Nawaf Al-Mutairi

The effect of weight reduction on treatment outcomes in obese patients with psoriasis on biologic therapy: a randomized controlled prospective trial

Background: Obesity has long been associated with psoriasis and it is considered to be an independent risk factor for chronic heart diseases in these patients. Recently, some of the biologic drugs used for psoriasis have been reported to cause increase in body weight. It is currently not clear if this increased body weight seen in psoriasis patients on biologics leads to decrease in there efficacy or vice versa. We carried out this study to see if reduction in body weight leads to increased efficacy of biologics in obese psoriasis patients. Objective: To evaluate the effect of weight reduction by dietary control on treatment efficacy of biologics in obese patients as indicated by the Psoriasis Area and Severity Index (PASI) score. Methods: Obese patients with psoriasis receiving biologic therapy, satisfying the inclusion criterion, were randomized in a 1:1 ratio to receive low-calorie diet versus normal diet (control group). We included 262 patients with moderate to severe, stable plaque psoriasis with a PASI score 20:50 on anti TNF-α biologic therapy (infliximab, etanercept, ustekinumab and adalimumab). The patients in the dietary intervention group were given a low calorie diet (≤ 1000 kcal per day) for 8 weeks to induce weight loss. The treatment outcome was assessed using PASI. The PASI scores were assessed at baseline and every 4 weeks up to week 24. Results: There were no significant differences in age, sex distribution, body weight, body mass index, waist circumference, psoriasis duration, or PASI score between the two studied groups at base line. At week 24, the mean (±SD) weight loss was 12.9 ± 1.2 kg in the diet intervention group, and −1.5 ± 0.5 kg in the control group. The average improvement in mean PASI score was 84% for the diet group, and 69% for the control group. PASI 75 was achieved by 85.9% in the diet group, and 59.3% in the control group (p < 0.001). The mean (±SD) body surface area values at week 24 were 3.3 ± 4.4% and 8.1 ± 6.9% in the diet group and control group. Conclusions: Body weight reduction in obese patients on biologics may increase the efficacy of the drug.

Clinical profile and impact on quality of life: Seven years experience with patients of alopecia areata

BACKGROUNDnAlopecia areata (AA) is the most common cause of localized, non-scarring alopecia. Stress and other psychological factors have been implicated in the causation of the disease, and it is also found to alter the course of the disease process. Unfortunately no one has studied the impact of AA on the quality of life, which includes the social life of the patients.nnnAIMnTo study the clinical profile and impact of alopecia areata on the quality of life, including the social life of adult patients with severe forms of the disease.nnnMETHODSnThe present study determined the clinical pattern of AA and its impact on the quality of life (QOL) in all the patients with severe forms of alopecia areata attending the Dermatology Outpatient Department.nnnRESULTSnThe male : female ratio was 1.86 : 1. Most (58.03%) of the patients were between 21 and 40 years of age. Almost 40% of the patients had associated systemic disease or other dermatological disorders. A family history of AA was found in 593 (20.02%) of the patients. Nail changes were observed in 297 (10%) of the patients. There were significant differences between the mean Dermatology Life Quality Index (DLQI) score in cases with severe forms of AA and controls ( P < 0.001).nnnCONCLUSIONSnSevere forms of alopecia areata had a major impact on the psychosocial well-being of the patients. These individuals had to be treated early, and they required more than just prescription drugs. Educational and psychological support in addition to medical therapy for AA could improve their long-term physical outcomes.

Long‐Term Results of Split‐Skin Grafting in Combination with Excimer Laser for Stable Vitiligo

