Marwah A. Saleh

Acral lesions of vitiligo: why are they resistant to photochemotherapy?

Background  Acral lesions of vitiligo are usually resistant to conventional lines of treatment as well as surgical interventions.

Diagnosis and Management of Pemphigus: recommendations by an International Panel of Experts

BACKGROUND Several European countries recently developed international diagnostic and management guidelines for pemphigus, which have been instrumental in the standardization of pemphigus management, OBJECTIVE: We now present results from a subsequent Delphi consensus to broaden the generalizability of recommendations. METHODS A preliminary survey, based on the European Dermatology Forum (EDF) and the European Academy of Dermatology and Venereology (EADV) guidelines, was sent to a panel of international experts to determine the level of consensus. The results were discussed at the International Bullous Diseases Consensus Group in March 2016 during the annual American Academy of Dermatology (AAD) conference. A second survey was sent following the meeting to more experts to achieve greater international consensus. RESULTS The 39 experts participated in the first round of the Delphi-survey while 54 from 21 countries completed the second round. The number of statements in the survey was reduced from 175 topics in Delphi I to 24 topics in Delphi II based on Delphi results and meeting discussion. LIMITATIONS Each recommendation represents the majority opinion and therefore may not reflect all possible treatment options available. CONCLUSIONS We present here the recommendations resulting from this Delphi process. This international consensus includes intravenous CD20 inhibitors as a first line therapy option for moderate to severe pemphigus.

Platelet-rich plasma for resistant oral erosions of pemphigus vulgaris: A pilot study

Oral erosions and ulcers of pemphigus vulgaris (PV) are a debilitating condition that is usually difficult to treat. The wound healing properties of platelet‐rich plasma (PRP) encouraged us to evaluate its usefulness in treatment of non‐healing oral PV lesions. Seven patients with chronic oral PV, resistant to conventional therapy, were treated with weekly to monthly injections of PRP of affected mucosal membranes. All recruits reported improvement in pain and mastication and 6 of 7 patients had an improvement in pemphigus disease area index scores with PRP treatment. PRP injections seems to accelerate the healing process and decrease the pain and eating discomfort associated with the oral erosions and ulcers induced by PV.

Salty and spicy food; are they involved in the pathogenesis of acne vulgaris? A case controlled study.

Many studies have suggested a strong relation between diet and acne. Many patients with acne believe that spicy and salty foods exacerbate acne.

A prospective study comparing patients with early and late relapsing pemphigus treated with rituximab

Background: Rituximab (RTX) is an effective therapy for patients with pemphigus; however, the therapy does not prevent relapse. Objectives: To compare early relapsing patients (before 12 months) and late relapsing patients (after 24 months) following RTX therapy. Method: In this prospective study, 19 patients were enrolled (14 with pemphigus vulgaris and 5 with pemphigus foliaceus). The baseline disease score, autoantibody levels, and percentage of CD20+ cells of patients with pemphigus were measured. Patients received 1 cycle of RTX and were followed for 26 months. Results: Among early relapsing patients (n = 5), the time to relapse was 6 to 11 months. Among late relapsing patients (n = 6), the time to relapse was 24 to 26 months. A significant difference was observed in the mean baseline anti–desmoglein 1 (DSG1) index between early relapsing (705.72) and late relapsing patients (210.4) (P = .0014). A significant negative correlation was found between the baseline anti‐DSG1 index and time to relapse (r = −0.777, P = .00009). Limitations: The small number of patients with pemphigus foliaceus. Conclusions: Because patients with high baseline anti‐DSG1 indices relapsed earlier, it may be important to follow these patients closely for the initial 12 months after RTX therapy. These patients may require a maintenance RTX dose during the first 12 months after RTX therapy.

Assessment of tissue levels of dickkopf-1 in androgenetic alopecia and alopecia areata

Androgenetic alopecia (AGA) is the commonest form of hair loss in men. Alopecia areata (AA) is an organ‐specific autoimmune disease. Studies revealed that Dickkopf 1 (DKK‐1), a powerful suppressor of the Wnt/β‐catenin signaling pathway, induced anagen‐to‐catagen transition in mice. Moreover, in vitro studies suggested that DKK‐1 played a role in dihydrotestosterone (DHT)‐induced balding.

Do normal Egyptians possess anti-desmoglein 3 antibodies?

