Ismaël Maatouk

Fractional laser for vitiligo treated by 10,600 nm ablative fractional carbon dioxide laser followed by sun exposure.

Vitiligo is an acquired disorder of the skin and mucous membranes. Many patients with vitiligo remain in the refractory state despite the availability of numerous potential treatments. To the best of our knowledge, only one trial considers ablative fractional CO2 laser in the treatment of vitiligo.

Diabetic neuropathy and Nd-YAG (1064 nm) laser for onychomycosis: be careful

purpuric papules, nodules and plaques. Laboratory tests: serum albumin 27.3 g/L (40–55); urine analysis, protein1+; Bence Jones proteinuria, weak positive; Quantitative immunoglobulins, IgA 25 g/L (0.82–4.53) and IgM 0.45 g/L (0.46–3.04); Serum protein electrophoresis, albumin 41.5% (46.6–62.6), c-globulin 34.8% (11.6–24.4); Serum immunofixation, light chain amyloid with Kappa and Lambda were positive. Additional examination: Cardiac ultrasonography showed expansion of both atrium, LADi (Left atrial diameter)39 (50 9 44) mm/m. The left ventricle was thickened and there was an enhanced myocardial echo. Aortic valve had degenerative diseases. A small area of pericardial effusion was found, and the sonogram showed a dark liquid area. Scrotum ultrasonography revealed that the scrotal wall was thickened with the depth of 2.15 cm, and there was an enhanced strip echo. A dark liquid area could be found in the scrotum, which suggested a small area of biateral hydrocoele effusion. Bone marrow aspirate and biopsy revealed plasmacytosis of 12% (<2%). Skin biopsy was performed, which showed amorphic acidophilic material in superficial and deep dermis (Fig. 2). PSA leading to a high mortality rate and the median survival is less than 6 months for symptomatic patients without specific treatment. Prognosis is determined by the presence and severity of heart involvement and response to therapy. Left atrial enlargement was an independent predictor of total long-term survival, with an almost 2.5-fold increase in the risk of overall mortality, even after adjusting for other important and independent predictors of mortality in this high-risk population. Our patient presented with multiorgan affected, pathological examination led eventually to the diagnosis. Analysis of his laboratory measurements and additional examination especially the cardiac parameter, we identify that the patient with the highest risk of early mortality. Until we reported this case, at least 13 months after the initial diagnosis, the patient was still alive without treatment, but presented with generalized oedema and poor condition.

Nicolau livedoid dermatitis occurring after sclerotherapy

A 53-year-old woman presented with a lesion within the left popliteal fossa 2 weeks following varicose vein sclerotherapy. Two days following the sclerotherapy (polidocanol 1%), she complained of pain within the injection site that did not respond to anti-inflammatory or analgesic medications. Clinical examination illustrated a livedoid lesion with geographic margins and a necrotic center at the site of injection of polidocanol (Panel). A duplex ultrasound documented occlusion of a small saphenous vein (SSV) tributary and incompetence within the proximal portion of the SSV proper. A diagnosis of Nicolau livedoid dermatitis (NLD) was rendered. Treatment included low-molecular weight heparin (LMWH; enoxaparin 40 mg/day), a class IV topical corticosteroid (clobetasol propionate), and a gradient compression stocking. The pain abated over several days and 10 days later the lesion resolved. NLD is a rare cutaneous reaction at subcutaneous or intramuscular injection sites characterized by intense pain followed by a violaceous livedoid plaque that may evolve to skin necrosis. It often occurs in weak areas (e.g. inguinal folds, popliteal fossa) and is due to direct arterial embolism, ischemia after perivascular compression of the injected product, and/or reflex arterial vasospasm due to para-neural or para-arterial injection. The latter mechanism was thought to underlie the pathogenesis of NLD in our subject. Until recently, it has been rarely reported with varicose vein sclerotherapy.1–4 Treatment of NLD is not well specified. Usual therapy relies on anticoagulants and prednisone.2 We used LWMH and a local potent corticosteroid, not prednisone as is the usual practice,1–4 with an excellent result. Thus, an appropriate topical glucocorticoid agent could replace systemic steroid therapy when treating a focal lesion of NLD. Images in Vascular Medicine

Depilatory laser: a potential causative factor for inguinal hyperhidrosis: Report of three cases

Abstract Hyperhidrosis has recently been described as a novel adverse effect of laser-assisted hair removal in the axillary area. Inguinal Hyperhidrosis (IH) is a localized and, typically, a primary form of hyperhidrosis affecting the groin area in individuals before age 25. IH has been reported in the literature after traumas and as a dysfunction of the central sympathetic nervous system. To the best of our knowledge, IH has never been reported as secondary to laser-assisted hair removal. Herein, we report three cases of IH following depilatory laser of the inguinal zone. Three female patients with no relevant medical history presented with the complaint of excessive sweating in the inguinal area after undergoing full bikini depilatory laser sessions. Although never described before, depilatory laser seems to trigger the occurrence of hyperhidrosis in the inguinal zone.