BACKGROUND Some cases of focal or segmental vitiligo are refractory to medical treatment, and surgical management is the treatment of choice. Postsurgical exposure to ultraviolet B rays can lead to faster and better cosmetic results. OBJECTIVE To determine the long‐term results of combination therapy with split‐skin‐thickness grafting and 308‐nm excimer laser for the management of stable focal or segmental vitiligo. PATIENTS AND METHODS Seventeen patients (8 female, 9 male) with stable focal or segmental vitiligo not responding to nonsurgical modalities were treated with split‐skin‐thickness grafting and postgrafting with 32 sessions of 308‐nm excimer laser, beginning 2 weeks after surgery. The patients were followed up every year for evaluation of results. RESULTS All seventeen (100%) patients showed repigmentation, and overall results were graded as excellent in 12 patients and good in the other five at the end of excimer laser therapy. Final evaluation done at the end of 1 year revealed excellent results in all 17 patients. Two patients developed new vitiligo lesion on other parts of the body during follow‐up. None of the patients developed depigmentation of the transplanted skin. CONCLUSION Combination treatment with split‐skin‐thickness grafting and postsurgical exposure to 308‐nm excimer laser in patients with stable focal or segmental vitiligo can lead to fast, cosmetically good, long‐lasting results.

Nosology and therapeutic options for lupus miliaris disseminatus faciei

Lupus miliaris disseminatus faciei (LMDF) is a distinctive facial eruption of a debatable nosology, unknown etiology and spontaneously resolving course albeit with scarring. The aim of this study was to present the clinico‐histopathological features, the rationale for treating and therapeutic response in patients with LMDF treated with different agents, and to attempt to clarify its nosology. Clinical details and demographic data of 29 biopsy‐proven cases of LMDF were studied. Laboratory work up included complete blood count, erythrocyte sedimentation rate, tuberculin testing, chest X‐ray, serum calcium levels and serum angiotensin‐converting enzyme levels. Special stains like Ziehl–Neelsen, periodic acid Schiff and reticulin staining were used, and acid‐fast bacilli culture was performed in each patient. The patients were treated with oral minocycline, dapsone, prednisolone and isotretinoin as monotherapeutic agents, or with a combination of oral dapsone plus prednisolone, and oral dapsone plus topical tacrolimus. Six patients had extrafacial lesions. Histological analysis revealed three different patterns: tuberculoid granuloma with central caseation necrosis in 20 patients; sarcoidal‐like granuloma in six patients; and non‐specific localized perifollicular lymphohistiocytic infiltrate in three patients. Nine out of 11 patients treated with minocycline did not respond, whereas dapsone and low dose prednisone alone or in combination produced good results. Topical tacrolimus with dapsone in seven patients yielded excellent results. Early and judicious use of medicines can clear this condition without scarring. LMDF should be accepted as a distinct entity. Facial idiopathic granulomas with regressive evolution (FIGURE), an acronym suggested is an apt, self‐explanatory and easy term for LMDF, with no connotation of tubercular etiology.

Photoprotection and vitamin D status: A study on awareness, knowledge and attitude towards sun protection in general population from Kuwait, and its relation with vitamin D levels

BACKGROUNDnThe primary cause of skin cancers is exposure to ultraviolet (UV) radiation. And, for decades sun protection has been promoted in various public health education campaigns. Recently, however, vitamin D deficiency has been related to increased risk of skin cancers. And, skin being the primary site for the synthesis of active form of vitamin D, excessive sun protection could lead to vitamin D-deficient states. But, the results have so far been conflicting.nnnAIMSnTo study the level of awareness, knowledge and attitude of representative groups from the general population from Kuwait towards sun protection. And, also study the correlation of the level of sun protective measures used and vitamin D levels in these groups.nnnMETHODSnThe study constituted of two main parts. First part comprised a questionnaire-based survey of representative group of people aged 18 and above to assess their knowledge, awareness and attitude towards sun protection. The second part consisted of measuring serum vitamin D levels in 150 volunteers amongst the responders of the questionnaire, who had been regularly using sunscreens for at least 2 years and compare to the levels seen in 150 age and sex-matched responders of similar skin phototypes, who had never used sunscreens.nnnRESULTSnOut of the total of 1044 responders, 80% of them had adequate knowledge of the beneficial and harmful effects of sun exposure, and had been using sunscreens regularly, and adopting other sun protective measures in their daily life. The levels of vitamin D were found to be deficient in both sunscreen users and those who had never used sunscreens. The difference between the two groups was statistically insignificant (60.67% vs 54.67%; P value>0.001).nnnCONCLUSIONnPopulation at large seems to be adequately informed about the beneficial and deleterious effects of sun exposure. Vitamin D levels are deficient in majority of our people, and there is a need to do larger surveys covering all parts of the country and give supplemental doses of vitamin D to those found deficient.

