Maria Simaljakova

The occurrence of dermatophytes in Slovakia

Summary. We have compared the epidemiology of dermatophytoses in Slovakia during the periods 1956–85 and 1986–92. Infections caused by Trichophyton rubrum gradually increased while infections due to Trichophyton verrucosum and Microsporum canis decreased.

A case of linear porokeratosis treated with photodynamic therapy with confocal microscopy surveillance.

Linear porokeratosis (LP) is a rare clinical porokeratosis variant, which typically presents at birth, but can also develop in adulthood. Differential diagnosis includes linear lichen planus, lichen striatus, linear verrucous epidermal nevus, incontinentia pigmenti and linear Dariers disease. An LP lesion has an increased risk of transformation into a squamous cell carcinoma or basal cell carcinoma. The treatment of LP is contradictory and disappointing in general. We present a case of a 16‐year‐old girl with multiple reddish‐brown macules and depressions on the medial aspect of her right arm, localized from the palmar joint up to shoulder region in a linear pattern. We performed confocal microscopy (CLSM) of multiple lesions and a punch biopsy after receiving informed consent to confirm the diagnosis. After diagnosis confirmation, we performed Photodynamic therapy (PDT). Methyl aminolevulinate cream in a 160 mg/g concentration (Metvix crm) was applied under occlusion on the previously cleaned surface of every single lesion for 3 hours. The lesions were subsequently illuminated with a dose of 37 J/cm2 (Aktilite, PhotoCure ASA, Norway). Two months after the first PDT treatment, the patient came for a third PDT session. Treatment follow‐up was performed 6 months after the initial PDT session. A CLSM image proved an increase in the width of the stratum spinosum to 42–48 μm, mild post‐inflammatory changes were also present. Cosmetic and clinical response up to date at the time of last follow‐up (1 year) was satisfactory. No progression was observed.

Footwear contact dermatitis from dimethyl fumarate

Background  Dimethyl fumarate (DMF) is an effective inhibitor of mold growth. In very low concentrations, DMF is a potent sensitizer that can cause severe allergic contact dermatitis (ACD). It has been identified as the agent responsible for furniture contact dermatitis in Europe. The aim of this study was to evaluate patients in Slovakia with footwear ACD associated with DMF, with regard to clinical manifestations, patch test results, and results of chemical analysis of their footwear.

Comparison of hair reduction with three lasers and light sources: Prospective, blinded and controlled study

Abstract Objective: The main goal of this study was to compare the hair removal efficacy of three methods: intense pulsed light (IPL), a combination of IPL and radio frequency (RF) and diode laser (810 nm). Methods: Forty participants were treated within three standardized squares on lateral sites on their legs. Each of these squares was treated twice with an interval of 4–6 weeks. The fourth square was left as a control. A blinded physician counted the hairs in each square before the first treatment and 8 months after the second treatment. Immediate and delayed side effects as well as pain scores were recorded. Results: The mean hair count reduction achieved by the diode laser, IPL and IPL+RF was 49.90%, 39.16% and 47.15%, respectively. This study did not show any serious side effects and the number of side effects was minimal. The mean pain scores for the first and second treatments by diode laser, IPL and IPL+RF were 4.65 and 4.58, 2.43 and 2.53, and 3.95 and 4.03, respectively. At the end of the study, a free hair removal treatment for both legs was chosen by patients in the proportion 20 diode laser, 10 IPL and eight IPL+RF. Conclusions: The combination of RF and optical energies proved its safety and efficacy for hair removal, which is comparable with diode lasers and approximately 20% more efficient than ‘pure’ IPL.

Extensive angiokeratoma circumscriptum - successful treatment with 595-nm variable-pulse pulsed dye laser and 755-nm long-pulse pulsed alexandrite laser

Angiokeratomas are rare vascular mucocutaneous lesions characterized by small-vessel ectasias in the upper dermis with reactive epidermal changes. Angiokeratoma circumscriptum (AC) is the rarest among the five types in the current classification of angiokeratoma. We present a case of an extensive AC in 19-year-old women with Fitzpatrick skin type I of the left lower extremity, characterized by a significant morphological heterogeneity of the lesions, intermittent bleeding, and negative psychological impact. Histopathological examination after deep biopsy was consistent with that of angiokeratoma. The association with metabolic diseases (Fabry disease) was excluded by ophthalmological, biochemical, and genetic examinations. Nuclear magnetic resonance imaging has not detected deep vascular hyperplasia pathognomic for verrucous hemangioma. The combined treatment with 595-nm variable-pulse pulsed dye laser (VPPDL) and 755-nm long-pulse pulsed alexandrite laser (LPPAL) with dynamic cooling device led to significant removal of the pathological vascular tissue of AC. Only a slight degree of secondary reactions (dyspigmentations and texture changes) occurred. No recurrence was observed after postoperative interval of 9 months. We recommend VPPDL and LPPAL for the treatment of extensive AC.