Etoricoxib‐induced toxic epidermal necrolysis

phages. We report a case of a 65-year-old man with Down syndrome (DS) presenting with multiple cutaneous lesions, which developed over the course of several months on his upper and lower limbs. These had been noticed by his caregivers. He was asymptomatic and otherwise well apart from learning difficulties in keeping with a diagnosis of DS. On examination, there were approximately 20–30 clinically similar lesions on the anterior and posterior aspect of his upper arms and lower legs (Fig. 1). The lesions measured up to 1 cm in diameter and were red or purple in color and firm. They appeared to be within the dermis with a positive dimple sign. Baseline biochemistry, glucose, cholesterol, immunoglobulins, protein electrophoresis, erythrocyte sedimentation rate, hepatitis and HIV serology, and a chest radiograph were within normal limits. A full blood count demonstrated a long-standing mild lymphopenia of 1.4 9 10/L (normal limits 1.5–4.0 9 10/L) likely related to his DS. Owing to the number of lesions and short clinical history, two lesions were biopsied, one on the shoulder and one on the leg, and pathology confirmed simple dermatofibromas (Fig. 2). Multiple eruptive dermatofibromas usually refers to the development of between four and eight dermatofibromas over a period of about four months, thought to be linked to immunodeficiency or autoimmune conditions. To our knowledge, there is only one previous report of patients with DS developing multiple dermatofibromas in the literature, and this report included one patient with DS who was immunosuppressed with methotrexate. The remaining two patients were found to have hypercholesterolemia and thyroid disease, both reported in association with multiple eruptive dermatofibromas. Our patient had a very mild lymphopenia but was otherwise not immunosuppressed and had no other history of autoimmune conditions. It is plausible that the development of eruptive dermatofibromas in this case is related to an altered immune system in keeping with the diagnosis of DS. It is known that patients with DS have altered antibody and cell-mediated immunity and altered phagocytic function leading to difficulty fighting infection and an increased frequency of cancers. For completeness, we therefore screened for a new immunodeficiency or malignancy, as outlined above. Consequently, multiple or eruptive dermatofibromas may be added to the list of dermatological disorders that appear with increased frequency and/or are more severe in patients with DS, including atopic eczema, seborrheic eczema, vitiligo, alopecia areata, elastosis perforans serpiginosa, psoriasis, syringomas, and milia-like calcinosis cutis.

Human papillomavirus prevalence in the oral cavity of men who have sex with men: a study of its first from Beirut, Lebanon.

Background: Human papillomavirus (HPV) infection is the most common sexually transmissible viral infection worldwide. HPV is highly prevalent in sexually active men who have sex with men (MSM). The main objective of this study is to assess HPV prevalence in the oral cavity of MSM from Beirut, Lebanon. Methods: From November 2015 to January 2016, 42 MSM were recruited using respondent-driven sampling and provided oral samples for HPV DNA and for linear array testing to detect HPV type. Results: In total, 28 (66.67%) HIV-negative and 14 (33.33%) HIV-positive MSM were included. Overall, HPV prevalence in the oral cavity was 10% (95% CI 0.93-19.07) among all participants, but there was no statistical difference according to HIV status. The HPV type was exclusively HPV-6. Conclusions: These findings did not find an urgent need for routine HPV prevalence and screening for cancers in the oral cavity of a MSM group in Lebanon; however, they confirm previous findings about geographic variations in HPV prevalences.

History of Podophyllin.

Podophyllotoxin is the principal active compound from the resin mixture known as podophyllin. It is obtained from 1 of the 3 species of Podophyllum: P peltatum (from North America), P hexandrum (from India; previously referred to as P emodi), or P pleianthum (from Taiwan). Podophyllum peltatum is an indigenous, North American, herbaceous perennial flowering in May and bearing fruit in late summer or fall. Other common names include May apple, mandrake, Indian apple, wild lemon, and ducks foot. One of the first recorded medicinal uses of this agent, mentioned in the pre-Conquest English medical book the Leech Book of Bald (AD 900950), was in a salve for cancer.Catesby, in his Natural History of the Carolinas (1731), described the May apple and noted that the root is “said to be an excellent emetic and is used as such in the Carolinas.” Jacques Cartier reported usage of this agent both as a mortal poison and as a topical antidote for snake venom. The root was considered both a medicine and a poison by the North American Indians, and it was used as a suicide agent among the Iroquois. John Uri Lloyd stated that Podophyllum was used by the Cherokees for deafness and as an anthelmintic, and by the Wyandottes and Southern Indians as a cathartic. The early colonists learned of the medical properties of the root from the Indians, and it was used as a cathartic in the first United States Pharmacopoeia (1820). It was listed until the 12th revision (1942), from which it was dropped. Stories of the new American drug spread to England and the continent of Europe.The resin, podophyllin, was first separated from Podophyllum by John King in 1835. With the preparation of podophyllin on a commercial scale in 1850 by Merrell the use of the resin supplanted that of the crude Podophyllum. Between 1863 (4th revision of the United States Pharmacopoeia) and 1942 (12th revision), podophyllin was reported to be a cathartic, purgative, deobstruent, vermifuge, hydragogue, cholagogue, choleretic, and expectorant. It was recommended, either alone or in combination with other herbs, for diseases of the liver and kidneys, for scrofula, syphilis, gonorrhea, obstructed menstruation, urinary obstruction, dropsy, and coughs. With the increased production of podophyllin, reports of its toxic properties appeared in the literature: pain in the eyes; hyperemia of the iris, cornea, mucous membranes, and eyelids; and erythematous eruptions of the scrotum. Moreover, oral and parenteral administration of podophyllin has been followed by serious results. Topical podophyllin was introduced in 1942 and is still accepted today as an effective treatment for condyloma acuminatum.

