Jasna Lipozenčić

Definitions and outcome measures for bullous pemphigoid: recommendations by an international panel of experts

Our scientific knowledge of bullous pemphigoid (BP) has dramatically progressed in recent years. However, despite the availability of various therapeutic options for the treatment of inflammatory diseases, only a few multicenter controlled trials have helped to define effective therapies in BP. A major obstacle in sharing multicenter-based evidences for therapeutic efforts is the lack of generally accepted definitions for the clinical evaluation of patients with BP. Common terms and end points of BP are needed so that experts in the field can accurately measure and assess disease extent, activity, severity, and therapeutic response, and thus facilitate and advance clinical trials. These recommendations from the International Pemphigoid Committee represent 2 years of collaborative efforts to attain mutually acceptable common definitions for BP and proposes a disease extent score, the BP Disease Area Index. These items should assist in the development of consistent reporting of outcomes in future BP reports and studies.

Phototherapy in Pediatric Patients

Abstract: The treatment of children with psoriasis, atopic dermatitis (AD), pityriasis lichenoides, and scleroderma poses a therapeutic problem because all therapeutic options are associated with numerous side effects. Therefore ultraviolet A and B (UVA and UVB) phototherapy is presented as a possible alternative to some of these therapies, primarily topical and systemic corticosteroids, in children. Our results in treating children with phototherapy and psoralen plus UVA (PUVA) bath phototherapy over the past 5 years are reported. UVB therapy (TL01) was used in 20 psoriatic children (6 boys, 14 girls; ages 6–14 years) during the stage of disease exacerbation and in 9 children (3 boys, 6 girls; ages 8–16 years) with pityriasis lichenoides. Combined UVA/UVB phototherapy was applied in 21 AD children (7 boys, 14 girls; ages 4–15 years). Photochemotherapy with local application of a PUVA bath was used in six children (2 boys, 4 girls; ages 9–16 years) with circumscribed scleroderma and in one girl with systemic scleroderma. All children received short courses of phototherapy with either no maintenance or short maintenance. All three therapeutic protocols resulted in a certain degree of improvement in most of the study patients. None of the patients exhibited any early phototherapy side effects. We conclude that phototherapy and PUVA bath are valuable and safe therapeutic options for selected children who do not respond to other treatments.

Pemphigus vulgaris: a review of treatment over a 19-year period

Background Pemphigus vulgaris is an autoimmune blistering disease of the skin and mucous membranes with a high mortality if left untreated.

Oxidative stress and ferritin expression in the skin of patients with rosacea

BACKGROUND Rosacea is a common chronic light-sensitive inflammatory skin disease of unknown origin. The purpose of this work was to determine the parameters of oxidative stress, antioxidative capacity, and the pathophysiologic role of ferritin expression in skin cells of patients with rosacea. OBJECTIVES The investigation consisted of measurements of serum peroxide levels, serum total antioxidative potential levels, and immunohistochemical analyses of ferritin in skin tissue samples. RESULTS Serum peroxide levels were significantly higher and serum total antioxidative potential levels were significantly lower in patients with rosacea than in healthy control subjects (P < .05). Compared with control subjects, the number of ferritin-positive cells was significantly higher (P < .001) in skin samples from patients with rosacea, especially those with severe disease. LIMITATIONS Patients with rosacea in the study were aged 30 to 70 years (average age was 56 years). Younger patients with flushing only were not included according to the request of the ethics committee, limiting the use of diagnostic biopsies only to the necessary cases. CONCLUSION The statistically significant differences in the expression of ferritin, higher peroxide levels, and lower antioxidative potential support the onset of systemic oxidative stress in patients with rosacea.

