Panagiotis G. Stavropoulos

Treatment of Pyoderma gangrenosum with Low-Dose Colchicine

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis of unknown origin. Systemic agents occasionally administered provide either incomplete long-term control of the disease or have been associated with serious adverse side effects after chronic administration. We present two patients with PG successfully treated with low-dose colchicine. Antimitotic, anti-inflammatory and immunomodulating properties of colchicine might account for its beneficial effects in PG patients. Colchicine is effective and well tolerated in low doses by most patients. In addition, it is inexpensive and safer for long-term treatment than corticosteroids and other immunosuppressive agents. Colchicine may be proposed either as a single agent or as a corticosteroid-sparing agent for early treatment of PG.

Treatment of cutaneous leishmaniasis with cryosurgery

Background  The management of cutaneous leishmaniasis with topical methods, if effective, can spare patients from long and costly inpatient treatments.

The Greek experience with efalizumab in psoriasis from a University Dermatologic Hospital.

Background  Efalizumab (anti‐CD11a antibody) targets T cell‐mediated steps important in the immunopathogenesis of psoriasis. As efalizumab is intended to be administered on a continuous long‐term basis in psoriasis, it is important to share experience concerning issues commonly occurring during its use in real daily practice.

Treatment of autoimmune urticaria with low-dose cyclosporin A: A one-year follow-up.

Patients with autoimmune urticaria (AIU) and positive autologous serum skin test (ASST) represent a more serious type of chronic urticaria that does not respond to treatment with antihistamines, but responds completely to systemic corticosteroids. Because of the chronic course of the disease, there is a risk of side-effects. Cyclosporin A (CsA) is an alternative treatment for patients with AIU. In order to determine the efficacy of CsA at the lowest possible dose in patients with chronic idiopathic urticaria and positive ASST, 30 patients were included in a 5-month study with a follow-up one year after the end of treatment. All patients had positive ASST before treatment and autoantibodies were present in 73%. Twenty- three patients completed the study and responded to low-dose CsA treatment. Three patients did not respond to a dose of 2.5 mg/kg CsA, and 4 patients dropped-out due to side-effects. After the first month of treatment, an improvement of 31% was noted, reaching 88% after the fifth month of treatment. The mean dose of CsA was 2.16 mg/kg for the first month and 0.55 mg/kg for the fifth month. Three to 6 months after the end of the study, the ASST was repeated and was negative in 78.3% of patients. At the one-year follow-up, 20 patients were symptom-free (87%) and 3 had relapsed (13%). CsA, even in low-doses, can be an effective and short-term treat- ment with minimum side-effects in patients with AIU.

Pemphigus vegetans confined to the scalp

Pemphigus vegetans confined to the scalp Pemphigus vegetans is a rare variety of pemphigus vulgaris, appearing with two clinical subtypes: Neumann and Hallopeau. The most commonly involved sites of the characteristic vegetating plaques are the intertriginous areas. In 60–80% of all cases, there is also an involvement of the oral mucosa. We report here a case of pemphigus vegetans confined exclusively to the scalp. A 54-year-old woman presented with two extensive, roundshaped, verrucous, vegetating plaques on the scalp, which had appeared 4 months previously (Fig. 1). The larger lesion, located on the crown of the head, had a diameter of 4.3 cm, protruding about 1.5 cm, and making the patient feel uncomfortable. There were no other lesions on the skin and/or mucous membranes and no history of other skin or systemic diseases. The patient had been treated with several antimicrobials without any benefit and the lesions were growing rapidly. Cultures for bacteria revealed Staphylococcus epidermidis. Direct microscopy and culture for mycology were negative. Full blood count, erythrocyte sedimentation rate (ESR), Creactive protein (CRP), blood sugar, liver and renal function tests were normal. Human immunodeficiency virus (HIV) serology was negative. Biopsy showed papillomatous, proliferating, acantholytic lesions in the epidermis and eosinophilic infiltrate in the dermis (Fig. 2). Direct immunofluorescence demonstrated intercellular immunoglobulin G (IgG) and C3 deposits mainly in the lower part of the epidermis. Antibodies to desmoglein 1 and 3 were analyzed using specific enzymelinked immunosorbent assay (ELISA). Index values to desmoglein 3 were 158 (normal, < 10), whereas those to desmoglein 1 were negative. The patient was treated with oral prednisolone (initial dose, 60 mg daily) and local application of clobetasol propionate twice daily. The lesions started to diminish rapidly within the first week and disappeared after 5 weeks, but relapsed 20 days after discontinuation of treatment. The same treatment was repeated and the lesions disappeared again, but relapsed when the dose of prednisolone was tapered below 15 mg. Therefore, during the last 4 months, we have combined an alternate-day dose of prednisolone (10 mg/15 mg) with mycophenolate mofetil (CellCept) (2 g/ 24h), and the patient has been free of recurrent disease. Our patient’s rather extensive lesions were confined exclusively to the scalp; therefore the diagnosis of pemphigus vegetans was not considered at the beginning. In the few cases of patients with scalp involvement mentioned in the literature, typical lesions have also existed in intertriginous areas and/or the oral mucosa. To our knowledge, single lesions of pemphigus vegetans confined exclusively to the scalp have not been described previously. There is, however, a report of a single lesion on the foot. According to the above, the diagnosis of pemphigus vegetans should be considered even in single lesions located in nontypical sites. Bearing in mind that this disease is a variety of pemphigus vulgaris, it should be treated with sufficiently high doses of corticosteroids and/or other immunosuppressive agents, even if it is limited to a single area.