Genital angiokeratomas of Fordyce 595-nm variable-pulse pulsed dye laser treatment

ABSTRACT Background: Angiokeratoma of Fordyce (AF) represents dark red or blue-black papules with a scaly surface located on scrotum, labia majora, and penis. Though usually asymptomatic, bleeding after mechanical trauma and sexual intercourse may occur. AF should be differentiated from malignant melanoma, angiosarcoma, and other pigmented lesions. The treatment, usually asked from patients as the result of anxiety and social embarrassment, should be performed in a non-aggressive manner. Objectives: To determine the safety and effectiveness of 595-nm variable-pulse pulsed dye laser (VPPDL) with a Dynamic Cooling Device (DCD) in the treatment of AF. Methods: Twenty-four patients (22 men and two women) aged 40.88 ± 12.48 years with AF were included in the retrospective study. Lesions located on scrotum, labia majora, and penis were treated with 595-nm VPPDL in the intervals of one to three months. Variable spot, fluence, and pulse-width parameters were used with and/or without DCD skin cooling. Results: AF were successfully removed in all patients in one to seven (mean ± SD = 3.38 ± 2.16) treatment sessions with no permanent side effects or complications such as dyspigmentations or scarring. Recidives were observed in four patients after 0.5–1 year intervals. Conclusions: 595-nm VPPDL with DCD represents an efficient and safe method for the removal of multiple lesions of AF in genital localization.

Management of Infliximab Treated Patients with Psoriasis Based On Infliximab Plasma Levels and Antibodies to Infliximab

Background: Infliximab is the fastest acting biological agent in psoriasis treatment due to the possibility of intravenous administration and a well-conducted induction phase of treatment (week 0, 2, and 6). Another advantage is the weight-based dosing. However, disadvantages include the risk of infusion reactions and the production of neutralizing antibodies that are responsible for the secondary loss of efficacy. Objectives: To analyze the dynamics of infliximab levels during one maintenance interval as well as the levels of anti-infliximab antibodies in patients with psoriasis treated with infliximab for a period of at least 22 weeks. Methods: We followed 25 patients with psoriasis treated with infliximab for a period of at least 22 weeks at a dose of 5 mg/kg. Based on the clinical picture at the time of blood sample collection, the patients were divided into responders, partial responders and non-responders. Plasma levels of infliximab and antibodies to infliximab were examined in venous blood samples taken during one maintenance interval. The levels of infliximab were examined in week 0, 2, 4, 6, 7 and 8 and anti-infliximab antibodies were examined in week 8. Results: According to the obtained data of infliximab levels and anti-infliximab antibodies, we divided the patients into 4 groups-responders, responders with shortened period of efficacy, non-responders with production of antibodies, and non-responders without production of antibodies. The dynamics of infliximab levels and the production of antiinfliximab antibodies were characteristic for each group. A definitive therapeutic management was created specifically for each group of patients. Conclusions: Monitoring the dynamics of infliximab levels and anti-infliximab antibodies is not only of scientific importance, but it may be crucial in daily clinical practice, enabling an objective management of infliximab treatment.

Hidradenitis suppurativa treated with combination of infliximab and dapsone.

Hidradenitis suppurativa (HS) is chronic inflammatory disease characterized by recurrent painful nodules, which leads to forming an abscess and sinus tracts, together with pustulation and hypertrophic scarring in the areas of apocrine sweat glands. Systemic and local antibiotic therapy, together with corticoid therapy, sulphonates, retinoids and surgical treatment with incisions and drainage belongs to actual treatment possibilities. Biological therapy represents the absolute peak in the treatment last years, mostly TNFα-inhibitors. Even though their very good short term effect is described, long term keeping up the good long effect of the treatment is not achieved with satisfaction. This is the reason to reach for traditional therapeutic possibilities combined with biological treatment in cases of torpid and resistive disease. In the following article a case report of a patient with hidradenitis suppurativa treated subsequently with combination of TNFα-inhibitors and dapson (Fig. 6, Ref. 19).

