Rehab A. Hegazy

Autologous Platelet Rich Plasma: Topical Versus Intradermal After Fractional Ablative Carbon Dioxide Laser Treatment of Atrophic Acne Scars

BACKGROUND A proposal has recently been made regarding the potential adjuvant use of platelet‐rich plasma (PRP) with fractional carbon dioxide laser (FCL) for the correction of acne scars. OBJECTIVE To compare the efficacy and safety of two administration modes of autologous PRP (intradermal injection (ID) and topical application) after FCL with that of FCL alone in the treatment of atrophic acne scars. PATIENTS AND METHODS Thirty patients were randomly divided into two groups. Both underwent split‐face therapy. Group 1 was administered FCL followed by ID PRP on one side and FCL followed by ID saline on the other. In group 2, one cheek was treated with FCL followed by ID PRP, and the other received FCL followed by topical PRP. Each patient received 3 monthly sessions. The final assessment took place at 6 months. RESULTS Combined PRP‐ and FCL‐treated areas had a significantly better response (p = .03), fewer side effects, and shorter downtime (p = .02) than FCL‐treated areas, but there were no significant differences in ID‐ and topical PRP–treated areas in degree of response and downtime (p = .10); topically treated areas had significantly lower pain scores. CONCLUSION The current study introduces the combination of topical PRP and FCL as an effective, safe modality in the treatment of atrophic acne scars with shorter downtime than FCL alone and better tolerability than FCL combined with ID PRP.

Interleukin 17, Interleukin 22 and FoxP3 expression in tissue and serum of non-segmental vitiligo: A case- controlled study on eighty-four patients

BACKGROUND Skewing of responses towards T helper (Th) 17 and away from T regulatory cells (T-regs) has been suggested to be partially involved in autoimmune diseases like vitiligo. AIMS Clarify the possible role and relationship between Th17 and T-regs in vitiligo by measuring tissue, systemic levels of interleukin (IL)-17, IL-22 and Forkhead box P3. PATIENTS AND METHODS 84 non-segmental vitiligo patients and 80 controls were included. Vitiligo Area Scoring Index, Vitiligo Disease Activity and stress score were determined. Skin biopsies underwent immunohistochemical staining for IL-17, IL-22 and FoxP3 and their systemic levels were determined by ELISA and quantitative real time PCR. RESULTS Mean area % of +ve immunostaining and serum levels of IL-17 (34.12 ± 5.12, 23.62 ± 8.17 pg/mL) and IL-22 (48.63 ± 19.23, 43.53 ± 11.95 pg/mL) were significantly higher in patients compared to controls (15.33 ± 4.19, 12.83 ± 3.29 pg/mL) (13.44 ± 3.82, 9.92 ± 4.7 pg/mL) (P<0.001). Mean area % of +ve immunostaining and peripheral blood levels of FoxP3 were significantly lower in patients (2.67 ± 0.54, 0.574 ± 0.32) compared to controls (7.12 ± 0.18, 1.48 ± 0.49) (P<0.001). In patients, a positive correlation between IL-17 and IL-22 was detected (r = 0.671, P<0.001), each showing negative correlation with FoxP3 (r = -0.548, P<0.001), (r = -0.382, P<0.001). VASI, VIDA and stress score correlated positively with IL-17, IL-22 and negatively with FoxP3. CONCLUSION Th17 and T-regs are intertwined in the complexity of vitiligo giving hope of treatment through adjuvant therapies controlling the delicate balance between them.