Inosiplex for Treatment of Alopecia Areata: a Randomized Placebo-controlled Study

Treatment of alopecia areata remains unsatisfactory. We decided to test if systemic therapy with inosiplex (Isoprinosine(R)), an immunomodulator could influence the disease. Thirty-two subjects with recalcitrant alopecia areata, aged 16-48 years (mean 30.3+/-5.1 years), were randomized into two treatment groups of 16 subjects each. They were assigned to receive either oral inosiplex (group 1), or placebo (group 2) on a double-blind basis. Inosiplex dosage was 50 mg/kg/day in five divided doses for 12 weeks. Of the 15 evaluable patients in group 1, 5 (33.3%) had full remission, 8 (53.3%) responded partially and 2 (13.3%) did not respond. Of the 14 evaluable patients in the placebo group, none had full remission, 4 (28.5%) responded partially and 10 (71.4%) did not respond. The therapeutic difference between patients receiving active and placebo therapy was statistically significant (?2=7.82, p<0.01). Compared with placebo, oral inosiplex showed considerable efficacy in alopecia areata with insignificant side-effects. Larger studies are required, however, before inosiplex may be recommended as an efficacious and safe alternative systemic form of therapy for recalcitrant alopecia areata.

Assessment of Cryotherapy for the Treatment of Verrucous Epidermal Naevi

Epidermal naevi are hamartomas that are characterized by hyperplasia of the epidermis and adnexal structures and may be associated with serious disfiguration. Management of epidermal naevi is challenging. We present here our experience with cryosurgery in the treatment of verrucous epidermal naevi. The aim of this study was to determine the efficacy and safety of cryosurgery for the treatment of epidermal naevi. Nine patients with verrucous epidermal naevi and two with extensive unilateral epidermal naevus were treated with cryosurgery. Two cycles of open spray technique were used, 10-15 sec each, depending on the size and extent of the naevus. Ten patients had their naevi treated successfully in 2-5 sessions with two cycles of therapy, and the cosmetic result was excellent with no scarring. One patient showed a relapse within 8 months after the treatment. One patient with phototype IV developed hypochromic scarring, but repigmentation occurred after 6 months. Postoperative healing time was 10-20 days. Cryosurgery is an extremely effective therapeutic modality for the treatment of epidermal naevi. The low cost, the simplicity of the technique and the good cosmetic result makes cryosurgery an excellent therapeutic modality for the treatment of epidermal naevus.

Impetigo herpetiformis during the Puerperium

We report on a 29-year-old primigravida who developed impetigo herpetiformis 1 day after delivery. To our knowledge, this patient is the second reported case of impetigo herpetiformis presenting during the puerperium. The patient responded quickly to systemic administration of methotrexate and prednisolone.

Molluscum contagiosum and cryosurgery: Triggering factors for wells' syndrome?

Sir, Wells’ syndrome, or eosinophilic cellulitis, is an uncommon inflammatory dermatosis characterized in most cases by skin lesions resembling cellulitis and peripheral eosinophilia (1, 2). Patients rarely have systemic symptoms (3). The cutaneous manifestations include localized oedema and infiltrated erythematous plaques, infrequently studded with vesicles or bullae. Occasionally, less inflammatory lesions, such as multiple annular or circinate erythematous plaques with indurated borders, may be seen (4). The disease is nonscarring, leaving a slowly resolving hyperpigmentation. The cause of Well’s syndrome is unknown. We want to report a case where the syndrome started after a viral infection (molluscum contagiosum) treated repeatedly with cryosurgery.

Assessment of the efficacy of cryosurgery in the treatment of granuloma faciale

Background  Granuloma faciale (GF) is an uncommon dermatosis of unknown pathogenesis. Multiple treatments have been proposed with varying results. We report nine cases treated successfully with cryosurgery and we review the literature.