Polymorphic eruption of pregnancy – new therapeutic approach

Background: Polymorphic eruption of pregnancy (PEP) also known as pruritic urticarial papules and plaques of pregnancy (PUPPP) is a benign disease associated with pregnancy.The polymorphic lesions usually begin to appear in the abdominal striae with sparing of periumbilical area. Etiology of this condition is unknown. Methods: Women with polymorphic eruption of pregnancy were randomized into two groups; Group A was treated with systemic corticosteroids and antihistamines and group B was treated with autologous haemotherapy. The efficacy of different therapeutic options was assessed. Results: In our study, we enrolled 6 women, In Group A (n=3/50%) the efficacy of therapy was very low. All participants took systemic corticosteroids and antihistamines until delivery. The skin changes were stable, patients suffered from serious pruritus. In Group B (n=3/50%) we used intramuscular autologous haemotherapy with whole blood in weekly intervals. Generally, pruritus improved in 2 days and skin changes disappeared in 10-15 days after starting the therapy. Conclusions: According to our study, intramuscular autologous haemotherapy should be considered as an effective alternative therapeutic method with a very good efficacy and safety profile for the mother as well as the child. Correspondence to: Martina Part MD, Faculty of Medicine, Comenius University in Bratislava, Dept. of Dermatology and Venerology, Mickiewiczova 13, 813 69 Bratislava, Slovakia, Email -martina.part@icloud.com, 00421 2 572 90 407

Management of psoriasis patients treated with infliximab based on the dynamics of infliximab levels and antibodies to infliximab

