Hakan Erbil

Efficacy and safety of serial glycolic acid peels and a topical regimen in the treatment of recalcitrant melasma

Melasma is a common acquired disorder of facial hyperpigmentation. In this study we investigated the efficacy and safety of a combined treatment regimen including serial glycolic acid peels, topical azelaic acid cream and adapalene gel in the treatment of recalcitrant melasma. Twenty‐eight patients with recalcitrant melasma were enrolled in a prospective, randomized, controlled trial lasting 20 weeks. The patients of the group receiving chemical peels underwent serial glycolic acid peels in combination with topical azelaic acid 20% cream (b.i.d.) and adapalene 0.1% gel (q.i.d., applied at night). The control group received only topical treatment including topical azelaic acid and adapalene. The clinical improvement was assessed with the Melasma Area Severity Index (MASI) at baseline and monthly during the 20‐week treatment period. The results showed a prominent decrease in MASI scores at the end of the treatment in both groups, although the results were better in the group receiving chemical peels (P = 0.048). All patients tolerated the topical agents well with minimal irritation observed in the first few weeks of the therapy. Three patients in the glycolic acid peel group developed a mild‐degree postinflammatory hyperpigmentation with total clearance at the end of the treatment period. Therefore, the present study suggests that combined treatment with serial glycolic acid peels, azelaic acid cream and adapalene gel should be considered as an effective and safe therapy in recalcitrant melasma.

Antioxidant enzymes and lipid peroxidation in the scalp of patients with alopecia areata

Alopecia areata (AA) is an autoimmune inflammatory disease. However, little is known about the alterations in lipid peroxidation and antioxidant enzymes in the scalp of patients with AA. Therefore, the aim of this study was to investigate the status of oxidative stress in the scalp of patients with AA. We measured the levels of thiobarbituric acid reactive substances (TBARS) as lipid peroxidation status, superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) as antioxidant enzymes in the scalp of ten patients with AA and ten control subjects. The levels of TBARS in scalp of patients with AA (3654.1+/-621.2 nmol/g tissue) were significantly higher than those of controls (1210.2+/-188.8 nmol/g tissue) (P=0.002). The levels of SOD (134.8+/-23.8 U/g tissue) and GSH-Px (332.7+/-66.2 U/g tissue) in scalp of patients with AA were also significantly higher than those of controls (63.2+/-8.8 U/g tissue, 112.0+/-18.4 U/g tissue, respectively) (P=0.019, P=0.002, respectively). The mean levels of TBARS, SOD and GSH-Px in early phase of disease were increased 2-fold as compared with late phase of the disease. These results indicate that oxidative status is affected in AA. Lipid peroxidation and antioxidant enzymes may be involved in the pathogenesis of AA. Furthermore, we found high SOD and GSH-Px activities in the scalp of patient with AA. These high levels could not protect the patients against the reactive oxygen species, because lipid peroxidation could not be lowered in AA patients.

Topical nadifloxacin 1% cream vs. topical erythromycin 4% gel in the treatment of mild to moderate acne

Topical antibiotics are the mainstay of therapy in mild to moderate inflammatory acne. Topical erythromycin is one of the most common prescribed topical antibiotics. Nadifloxacin, another topical antibiotic for acne, was recently introduced into the market in our country. In this study, we compared the efficacies and safety of topical nadifloxacin 1% cream and erythromycin 4% gel in acne. A total of 86 patients with mild to moderate facial acne were randomized into two treatment groups. The efficacies of the drugs were assessed by lesion counts. An acne severity index (ASI) was also calculated. In both groups, there was a significant reduction in lesion counts and ASI scores beginning from the first visit at week 4. This reduction continued throughout the 12‐week study period. Both treatments were well tolerated. We conclude that when topically applied, both nadifloxacin 1% cream and erythromycin 4% gel are equally effective and safe treatments for mild to moderate facial acne.

Angiolymphoid hyperplasia with eosinophilia mimicking Bowenoid papulosis

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare, benign condition of unknown aetiology characterized by single or multiple brown-red nodules or plaques, usually occurring in the head and neck region, with a reported predilection for the retroauricular area. ALHE is considered to be a vascular proliferative disease, with marked proliferation of blood vessels lined by ‘‘hobnail’’ endothelial cells in conjunction with a dense inflammatory infiltrate mainly composed of eosinophils and lymphocytes. Involvement of the inguinal region is exceedingly rare, with only a few cases reported in the literature involving the penis, inguinal folds and vulvae. In this report, we describe an unusual case of ALHE, presenting with hyperpigmented brownish to pink plaques on the inguinal folds, scrotum and perineal area, masquerading as Bowenoid papulosis.