Targeted phototherapy using 308 nm Xecl monochromatic excimer laser for psoriasis at difficult to treat sites.

Psoriasis is a chronic inflammatory multisystem disease involving skin and joints affecting 1–3xa0% of the world population. The 308-nm excimer laser has been recently used in the treatment of psoriasis, especially localized psoriasis of scalp and palm and soles. The objective of the study is to evaluate the therapeutic efficacy and safety of a 308-nm excimer laser for the treatment of scalp and palmoplantar psoriasis. A total of 41 adult patients (25 males and 16 females) were enrolled in this study, of which 26 patients had lesions localized to scalp, and 15 patients had involvement of palm and soles. The mean age was 44.5xa0years (range 18–73). And, the mean duration of psoriasis in our patients was 15xa0years. They were treated with a 308-nm excimer laser. The initial dose was based on multiples of a predetermined minimal erythema dose, twice weekly for a maximum 12xa0weeks. Twenty-two of the 23 patients with scalp psoriasis showed improvement, while one patient showed no change; none experienced worsening of symptoms. The mean minimal erythema dose (MED) was found to be 383xa0mJ/cm2 (range 180–650xa0mJ/cm2). The cumulative dose of irradiation was 1,841xa0mJ/cm2 (range 600–2,500). The percentage improvement from baseline in PSSI score was 78.57xa0%. Side effects were seen in 20 patients (86.96xa0%) mainly in the form of erythema. Four patients developed mild relapse at the end of 6xa0months after the therapy. In 15 patients with palmoplantar psoriasis, the mean MED was found to be 415xa0mJ/cm2 (range 200–950xa0mJ/cm2). The cumulative dose of irradiation was 28.4–115.5xa0Ju2009cm2 (mean 59.1xa0Ju2009cm2). The mean number of treatments to achieve clearance (equal to 90xa0% reduction of PSI score) was 16. Two patients relapsed at the end of 6xa0months after the therapy. The 308-nm excimer laser is an effective, safe, easy, and relatively quicker method for the treatment of psoriasis at difficult to treat sites, with good results in a somewhat short time.

Efficacy of 308‐nm Xenon Chloride Excimer Laser in Pityriasis Alba

Objective Pityriasis alba (PA) is the most common cause of facial hypopigmentation presenting to the dermatologist. The objective of the current study was to study the effect of the 308‐nm excimer laser in the treatment of PA. Materials and Methods Twelve patients with 37 PA patches were enrolled in this study. The lesions were treated using the 308‐nm excimer laser twice a week for 12 weeks. The hypopigmented areas were evaluated at baseline and at weeks 0, 3, 6, and 12 for scaling, hypopigmentation, and pruritus on a 4‐point scale (0 = none to 3 = severe). All adverse effects were recorded. Results There were seven male and five female participants in (aged 5–21 years), with skin type III to V. After 1 month of laser therapy, the clinical scores were significantly lower than at baseline. Similar decreases were observed for the scaling and pruritus scores. Uneven skin color improved by the third week, and near‐complete resolution was noticed by the end of 3 months. No serious or unpleasant side‐effects were observed, and all patients completed the 12‐week treatment. Patients were satisfied or very satisfied with the treatment. Conclusion The 308‐nm excimer laser is an effective therapeutic option for PA.

Effect of Narrowband Ultraviolet B Therapy on Serum Vitamin D and Cathelicidin (LL-37) in Patients with Chronic Plaque Psoriasis