Oral propranolol: an effective, safe treatment for infantile hemangiomas

Infantile hemangiomas (IH) are the most common childhood tumors. In 2008, Labreze reported the serendipitous effect of oral propranolol on hemangioma and since then it has overshadowed the use of other therapeutic modalities in the treatment of IH. The aim of this prospective, clinical study was to assess the efficacy and safety profile of oral propranolol at a fixed dose of 2 mgkg(-1) in the treatment of 30 patients with problematic IH. Propranolol treatment continued for a duration of 2-14 months where 60% of the patients (n=18) showed a final excellent response with complete resolution of the lesion (P<0.001). 20% (n=6) showed a good response with more than 50% reduction in the size of the IH. 16.6% showed a fair response (n=5) with less than 50% reduction in the size of the IH. Only one patient (3.3%) was resistant to treatment. Five patients (17.24%) showed evidence of rebound growth after cessation of therapy and responded well to re-treatment.We did not face any side effects related to the oral propranolol. In conclusion, propranolol therapy at a fixed dose of 2 mgkg(-1), given in three equally divided doses, is a very safe and effective regimen in the treatment of IH.

Intralesional botulinum toxin type A equally effective and better tolerated than intralesional steroid in the treatment of keloids: a randomized controlled trial.

Intralesional (IL) corticosteroid therapy is a treatment for keloids. IL botulinum toxin type A (BTA) has been postulated in such an indication with controversial reports. To compare efficacy and safety of IL BTA to the IL corticosteroid therapy in treatment of keloids. Twenty‐four patients with keloids were randomly divided into two equal groups: receiving IL steroid repeated every 4 weeks for six sessions (group A) and IL BTA 5 IU/cm3 repeated every 8 weeks for three sessions (group B). Objective parameters (hardness, elevation, and redness), subjective complaints (itching, pain, and tenderness), patient satisfaction, and side effects were evaluated. There was a significant decrease in the volume of the lesions after treatment (P < 0.01), with a volume reduction of 82.7% and 79.2%, respectively, in both groups. A significant softening of lesions vs. baseline was observed (P < 0.01), with statistically significant improvement in softening in group A (P < 0.01). There was a significant decrease in height of lesions and in redness score compared with baseline (P < 0.01) with no significant difference in between both groups. All patients mentioned a significant reduction of their subjective complaints (P < 0.01) that were more significant in group B. Skin atrophy and telangiectasia were evident in three patients of group A. The efficacy and safety of the IL BTA were clearly evident in the current work from the rapid significant amelioration of the subjective complaints and the comparable significant improvement of the objective parameters as well as the volume of the keloids in comparison with the IL corticosteroids.

Vitamin D and the skin: Focus on a complex relationship: A review

Graphical abstract

T helper 17 and Tregs: a novel proposed mechanism for NB-UVB in vitiligo.

Narrowband ultraviolet (NB‐UV)B is accepted as corner stone therapy for vitiligo. Its influence on the expression of IL‐17, IL‐ 22 and FoxP3 as markers for the Th17 and Tregs lineages has not been studied before in the context of non‐segmental vitiligo (NSV). The study included 20 active NSV patients who received 36 NB‐UVB sessions and 20 controls. Clinical evaluation Vitiligo Area Scoring Index (VASI) and determination of tissue expression of IL‐17, IL‐22 and FoxP3 by qRT‐PCR (lesional, perilesional) were carried out before and after therapy. Baseline levels of IL‐17 and IL‐22 were significantly higher in patients, whereas FoxP3 was significantly lower. After therapy, IL‐17 and IL‐22 significantly dropped, whereas FoxP3 significantly increased (lesional, perilesional). Baseline and post‐treatment VASI showed significant positive correlations with IL‐17 and IL‐22 and significant negative correlation with FoxP3 expression. Restoration of the balance between Th17 and Tregs might represent a novel pathway for the improvement that NB‐UVB exerts in vitiligo patients.