Pemphigus is a group of autoimmune blistering diseases targeting the cell–cell adhesion molecules, desmogleins (Dsgs). Anti‐Dsg antibodies, the hallmark of the disease, were not detected in normal individuals in many populations. In spite of the rarity of pemphigus vulgaris (PV) disease in many parts of the world, PV is not rare in Egypt. The purpose of the present study is to investigate the presence of anti‐Dsg3 antibodies in normal Egyptians aiming to determine the reason for the increase in number of patients in Egypt with pemphigus.

Matrix metalloproteinase in acral and non-acral vitiligo

Repigmentation in vitiligo requires activation, proliferation, and migration of the melanoblasts and melanocytes into the depigmented epidermis.1 Cell migration involves modifications of the architecture of cells which requires activation of enzymes that are involved in ECM degradation such as matrix metalloproteinases (MMPs). The significant reduction in their expression in vitiliginous skin has been previously demonstrated 2 and thereby incriminated to share in reducing the migration of melanocytes and their precursors. Phototherapy in the form of narrow band UVB and photochemotherapy (PUVA) are still considered the pillar in the treatment of vitiligo.3 Among a vast array of effects that could account for their efficacy, it has been demonstrated that UVA can lead to increased expression of MMPs 4 which could aid in the process of repigmentation of vitiliginous lesions. In the current work, we aimed at detection of the differences between acral and nonacral vitiligo skin as regards the expression of three members of the MMP family; MMP1, MMP2, and MMP9, and how would they change after PUVA therapy.

Autoantibodies other than anti-desmogleins in pemphigus vulgaris patients

Background: Pemphigus vulgaris (PV) is an immunoglobulin G-mediated autoimmune bullous skin disease. Nonorgan-specific antibodies were detected in Tunisian and Brazilian pemphigus patients with different prevalence. Materials and Methods: Fifty PV patients and fifty controls were screened for antinuclear antibodies (ANAs), anti-smooth muscle antibodies (ASMAs), anti-parietal antibodies (APAs), anti-mitochondrial antibodies, and Anti-nuclear cytoplasmic antibodies (ANCA) by indirect immunofluorescence. Results: Thirty-nine patients were female and 11 were male. Fifteen patients did not receive treatment before while 35 patients were on systemic steroid treatment ± azathioprine. Twenty (40%) of the PV patients and 1 (2%) control had positive ANA. ANA was significantly higher in PV patients than controls, P< 0.0001. ASMAs were detected in 20 (40%) PV patients and none of the controls. ASMA was significantly higher in PV patients than controls, P< 0.0001. No significant difference was detected between treated and untreated regarding ANA, P - 0.11. However, there was a significant difference between treated and untreated regarding ASMA, P- 0.03. Six patients (12%) and none of the controls had positive APA. There was a significant difference between the patients and the controls in APA. P- 0.027. Conclusion: Egyptian PV patients showed more prevalent ANA, ASMA, and APA than normal controls. Follow-up of those patients is essential to detect the early development of concomitant autoimmune disease. Environmental factors might account for the variability of the nonorgan-specific antibodies among different populations.

Effect of Procedural-Related Variables on Melanocyte-Keratinocyte Suspension Transplantation in Nonsegmental Stable Vitiligo: A Clinical and Immunocytochemical Study.

BACKGROUND Melanocyte–keratinocyte suspension (M–K susp) is gaining popularity for vitiligo treatment. Few studies have addressed procedure-related variables. OBJECTIVE To assess the effect of different M–K susp procedure-related variables on the clinical outcome in stable vitiligo. METHODS This prospective multicenter comparative study included 40 cases with nonsegmental stable vitiligo. Donor site was either a skin graft in noncultured epidermal cell suspension (NCECS) or hair follicle units in outer root sheath hair follicle suspension (ORSHFS). Recipient site was prepared by either cryoblebbing or CO2 laser resurfacing. Cell counts and viability were recorded in the cell suspensions. Tissue melanocytes and keratinocytes were examined by melan-A and cytokeratin, respectively. Assessment of repigmentation was performed 18 months after the procedure. RESULTS Thirty-seven subjects completed the study. Cell count was significantly lower in the ORSHFS compared with NCECS with no significant difference in the repigmentation outcome. On comparing techniques of recipient site preparation, homogenicity was better in the CO2 group. Elbows and knees responded better to CO2 resurfacing, whereas distal fingers responded better to combination of cryoblebbing with NCECS. CONCLUSION Using different techniques in M–K susp produces comparable results. However, the distal fingers showed better results using combination of donor NCECS and recipient cryoblebs.