İdil Ünal

Efficiency of ellagic acid and arbutin in melasma: A randomized, prospective, open-label study

The aim of this study was to compare the effectiveness of gel formulations containing arbutin, synthetic ellagic acid and plant extracts that contain ellagic acid, on patients with melasma. Thirty patients who applied to Ege University Medical Faculty, Department of Dermatology, were included in the study. A signed consent was obtained from each patient prior to study. Patients whose type of melasma was determined via Woods lamp were randomized to groups of arbutin, synthetic ellagic acid and plant extract containing natural ellagic acid. The pigment density of patients was evaluated via Mexameter before and after the treatment. The approval of the Institutional Ethics Committee of Ege University was obtained before the study. Wilcoxon and Kruskal–Wallis tests were used in the statistical analysis. Nine of 10 patients, for whom synthetic ellagic acid was started, completed the study. A decrease in the level of melanin was determined in eight of these nine patients (P = 0.038). A significant decrease in the level of melanin was also determined in all 10 patients who used plant extract containing ellagic acid (P = 0.05). A significant response was obtained from all of 10 patients who used arbutin. The difference between pre‐ and post‐treatment levels of melanin was statistically significant (P = 0.05). Formulations prepared with plant extracts containing ellagic acid was found effective on melasma, similar to the formulations containing synthetic ellagic acid and arbutin. This material that is not yet being used widespread commercially on melasma could be an effective alternative for treatment of melasma.

Atypical melanosis of the foot showing a dermoscopic feature of the parallel ridge pattern.

A 62‐year‐old male Turkish patient had a pigmented lesion on the sole with a 10‐year history. It was an asymmetrical macular lesion with an irregular border and irregular brown pigmentation and had a diameter of 1.2 cm × 1.7 cm.

Skin diseases in Turkish renal transplant recipients.

Background  Organ transplant recipients are predisposed to a variety of cutaneous complications due to immunosuppressive therapy. We aimed to determine the prevalence and the clinical spectrum of skin diseases in renal transplant recipients (RTRs).

Is it necessary to have routine blood tests in patients treated with isotretinoin

Objectives: Several side effects can be observed from isotretinoin use, which has been used in acne therapy for years. In this study, the side effects of isotretinoin on skin and mucosa, blood test changes and their relation with total dose were investigated in patients who used equal doses of isotretinoin. Materials and methods: A total of 91 outpatients with acne vulgaris (57 females and 34 males; age range 17–28 years, mean 21±2.19 years) were enrolled in this study. Skin and mucosal findings and pre‐ and post‐treatment blood tests and their correlation with the total dose were investigated. Students t‐test and the Mann–Whitney U‐test were used in the statistical analyses. Results: In all, 89 out of 91 patients completed the study. Cholesterol (p = 0.00), triglyceride (p = 0.00) and low density lipoprotein (LDL) (p = 0.001) levels were found to be significantly elevated. But these values were not over the double of the upper limits. No correlations were found among the total dose and the skin and mucosal changes as well as the blood test results. Conclusion: It is concluded that examination of cholesterol, triglyceride and LDL‐cholesterol should be performed monthly if the initial blood tests are close to the upper limits; otherwise, examinations at 2‐ or 3‐month intervals are sufficient, which would save unnecessary costs.

A case with Stevens Johnson syndrome triggered by combination of clobazam, lamotrigine, and valproic acid treatment

hair follicle. It has been hypothesized that the pathogenesis of trichomegaly is caused by increased terminal differentiation resulting from EGFR inhibition. Many cases of the secondary effects of anti-EGFR therapy have been reported. In 2003, two cases of trichomegaly were described in two patients who received treatment with cetuximab. Another case of trichomegaly was described in a patient who started treatment with gefitinib. In 2005, a woman who was given cetuximab showed a marked increase in the length of her eyelashes after 5 months of treatment. One month after stopping cetuximab, the eyelashes returned to their normal length. One case of hypertrichosis of the chest has been reported in association with anti-EGFR therapy. In July 2006, a prospective study of the side-effects of cetuximab or erlotinib treatment in 30 patients was published. Changes in hair growth were found in 18% of the patients treated with cetuximab and in 30% of the erlotinib group. Recently, a case of trichomegaly of the eyebrows and eyelashes and severe hypertrichosis of the face has been described in a patient treated with cetuximab. Our case is the first description of simultaneous facial hypertrichosis and trichomegaly of the eyelashes in a patient receiving erlotinib. Certain commonly used medicines are known to cause hypertrichosis (testosterone, danazol, anabolic steroids, corticoids, cyclosporine, streptomycin, penicillamine, suramin, minoxidil, phenytoin, interferon, psoralens) and trichomegaly of the eyelashes (cetuximab, interferon-2b, cyclosporine, bimatoprost, gefitinib). To these, we should add erlotinib, as anti-EGFR therapy is increasingly being used. Gemma Márquez, MD Enrique Herrera-Acosta, MD Isabel Vidal, MD Loida Galvany, MD Maribel Iglesias, MD Pablo Umbert, MD Barcelona, Spain