The diagnostic value of atopy patch testing and prick testing in atopic dermatitis: facts and controversies

We conducted a systematic Medline search of the literature (1998-2008) on the criteria for performing the skin prick test and atopy patch testing (APT) to determine their utility in atopic dermatitis (AD). The skin prick, scratch, and skin patch tests are performed to identify which allergen is causing eczematous skin symptoms in patients with AD, or sneezing, nasal congestion, itchy eyes, wheezing, skin rash, and swelling. Many allergens in foods, drugs, and environmental substances (eg, ragweed and fungus), as well as contact allergens, can elicit eczematous skin reactions after epicutaneous application. Because no gold standard exists for aeroallergen provocation in AD, the APT is currently used to evaluate allergen without comparison with another accurate and reliable method. The APT is presumed to reflect delayed-phase clinical reactions. Even with delayed onset of symptoms (more than 2 hours after food ingestion), APT findings were not consistent among AD children. The APT could be used in children with gastrointestinal reactions to foods as well as AD. After standardization, the APT may provide further diagnostic information in addition to the skin prick test and serum immunoglobulin E values and may be able to evaluate the actual clinical relevance of immunoglobulin E-mediated sensitizations for eczematous lesions. The European APT model used with standardization of allergen concentration and vehicle may provide an important diagnostic tool to select patients for avoidance and for procedures of allergen-specific immunotherapy, but the clinical relevance of positive APT reactions awaits standardized provocation and avoidance testing.

Autoimmune bullous diseases associations

The presence of one autoimmune disorder helps lead to the discovery of other autoimmune conditions. It is thought that diseases in which autoimmunity is a feature tend to be associated together more often than one can ascribe to chance. A variety of diseases have been implicated in the onset of intraepidermal and subepidermal autoimmune diseases. The presence of one autoimmune disease should alert the physician to watch for a second immunologic disorder. A list of autoimmune bullous diseases associations includes autoimmune bullous diseases, pemphigus, pemphigoid, epidermolysis bullosa acquisita, dermatitis herpetiformis (Duhring), linear immunoglobulin A disease, and multiple autoimmune syndrome.

Human papillomavirus male genital infections: clinical variations and the significance of DNA typing

Anogenital human papillomavirus (HPV) infections are the most frequently diagnosed sexually transmitted diseases (STDs) of viral origin. The HPV types associated with such lesions have been studied extensively during the last several years.1,2 HPV-associated genital pathology represents one of the major problems with STDs, due to the high recurrence rate, difficulty in eradication, and the oncogenic potential of some HPV types.3–5 HPV genital infections are also among the most frequent diagnoses made in the STD Out-patient Clinic of the Department of Dermatology and Venereology of the Zagreb University Medical School. The frequency of HPV genital infections ranged from 125 patients in 1991 to 193 patients in 2000.6,7 Generally, the patients with HPV genital infection visit the STD Clinic regularly, and their compliance rate is mostly satisfactory, as opposed to patients carrying the diagnosis of nongonococcal urethritis. The association between certain HPV types and cervical intraepithelial neoplasia is well documented among Croatian women8–11; however, similar studies are very rare.12 During the last few years, different diagnostic tools have been used for the patients with HPV genital infection, including pathohistology.13–15 The results have not been sufficiently satisfactory in certain cases; ie, the answer was not precise enough as to whether the lesion was HPV induced or not. Because of the small sample size that can only be taken for HPV DNA detection from male genital lesions, we used a very sensitive and specific molecular method, the polymerase chain reaction (PCR) with HPV consensus primers. With type-specific primers, we typed HPV types 6/11, 16, 18, 31, and 33. Restriction fragment length polymorphism (RFLP) was applied on HPV 6/11 PCR products to distinguish further between HPV types 6 and 11. This would permit us to evaluate the value of viral detection by means of PCR in case of male anogenital lesions.