Sulfur Mustard is a potent chemical warfare agent that was widely used during First World War and Iran –Iraq conflict. This vesicant agent has a lot of acute and chronic destructive influences on the skin, eye and respiratory system. SM via the alkilation of DNA and several cellular proteins (structural, cytoplasmic and enzymes) and cell nuclei; produce several toxic, mutagenic and carcinogenic effects. Methods: In this historical Cohort, a population of 1100 veterans with documented history of exposure to Sulfur Mustard during the period of 1982-88 (all have been under the close health monitoring program) were examined. Results: 1) The mean age of the patients was 43.3 ± 9.8 years2) 12 cases amongst 1100 are found to have developed mycosis fungoides( CTCL) over the past years which was much higher than our expectation, while in general population prevalence of CTCL is 1.28/100,000/year for patient 70 to 79 years old. 3)The most common sites of lesions were folds, flexural and thin epidermis areas. (The same places that were most affected by SM-induced bulla during war time between 1982-1988). 4) Most of the patients had a past history of xerosis, chronic dermatitis and itching that begun shortly after exposure to SM 5Most patients with CTCL presented with pigmentory and vascular changes (like SM scar). Finally, chemical weapons are very harmful to life hence blocking of production, prevention of use and immediate treatment and long term follow up of victims are the most important measures to be taken by all scientists. Biography Seyed Naser Emadi has completed his post graduate training of dermatology in Tehran University of medical sciences,Iran (2000-2004). His Professional Experience is to manage skin diseases amongst black people especially those who infected with HIV, AIDS and Cutaneous Leishmaniasis. He is a member of medicines without frontier since 2005 to now and has been worked in Kenya,Ghana, Zimbabve as a volunteer to serve needy people particularly HIV patients. He has published more than 15 papers in reputed journals (Arch Dermatol, CED, International Journal of Dermatology, DOJ). Now he is working on the case of Kaposi Sarcoma among HIV patients that referred to Mbagati District Hospital in Nairobi –Kenya.A aging in skin and impaired wound healing are among the severe complications in patients with diabetes. Prolonged or chronic inflammation in diabetes can result in elevated levels of pro-inflammatory cytokines, matrix metalloproteinases (MMPs) and other inflammatory mediators, which can lead to excessive degradation of newly-synthesized (non-crosslinked) collagen and pile-up of older cross-linked collagen (i.e., accelerated aging of the skin) and delayed wound healing. Curcumin has significant regulatory effects on inflammatory mediators, but is characterized by poor solubility and low bioactivity. Recently, we developed a series of chemically-modified-curcumins (CMCs) with increased solubility and zinc-binding activity, which greatly enhanced their therapeutic efficacy. In the current study, a novel tri-ketonic chemicallymodified-curcumin, CMC2.24, (in contrast to the natural di-ketonic compound), demonstrated significant efficacy on skin atrophy and healing of standardized skin wounds in streptozotocin-induced diabetic rats. Topical application of 1% and 3% CMC 2.24 or systemic administration of CMC 2.24 significantly improved wound healing at 7, 14, and 30 days with no effect on the severe hyperglycemia, assessed by gross and histologic measurements. Densitometric analysis of gelatin zymograms revealed that MMP-9 was increased 125% in the diabetic wounds relative to non-diabetic wounds, and the topical and systemic effects of CMC2.24 on this proteinase showed the same pattern of efficacy as that seen for wound-healing.Lipocalin-2 (Lcn2), an innate immune protein, predominantly secreted by neutrophils is upregulated by several logs during inflammatory conditions including autoimmune diseases. However, the defined role of Lcn2 in autoimmune diseases is largely unknown. We investigated the role of Lcn2 in an acute model IC-mediated inflammation using Lcn2 knock out (Lcn2KO) and their wild type (WT) littermates. In an acute skin inflammation model, Lcn2KO mice demonstrated a 50% reduction in inflammation as evidenced by histopathological analysis which revealed strikingly reduced immune cell infiltration compared to WT mice. Administration of recombinant Lcn2 to Lcn2KO mice restored inflammation to levels observed in WT mice. Neutralization of Lcn2 using a monoclonal antibody significantly reduced inflammation in WT mice. In contrast, Lcn2KO mice developed more severe serum-induced arthritis compared to WT mice. Histological analysis revealed extensive tissue and bone destruction with significantly reduced neutrophil infiltration but considerably more macrophage migration in Lcn2KO mice when compared to WT. Moreover, we also observed a 16 fold increase of Lcn2 upregulation in lupus prone chronic autoimmune disease mice. Collectively, our studies demonstrate that targeting Lcn2 may be a promising approach for treating autoimmune inflammatory disorders.B disease is an inflammatory disorder characterized by multiple system involvements. Oral ulcer is the major clinical finding and diagnostic criteria of the disease. As recurrent aphtous stomatitis affects 10% of the general population, we should keep in mind Behcet’s disease in the differential diagnosis. Its prevalence is higher in the countries that ancient Silk Road had passed through once upon a time. The lower incidence seen in the people who migrated from these areas suggests not only genetical factors but also environmental factors play roles for the disease.INTRODUCTION Malignant melanoma is one of the most rapidly increasing cancer types globally, and it is by far the most serious skin cancer. Patients with a melanoma ≥ 1 mm in Breslow thickness are offered sentinel node (SN) biopsy and subsequent radical lymph node dissection if the biopsy is positive. The objective in the present paper was to describe post-operative complications in this group of patients. A standard operation and drainage regime was used. MATERIAL AND METHODS This was a retrospective study based on 96 consecutive SN-positive patients with primary cutaneous malignant melanoma who underwent subsequent radical axillary or inguinal lymph node dissection. Fishers exact test and Mann-Whitney U-test were used to evaluate associations. RESULTS In all, 57 patients were male and 39 female. A total of 71 had an axillary and 25 an inguinal operation. The median drainage period was seven days (2-15 days). Forty patients developed seroma which needed puncture; three of these cases were chronic, there was no difference between the two groups. Seroma puncture was only associated with infection in the inguinal group (p = 0.04). 25% in the axillary group were diagnosed with lymph oedema after three months versus 48% in the inguinal group (p = 0.04). A body mass index ≥ 25 kg/m2 was associated with a slight, but non-significant increase in complications (p = 0.08). No association was found for smoking or co-morbidity. CONCLUSION Patients undergoing axillary or inguinal lymph node dissection experience a significant number of complications, especially seroma and lymph oedema. Long-term complications are severe and can profoundly impact the patients quality of life.D the advancement of Laser and surgical resurfacing procedures, atrophic acne scars is still the Achilles’ heel of dermatologic surgery. According to the theory of Orentreich (1994), fibrous strands that are the consequence of inflammatory acne vulgaris result in tethering the skin surfaceto the hypodermis. Therefore, releasing these fibrous strands and subsequent formation of new connective tissue in the course of wound healing can lead to level up the skin which is the basis of “subcutaneous incisionless surgery” or “subcision” procedure. Tri-beveled hypodermic needle (Nokor) is the most common device to undermine atrophic acne scars. Since the introduction of subcision, several methods have been proposed in order to enhance clinical efficacy besides reduction of complications and discomforts. Although various instruments such as a tribevelled needle, triangular Nokor needle, or conventional needles (hypodermic 18 to 27G needle), cataract blade and wire with different techniques for better device controlling have been suggested, their effectiveness is a subject of controversy. Moreover, Low length of the Nokor needle, difficulty to control horizontal movements, need to multiple needle entrance sites, the high risk of needle sticking for surgeon, the possibility of neurovascular injuries and complications such as permanent discoloration, iatrogenic scars of the needle entry, bleeding and excessive fibroplasia leading to subdermal nodule formation in addition to moderate patient satisfaction has led to lose overall popularity of this type of subcision based on cutting the fibrotic bands and producing hematoma as an autologous filler.