Effective topical delivery systems for corticosteroids: dermatological and histological evaluations

Abstract Atopic dermatitis (AD) is a chronic and relapsing skin disease with severe eczematous lesions. Long-term topical corticosteroid treatment can induce skin atrophy, hypopigmentation and transepidermal water loss (TEWL) increase. A new treatment approach was needed to reduce the risk by dermal targeting. For this purpose, Betamethasone valerate (BMV)/Diflucortolone valerate (DFV)-loaded liposomes (220–350 nm) were prepared and incorporated into chitosan gel to obtain adequate viscosity (∼13 000 cps). Drugs were localized in stratum corneum + epidermis of rat skin in ex-vivo permeation studies. The toxicity was assessed on human fibroblast cells. In point of in-vivo studies, pharmacodynamic responses, treatment efficacy and skin irritation were evaluated and compared with previously prepared nanoparticles. Liposome/nanoparticle in gel formulations produced higher paw edema inhibition in rats with respect to the commercial cream. Similar skin blanching effect with commercial creams was obtained via liposome in gels although they contain 10 times less drug. Dermatological scoring results, prognostic histological parameters and suppression of mast cell numbers showed higher treatment efficiency of liposome/nanoparticle in gel formulations in AD-induced rats. TEWL and erythema measurements confirmed these results. Overview of obtained results showed that liposomes might be an effective and safe carrier for corticosteroids in skin disease treatment.

Hobnail haemangioma: dermatoscopic findings facilitating the differential diagnosis.

A 58-year-old man presented with a single asymptomatic skin lesion on his upper back. The lesion had appeared as a small red papule and gradually enlarged in a year. He was otherwise healthy. On physical examination, a red-violaceous coloured plaque, 15 · 20 mm in size, showing a papillomatous raised centre and a brownish hue at the periphery (Fig. 1a). On dermatoscopy, there were lagoon-like areas that were partly circumscribed and partly seen as homogenous red areas. Linear white structures surrounding these lagoon-like areas were prominent. A delicate pigmented network was seen at the periphery (Fig. 1). Histological examination of a biopsy taken from the lesion showed a biphasic growth pattern, with dilated vascular spaces on the surface and narrower vascular spaces in the deeper parts of the dermis. Neoplastic endothelial cells with hobnail cytomorphology, particularly evident on the superficially located vascular channels (Fig. 2a), did not show any cytological atypia or mitotic activity. Prominent lymphocytic infiltration and slight fibrosis were present. A scattered haemosiderin deposition was seen throughout the mid dermis after staining with Prussian blue. Immunohistochemical analysis showed that the endothelial cells lining the vascular spaces were positive for CD31 (Fig. 2b). In some parts of the periphery of the main lesion, there was acanthosis with elongated rete ridges and slight lentiginous hyperplasia, and hyperpigmentation of the basilar layer (Fig. 2c,d). Based on the histopathological findings, the lesion was diagnosed as a hobnail haemangioma (HH). The originally reported characteristic targetoid appearance of HH has been shown to be variable, being an angiomatous ⁄ pigmented, nontargetoid, flat, or exophytic lesion. The lesions are often misdiagnosed, with diagnoses including haemangioma, angiokeratoma, melanocytic naevus, melanoma, dermatofibroma and even insect-bite reaction. Dermatoscopy, a noninvasive technique for the evaluation of pigmented skin lesions, may be helpful in such cases.

Facial angiofibromas of tuberous sclerosis: successful treatment with podophyllin