Prominent Involvement of Activated Th1-Subset of T-Cells and Increased Expression of Receptor for IFN-Gamma on Keratinocytes in Atopic Dermatitis Acute Skin Lesions

Background: Atopic dermatitis (AD) is an allergic skin disease mediated by antigen-specific IgE and an important role has been ascribed to CD4+ cells (Th cells). The objective of the study was to evaluate humoral and cellular immunological factors in the blood and the skin lesions of AD patients, and to analyze the presence of inflammatory cell-surface markers in blood and skin biopsies. Methods: The parameters for monitoring of 40 AD patients included results of prick test to inhalant allergens and epicutaneous (patch) test to contact allergens; values of total IgE, serum immunoglobulins (IgG, IgA, IgM) and different cell markers in the sera (CD3, CD4, CD8, CD20, CD21, CD23, HLA-DR). We also analyzed the presence of inflammatory cell-surface markers (CD3, CD4, CD8, CD20, CD20, CD1a, CD23, CD29, CD45Ro, IFNγ+ markers) in the biopsies of skin lesions from 10 AD patients and 5 healthy controls (HCs) by immunohistochemical analysis (method of avidin-biotin immunoperoxidase). Results: Beside increased total serum IgE and positive skin tests, a significantly higher percentage of CD23+ cells with lower percentage of CD21+ cells was revealed in peripheral blood of AD patients in comparison to HCs. A positive epidermal expression of the majority of markers of T cells (CD3+, CD4+, CD8+, CD29+, CD45Ro+, IFNγ+) and those of Langerhans’ cells (LCs) (CD1a, CD23+), without those of B cells (CD20+) were noted in AD patients, but no in the skin of HCs. Furthermore, significant difference was also found between the two groups for increased expression of CD3, CD4, CD8, CD29, CD45Ro, IFNγ+ markers (markers for IFNγ receptor) and higher intraepidermal CD23+ LCs and intradermal CD1a+ LCs in AD skin lesions. Conclusions:The obtained results suggest involvement of various humoral factors with increased production of IgE and cooperation between Th subsets and LCs, with higher production of related cytokines, and disturbed cellular immunity, including epidermal LCs with IgE receptors of high and low affinity in AD. The annotation of activated Th1 cells with increased producing of IFNγ in acute AD skin lesions is notable, and might lead to IFNγ binding to keratinocytes and consequently inflammatory skin changes in the disease.

Interest of the association retinaldehyde/glycolic acid in adult acne

Background  Topical retinoids have been successfully used in the treatment of acne vulgaris but may induce irritation when used twice daily. The association of retinaldehyde (RAL) with glycolic acid (GA) have complementary activities, which could be of interest for adult women with acne because of a better tolerance/efficacy ratio. The aim of this study was to evaluate the tolerance and the efficiency of RAL (0.1%)/GA (6%) in adult women with acne when used alone or in combination with their usual acne products except retinoids.

Will nonablative rejuvenation replace ablative lasers? Facts and controversies

Since the early 1980s, the field of skin rejuvenation has evolved rapidly. Traditional ablative resurfacing with carbon dioxide and Er:YAG lasers offered dramatic improvement of the skin tone and texture, but prolonged postoperative period and an increased risk for side effects and complications were unacceptable for the majority of patients. It prompted the development of nonablative lasers and non-laser systems, which stimulate dermal neocollagenesis without epidermal disruption, and therefore, produce less adverse effects with little or no healing time. Recently, fractional nonablative and ablative lasers have been introduced, employing a completely new concept of fractional photothermolysis, which ensures high efficacy and fewer risks. Ablative laser resurfacing still remains the gold standard for treating advanced and severe photoaging providing excellent results in experienced hands. Alternatively, ablative fractional resurfacing can be used, with the results, which are comparable to fully ablative lasers with better standard of safety. Nonablative resurfacing is ideal for patients under the age of 50 years with minimal facial sagging, and for those who are unwilling to undergo expensive and demanding ablative procedures. It can be concluded that the key of therapeutic success is in proper patient selection, setting appropriate expectations and combining different rejuvenation technologies with other therapeutic modalities, such as botulinum toxin and fillers.