Propranolol and infantile hemangiomas: Different routes of administration, a randomized clinical trial

UNLABELLED Oral propranolol has become the treatment of choice of infantile hemangiomas (IH)s. However, the safety of systemic propranolol is questioned. Topical therapy with 1% propranolol has been reported to be safe and effective. Intralesional (IL) administration may possibly allow safe delivery of higher drug dosages. AIM To assess the efficacy and safety of two locally administered routes of propranolol (topical and IL), in comparison with its systemic oral use in the treatment of IHs. PATIENTS AND METHODS 45 patients with IHs were randomly divided into 3 groups, A, B and C (n = 15 in each), receiving oral propranolol, 2 mg/kg/day, topical propranolol 1% ointment twice daily, IL propranolol, 1 mg of propranolol hydrochloride in 1 ml of injection once weekly, respectively. Follow up was done for 6 months after treatment was stopped. RESULTS Excellent response was achieved in 9 patients in group A (60%), 3 in group B (20%) and 2 in group C (13.3%), (P value : 0.04). As regards safety, all 3 modalities proved safe with no major side effects apart from 1 patient in group A and 3 in group C who dropped out due to pain or inconvenience of therapy. CONCLUSIONS Further work is needed to establish clear guidelines and reach best formulations. Nevertheless, in properly selected patients with IHs, we recommend the usage of oral propranolol. Topically administered propranolol could be considered in patients at risk of potential side effects from oral administration. As IL application did not offer any more benefits, it could not be recommended.

Beyond vitiligo guidelines: combined stratified/personalized approaches for the vitiligo patient.

‘Vitiligo’ is a word that bears endless possibilities and no promises. Each vitiligo patient has a different story that demands a different therapeutic approach. Even though great efforts have been made to evaluate, study, compare and document the different therapeutic modalities available for vitiligo, clearly handling their modes of actions as well as their side effects and establishing clear stratified guidelines, numerous dilemmas are frequently met on practical grounds. ‘Stabilize’, ‘repigment’, ‘depigment’ or ‘camouflage’? ‘for whom and how do we achieve the best results’ ? ‘Separately or in combination ? – questions that need to be answered and decisions need to be taken in the appropriate timing and altered when the necessity arises. In the current viewpoint, we have utilized the available knowledge and exploited years of experience in an attempt to go beyond the guidelines to set the rationale for an optimal and personalized therapy, within the framework of a stratified approach.

Treatment of dystrophic epidermolysis bullosa with bone marrow non‐hematopoeitic stem cells: a randomized controlled trial

Patients with dystrophic epidermolysis bullosa (DEB) have mutations in type VII collagen gene. Type VII collagen is synthesized by keratinocytes and fibroblasts. Based on the ability of bone marrow non‐hematopoeitic stem cells (NHBMSC) to develop into fibroblasts, we decided to investigate the use of NHBMSC in the treatment of recessive DEB (RDEB). This study included fourteen patients with RDEB; the first seven of them were given cyclosporine after the infusion of NHBMSC. As cyclosporine has been used for the treatment of RDEB we decided not to use cyclosporine for the second group of seven patients. Skin biopsies from the lesions were studied by electron microscopy before and after treatment. The number of new blisters decreased significantly after treatment in both groups (p = 0.003 and 0.004 respectively) and the rate of healing of new blisters became significantly faster after treatment in both groups (p < 0.001) with no significant difference between the two groups. Electron microscopic examination revealed increased number of anchoring fibrils after treatment in both groups. No major side effects were reported during the 1‐year follow‐up period. Our findings highlight the efficacy as well as the safety of NHBMSC in the treatment of RDEB.

Assessment of interleukin-17 and vitamin D serum levels in psoriatic patients.

Livia Delgado, MD, Stephane Giraudier, PhD, Nicolas Ortonne, PhD, Ouidad Zehou, MD, Catherine Cordonnier, MD, Anne Hulin, PhD, Olivier Chosidow, PhD, Michel Tulliez, MD, and Laurence Valeyrie-Allanore, MD Department of Dermatology, Referral Centre for Auto-immune and Toxic Bullous Diseases, Department of Hematology, Department of Pathology, Laboratory of Pharmacology, Laboratory of Hematology, INSERM, CIC 006, and LIC EA4393, Henri-Mondor Hospital (Assistance Publique eHôpitaux de Paris), UPEC, F-94010 Cr eteil, France