Editor Tuberous sclerosis is a rare dominantly inherited neurocutaneous syndrome characterized by hamartomas in many organs particularly skin, brain, kidney, heart, and eyes.1 Facial angiofibromas are one of the major cutaneous manifestations of tuberous sclerosis occurring in about 75% of the patients.2 They often appear at puberty and then remain unchanged. Clinically, they appear as 0.1–1.0 mm in diameter, reddish, dome-shaped smooth telangiectatic papules on the face. They may lead to cosmetic and psychological problems. Here, we report a patient who had multiple facial angiofibromas treated successfully with podophyllin 25% solution. A 27-year-old woman presented with a 15-year history of skin-coloured papules on the face. Dermatological examination revealed numerous pink to red, domed-shaped papules 0.5–2.0 mm in diameter symmetrically distributed on the cheeks, nasolabial folds, chin, forehead, and perioral area (Fig. 1). She also had multiple ash leaf macules on her trunk, Koenen tumours on the toes, and a shagreen patch in the lumbosacral region. Complete blood count, erythrocyte sedimentation rate, liver, renal function tests, chest X-ray, abdominal ultrasonography, thorax, and abdominal computerized tomography were normal. Asymptomatic cortical and subcortical tubers on bilateral frontal, occipital, and parietal regions detected at magnetic resonance imaging of brain. Podophyllin (25%) extract in benzoin tincture was applied only to the surface of facial angiofibromas by means of haematocrit pipet. She thoroughly washed her face with soap 4 hours after application. We observed flared erythema on the papules followed by superficial necrosis that healed within a few days. The application was repeated once monthly for 3 months while the papules were flattened (Fig. 2). There were no side effects except slight burning sensation. All treatment was well tolerated by the patient, and there was no recurrence at the end of a year of follow-up. The treatment of facial angiofibromas has been a problem because of the multiplicity of the lesions and the presence of the lesions at anatomically difficult sites such as nasolabial folds, chin, upper lip, nose, and periorbital areas. Several treatment modalities causing non-selective destruction of tissue such as curettage,3 dermabrasion,4 chemical peeling,3 cryotherapy,5 electrosurgery,6 excision,4 and lasers7–9 have been used for the treatment with

A case of juvenile pityriasis rubra pilaris: could varicella be an aetiological agent?

Pityriasis rubra pilaris (PRP) is characterized by follicular erythematous papules and diffuse erythematous plaques with pityriasiform scale. However, the precise aetiology is not known; genetic factors, human immunodeficiency virus (HIV) and other infections are thought to be involved. A 7-year-old girl was admitted to our clinic with a 10-day history of fever and erythematous and squamous lesions on the face, trunk and limbs. The child had been diagnosed with varicella infection 10 days before the development of these lesions. On physical examination, bilateral ectropion, erythema and oedema on the face, and diffuse follicular erythematous papules on the trunk and limbs were seen (Fig. 1a). There were also a few crusted varicella lesions on the arms. The oropharynx and tonsils were hyperaemic. Histological examination of a skin biopsy found superficial thick orthokeratosis, parakeratotic shoulders and expansion of the follicle pores on the keratinous layer, keratin plugs, and epithelial irregular psoriasiform hyperplasia. Chest X-ray was normal. A full blood count revealed leucocytosis and thrombocytosis. Liver and renal function tests were normal. Blood, urine and oropharyngeal cultures were negative. Serology for Epstein–Barr, cytomegalovirus, rubella and parvovirus-B19 was negative. As there was no response to topical treatments, methotrexate 7.5 mg weekly was started. The lesions healed within 3 months (Fig. 1b), and the blood count normalised. Several case reports have suggested the role of infection in the aetiology of PRP, but this has not yet been proved. Betlloch et al. reported a case of juvenile acute PRP that developed after Kawasaki s disease, and suggested that PRP may be a reactive exanthema related to a superantigen. In two cases reported by Mohrenschlager et al., the clinical presentation of juvenile PRP developed after infection with group A b-haemolytic streptococcal infection, with presence of infection confirmed by culture in one case. These authors stated that the bacterial superantigens are among the factors that trigger PRP. HIV-related PRP cases have also been reported, and this clinical presentation is considered type 6 PRP. However, the pathogenetic

Radiation recall reaction with anastrozole treatment in breast cancer

Our case is a 68-year-old postmenopausal female patient with suspicion of cancer in the right breast. Cancer was detected by mammography. Partial mastectomy and axillary dissection (in physical examination she had palpable lymph nodes in right axillary) were performed in February 2010. Pathologic staging of the patient was pT2N0M0. Diagnosis was invasive ductal carcinoma, with the tumor 4.5 cm in size, located in the lower inner quadrant; cellular grade, 3; nuclear grade, 2; modified Bloom and Richardson grade, 2. None of the 24 axillary nodes displayed metastatic involvement. Surgical margin was 1 cm. In immunohistochemical analysis, it was reported that estrogen receptor was 20% (+2), progesterone receptor 40% (+3), p53 10%, c-erb B2 (-), and Ki 67 30%. Chemotherapy was not considered due to the patients comorbidities (heart failure, diabetes mellitus) but radiotherapy, and afterward hormonal therapy regimens, were