Hyperpigmented mycosis fungoides: a case report

982

Norwegian scabies of the legs in a patient with paraplegia

A 54-year-old woman was admitted from a nursing home to our institution with a 2-month history of a pruritic rash unresponsive to oral antihistamines and topical menthol ⁄ camphor lotions. The patient’s medical history was consistent with paraplegia, secondary to spinal trauma that had developed after a traffic accident. Her daughter and three of the nursing home staff also complained of an intermittent, generalized itchy rash that interfered with sleep. A physical examination revealed diffuse, scaly, crusted erythematous plaques on the patient’s lower limbs and excoriated erythematous papules located on the periumbilical and periareolar region, axillae, and flexor surfaces of the wrist and hands (Fig. 1). Paralysis and sensory loss of the lower extremities were also detected. Videodermatoscopic examination of the legs at · 40 magnification (Molemax I, Derma Instruments, USA) revealed numerous triangular and jet aircraft trail structures (Fig. 1). Skin scrapings obtained from crusted lesions yielded huge numbers of mites, eggs and faecal pellets, confirming the diagnosis of Norwegian scabies (NS). Treatment was initiated with overnight and alternating use of topical 5% permethrin lotion and 6% precipitated sulphur ointment over a 2-week period. At the end of the treatment period, the patient was symptom-free, and complete resolution of the lesions was observed. Videodermoscopic examination and control skin scrapings were negative for scabies infestation. NS, or crusted scabies, is a rare and severe form of Sarcoptes scabiei infection, characterized by huge numbers of mites infesting the skin. NS is mostly seen in immunosuppressive conditions including lymphoma, leukaemia, acquired immunodeficiency syndrome and graft-vs.-host disease, and in patients undergoing treatment with immunosuppressants and topical corticosteroids. Failure of cell-mediated immune response has been considered in the pathogenesis of the disease. Neurological impairments, resulting in sensorial deficits and physical disability, such as leprosy, syringomyelia, tabes dorsalis, and cerebrovascular disease, have also been implicated in the pathogenesis of this disease. NS usually manifests as greyish, thick, crusted and scaly lesions as observed in our case. In our patient, the characteristic crusted lesions of NS were strictly confined to the lower extremities, where paraplegia and sensory loss had been detected, while an examination of the rest of the body yielded classical scabies lesions in our patient. We suggest that reduced scratching of the legs secondary to a lack of pruritus in this region, which resulted from neurological impairment, may have contributed to this phenomenon. These findings suggest that scratching may be an effective host mechanism against the development of NS infestation. Barbosa et al. reported a 26-year-old man diagnosed with NS associated with lepromatous leprosy of the upper extremities, which resulted in altered sensibility. Unlike our case, diffuse involvement of the skin with thickened and crusted lesions were observed in that patient, suggesting that a mechanism other than neurological involvement may play a role in the dissemination of NS. To the best of our knowledge, our patient is the second reported with NS associated with paraplegia. The other previously reported case experienced recurrent strokes with limb paralysis secondary to cerebrovascular disease. Recently, digital dermoscopy has been introduced as a useful tool for the in vivo diagnosis of scabies, with high sensitivity and specificity rates. The characteristic triangular structures, as observed in our case, correspond with the anterior section of the mite including the mouth part and the two pairs of front legs. A linear segment observed below the base of the triangle, with a structure resembling the condensation trail of a jet aircraft, is considered to result from small PD

Phenol application to distal nail matrix for the treatment of nail thickening

vulvar hypertrophy, vulvar mass, vulvar edema, draining sinuses, ulceration, or abscess formation. “Knife-cut” ulcers which resemble lacerations are almost pathognomonic of Crohn’s disease although they have been reported in herpetic infections in the immunocompromised and in cutaneous tuberculosis. “Apthous-like” ulcer is the other morphological presentation seen. Vulvar involvement in Crohn’s disease may be by virtue of contiguity, as a direct extension of intestinal involvement, or non-contiguous (metastatic) in which there is no connection between the vulva and the bowel.[6] In a review by Andreani et al., 91% of cases of vulvar Crohn’s disease had metastatic spread, while only 5% had contiguous spread.[4] In the same study, 25% of vulvar Crohn’s disease did not have any intestinal involvement at the time of the vulvar lesion. It is in these cases that making a correct diagnosis becomes difficult. Werlin et al., have reported that vulvar ulcers may precede intestinal manifestations by up to 18 years.[7] Initial stages of vulvar Crohn’s disease can be medically managed. Metronidazole alone or in combination with steroids has been the most effective treatment with a success rate of 87.5%.[4] The optimal recommended dose of metronidazole is 20 mg/kg/day for at least 12 to 36 months.[8] Bilateral pedal paresthesia is a complication reported with long-term metronidazole. Other drugs like sulfasalazine, azathioprine, infliximab, and thalidomide have been used with varied response. Advanced cases may require vulvectomy, but local excision has been reported to show recurrence of the disease.

Coexistence of lichen aureus with familial Mediterranean fever

© 2007 The Authors 1001 JEADV 2007, 21, 977–1010 Journal compilation