Background: Narrowband ultraviolet B (NB-UVB) has been widely used in the treatment of psoriasis. It has been shown that vitamin D is a major regulator of the expression of human antimicrobial peptide cathelicidin LL-37, which has a critical role in inflammatory cascade in psoriasis. Objective: To evaluate the effect of NB-UVB therapy on serum levels of cathelicidin LL-37 and 25-hydroxyvitamin D [25(OH)D] in psoriasis patients. Methods: Ninety-three psoriasis patients and 50 controls were included in the study. For psoriasis patients, serum levels of 25(OH)D and cathelicidin LL-37 were estimated before and after NB-UVB therapy. Results: Before treatment, serum 25(OH)D levels were significantly lower in psoriasis patients (31.5 ± 14.41 nmol/L) compared to controls (53.5 ± 19.6 nmol/L), p = .015. In contrast, serum LL-37 was significantly higher in psoriasis patients (13.24 ± 3.2 ng/mL) than in controls (7.92 ± 5.33 ng/mL), p < .001. After NB-UVB treatment, there was a highly significant elevation of serum 25(OH)D to reach 56.85 ± 5.2 nmol/L (p < .001) and further elevation of serum LL-37 to reach 29.4 ± 4.2 (p = .02). Conclusions: The elevation of serum 25(OH)D and cathelicidin LL-37 could be an additional possible mechanism of action of NB-UVB therapy in the treatment of psoriasis.

Onychomycosis in patients of nail psoriasis on biologic therapy: a randomized, prospective open label study comparing Etanercept, Infliximab and Adalimumab

Introduction and objective: The association between patients of psoriasis on anti TNF therapy and onychomycosis has not been explored. The aim of this study was to determine the rate of onychomycosis in patients of psoriasis with nail involvement on anti TNF therapy. Materials and methods: All patients of psoriasis with nail involvement seen between February 2007 – July 2012 were examined. All the patients with negative nail scrapings for fungus were enrolled. Patients found fit for biologics after investigations were randomly divided into 3 groups (Group A: Infliximab, Group B: Etanercept and Group C: Adalimumab). The patients were followed up every 4 weeks for 24 weeks. Repeat nail scrapings were done at week 24. The results were compared with controls. Result: In total, 315 (178 males and 137 females) patients were enrolled. The mean age was 37.5 ± 11.4 years. The results for scraping for fungus at the end of 24 weeks were as follows: 33% (33/100) in patients on Infliximab followed by 15.45% (17/110), 13.33% (14/105) in patients on treatment with Etanercept and Adalimumab respectively as compared to 13.89% (25/180) among controls. Onychomycosis in association with nail psoriasis was more common in males. Conclusion: This study revealed statistically significant association between fungal infections of the nail in patients of psoriasis on treatment with Infliximab.

Single Blinded Left-to-Right Comparison Study of Excimer Laser Versus Pulsed Dye Laser for the Treatment of Nail Psoriasis

IntroductionNail psoriasis is relatively difficult to treat. Excimer laser has been approved for the treatment of psoriasis since 2000. Pulsed dye laser (PDL) in psoriasis therapy has shown good response rates, with extended remissions. This is the first study assessing both the excimer and PDL lasers in nail psoriasis.MethodsIn a comparison study, excimer laser versus PDL for the treatment of nail psoriasis was evaluated in 42 patients. The right hand nails were treated with excimer laser twice weekly and the left hand nails were treated with PDL once every 4xa0weeks, for total 12xa0weeks. The patients were then followed up after a further 12xa0weeks. Nail Psoriasis Severity Index (NAPSI) scores were recorded at baseline, weeks 4, 8, and 12, and then at week 24. Patients were also asked to grade the clinical response to each treatment.ResultsA total of 304 nail changes, 148 with excimer laser and 156 with PDL, were treated. The mean NAPSI score in nails treated with excimer laser was 29.8 at baseline, reduced to 16.3 at week 24. In PDL-treated nails, the NAPSI scores dropped from 29.5 at baseline to 3.2 at week 24. NAPSI improvement was significantly greater in PDL than excimer (Pxa0=xa00.001; Wilcoxon signed-rank test). Thirty-four (81%) hands achieved NAPSI-50, and 23 (55%) achieved NAPSI-75 at week 12, while complete nail recovery was shown in 6 (14%) hands treated with PDL. Regarding the hands treated with excimer laser, only 16 (38%) hands achieved NAPSI-50, while no hands achieved NAPSI-75 at week 12. In general, subungual hyperkeratosis and onycholysis improved significantly, while nail pitting was least responsive. Oil drops and splinter hemorrhages showed moderate response.ConclusionsWhen compared to excimer laser, PDL demonstrated a good response for treating nail psoriasis, with minimal side effects.