Development of multiple nevi and lentigines in a child with Netherton's syndrome treated with narrowband ultraviolet B phototherapy.

A newborn boy presented with skin problems that his mother reported had been present since birth. The patient was born at term to consanguineous parents (seconddegree cousins). His parents described generalized exfoliative erythroderma (Fig. 1), rapidly complicated with septicemia in his first week of life. His medical record showed continuous diarrhea and a difficulty to thrive. After that, the patient did not show for his follow-up visit. He returned to our department at the age of 2 years. On physical examination, his hair was brittle and dry, with partial alopecia. His skin condition had not improved (Fig. 2). On examination of the hair under polarized light, trichorrhexis invaginata was noted. Genetic examination revealed a mutation of the gene SPINK5, mapped to chromosome 5q32. The diagnosis of Netherton syndrome was made. The patient has a phototype III. The patient’s skin condition had worsened with continuous generalized activity, refractory to topical corticosteroids, emollients, and topical pimecrolimus. We proposed narrow band ultraviolet B (NB-UVB) phototherapy. The starting dose was 350 mJ/cm, and at each visit, the dose was increased by 20% until 1700 mJ/cm (maximum dose). The patient noted a marked improvement after 18 sessions. Since then, the patient was lost to follow-up. He returned after four years for follow-up, when he was 6 years old. As he responded very well to UVB with fewer flares and less pruritus, he continued to have the sessions without medical supervision. When reviewing his record, we noticed that he has done a total of 170 sessions of NB-UVB phototherapy, with a cumulative dose of 240 J over three years. We immediately asked the patient to stop the sessions and to get a skin and ophthalmological checkup. On physical examination at that time, there was neither erythroderma nor ichthyosis. Nevertheless, over time he has developed multiple pigmented lesions all over his body. We counted more than 100 lesions over his chest and abdomen (Fig. 3). One of them was excised. The histopathologic features revealed a lentigo. Netherton syndrome is a rare autosomal recessive disorder of the skin, hair, and immune system, manifested by ichthyosis linearis circumflexa or congenital ichthyosiform erythroderma, trichorrhexis invaginata, and atopy. The underlying genetic defect of Netherton syndrome has been mapped on chromosome 5q32, and the affected gene encoding a serine protease inhibitor has been reported to be SPINK5. SPINK5 encodes a Kazal-type serine proteinase inhibitor, designated LEKTI. The possible role of LEKTI and its mutations in cutaneous neoplasia was mentioned by Krasagakis et al. On the other hand, the development of cutaneous neoplasm may be causally related to congenital ichthyosis. This was recorded in patients with keratitis–ichthyosis– deafness syndrome. Multiple skin carcinomas were also reported in patients with Netherton syndrome. Phototherapy (psoralen + UVA [PUVA] and NB-UVB) is a well-known treatment modality in the long-term management of psoriasis. It can also be used in various dermatological conditions. Among them, ichthyosis can be treated with phototherapy. Short-term side effects are commonly known (e.g., erythema). Long-term and dosedependent side effects include an increased risk of developing accelerated skin aging, actinic keratosis, atypical

Isotretinoin-induced urethritis versus non-gonococcal urethritis in a man who has sex with men: an open debate

This is the case of a young man presenting with urethritis despite a negative infectious work-up. Careful history taking elucidated a strong correlation between symptom onset and a recent dose escalation of isotretinoin for treatment of his refractory cystic acne. The urethral symptoms quickly resolved with dose reduction, suggesting urethritis as a rare adverse reaction of isotretinoin.

Neisseria meningitidis urethritis: synthesis of published data

crown vessels. Systemic amyloidosis could exceptionally present with translucent papules around the eyes, which show at dermoscopy hemorrhagic spots invisible to the naked eye. Although an isolated report, our observation could be useful for the clinician to raise the suspicion of a rare disease as CM through dermoscopy. More dermoscopy–histopathology correlation studies are desirable to understand why the orange color, once thought to be specific of cutaneous granulomatous diseases, and now progressively expanding its spectrum toward different diseases such as lymphoproliferative disorders and deposit diseases.