersin Aydın, Yakup Aksoy*, Ercan Karabacak, Bilal Doğan, Murat Velioğlu**, Kürşat Göker

Erythrocyte zinc level in patients with atopic dermatitis and its relation to SCORAD index

Introduction Atopic dermatitis (AD) is a chronic, pruritic inflammatory disease, characterized by a relapsing-remitting course. The pathogenesis of atopic dermatitis is not completely understood, although the disorder appears to result from the complex interaction between immune abnormalities, genetic and environmental factors. Trace elements are essential for normal functioning of the immune system. Aim To determine zinc levels in serum and erythrocytes of patients with AD using an atomic absorption spectrometric technique and to investigate the relationship between those levels and disease activity. Material and methods Sixty-seven patients and 49 controls were enrolled into the study. The disease severity of AD patients was determined according to the Scoring Atopic Dermatitis (SCORAD) index. We measured zinc levels in serum and erythrocytes by the atomic absorption spectrophotometric technique. Results Erythrocyte zinc levels were significantly lower in AD patients than in the control group (p < 0.001), whereas serum zinc levels did not differ between the groups (p = 0.148). In the AD patient group there was a negative correlation between the SCORAD score and erythrocyte zinc levels (r = –0.791; p < 0.001). Conclusions The negative relationship between disease severity and erythrocyte zinc levels might suggest an immunopathological link between AD progression and intracellular zinc metabolism.

Besinlerle Yapılan Atopi Yama Testinin SCORAD İle İlişkisi

Amaç: Besinlerle atopik dermatit (AD) kliniği arasındaki ilişki tartışmalıdır.Besinlerle yapılan “fresh prick testleri”nin (FPT) özgünlüğünün düşük olması, AD’de çoğunlukla lezyonların geç ortaya çıkması ve buna bağlı anamnezdeki tutarsızlıklar, provokasyon testinin zaman alıcı ve riskli olması, hastalığın fizyopatolojisinde T lenfositlerin oynamış olduğu rol, atopi yama testini (APT: “Atopy Patch Test”) ön plana çıkartmaktadır. Bu çalışmada besinlerle yapılan APT ve FPT’nin hastalığın ağırlığını yansıtan SCORAD indeksi ile olan ilişkisi araştırılmıştır. Gereç ve Yöntem: Çalışmaya Mayıs 2006-Mayıs 2007 tarihleri arasında polikliniğimizde AD tanısı alan, yaşları 2–15 yaş arasında 21’i erkek, 24’ü kız 45 hasta dahil edildi. Tüm hastalara yumurta, süt ve buğday unu ile FPT ve APT uygulandı. Hastalığın şiddeti SCORAD indeksi kullanılarak değerlendirildi. Çalışmanın istatistiksel analizinde SPSS sürüm 11.0. istatistik paket programı kullanıldı. P<0,05 ise istatistiksel olarak anlamlı kabul edildi. Bulgular: Besinlerle yapılan FPT hastaların %32,5’inde pozitif, %67,5’inde negatif olarak bulundu. En yüksek besin FPT pozitifliği %20 ile buğday ununa karşı gözlendi. Besinlere karşı 21 (%56,8) hastada pozitif APT reaksiyonu vardı. Besinlerle en yüksek APT pozitifliği yumurtaya karşı (%54,1) gözlendi. SCORAD indeksi ile besin allerjenlerine karşı FPT pozitifliği arasında anlamlı ilişki gözlenmedi. Aynı şekilde besinlerle yapılan APT ile SCORAD indeksi arasında ilişki saptanmadı. Sonuç: Çalışmamızda besinlerle allerji testleri pozitifliklerinin AD’nin klinik şiddetini yansıtan parametrelerle ilişkisi gözlenmedi. Özellikle besin APT sonuçlarına göre eliminasyon diyeti kararı vermenin uygun olmadığını düşünmekteyiz. (Türk derm 2013; 47: 99-102) Anah tar Ke li me ler: Atopik dermatit, atopi yama test, skin prick test, SCORAD

Pustulosis palmaris et plantaris

A 63-year-old woman presented with multiple painful pustular lesions over both her feet. The patient reported that the lesions used to exacerbate every 1 week in a month for the last 10 years. She claimed to receive several courses of unsuccessful treatment attempts including various medication and off-label drugs. On examination, she had multiple erythematous pustular lesions of 2–7 mm in diameter over the plantar surfaces of …

The role of systemic use of methotrexate on the oxidative stress in patients with psoriasis should be evaluated with a randomized controlled trial

We read the article ‘‘Effect of the systemic use of methotrexate on the oxidative stress and paraoxonase enzyme in psoriasis patients’’ by Kılıc et al. [5] with great interest. In this well-presented study, the relationship between the systemic methotrexate (MTX) treatments and oxidative stress (OxS) and its impact on the total oxidant and antioxidant status were investigated in patients with psoriasis. They found no statistically significant alterations in serum levels of paraoxonase (PON), total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI) before and after the 8-week MTX therapy. The oxidative stress emerging with 8-week MTX treatment is not significantly increased in patients with psoriasis. They suggested that expected reduction in OxS might have been precluded by MTX-induced OxS. Oxidative stress emerges as a result of overproduction of oxygen radicals or inadequate antioxidant defense mechanisms. Oxidative stress has received increased attention because of its pathogenesis of the disease and its complications, e.g., cardiovascular disease and diabetes [4]. It has been shown that OxS plays a role in the pathogenesis of more than 100 disorders, including allergic diseases, inflammatory skin diseases, vitiligo, acne vulgaris, atopic dermatitis, Behcet’s disease, and skin cancers [2]. It can also be affected by other inflammatory dermatological diseases (such as seborrheic dermatitis, atopic dermatitis, acne, irritant contact dermatitis, physical urticaria, rosacea) [2, 7], photochemotherapy and antioxidant supplements. In the present study, we could not find any clinical information regarding whether the patients with psoriasis had other inflammatory skin diseases, usage of antioxidant supplements, treatment of photochemotherapy which possibly affect the redox status. In this point of view, it would be very useful, if the authors provided information about these factors. Furthermore, in recent studies, systemic levels of OxS markers were found to be significantly higher in psoriasis patients than in healthy controls [3, 4]. The psoriasis severity was positively correlated with oxidant molecules and negatively correlated with antioxidant molecules in the serum of patients [3]. For this reason, in the present study if there was a control group consisting of healthy subjects, it would have shown whether there was increased OxS initially. In addition, Sikar Aktürk et al. [7] recently demonstrated that lesional tissue levels of OxS in psoriasis patients were significantly higher than those in non-lesional tissues as well as plasma levels of OxS. They considered increased OxS levels in plasma and tissue to be important element in the inflammatory process in psoriasis. In this point of view, it would be useful if OxS markers were also measured in lesional tissue. If these assessments were made, they would have identified lesional values of OxS parameters before and after the MTX therapy. Methotrexate is an effective systemic treatment agent for psoriasis. It inhibits folate-dependent enzymes which E. Aydin (&) Department of Dermatovenereology, Kasimpasa Military Hospital, Istanbul, Turkey e-mail: drersinaydin@yahoo.com