Zulal Erbagci

The significance of Demodex folliculorum density in rosacea

Background Demodex folliculorum has been reported in rosacea in a number of clinical studies. As the Demodex mite is also present in many healthy individuals, it has been suggested that the mite may have a pathogenic role only when it is present in high densities. Moreover, some authors have proposed that a mite density above 5/cm2 may be a criterion for the diagnosis of inflammatory rosacea. In this study, the possible role of D. folliculorum and the importance of mite density in rosacea were investigated using a skin surface biopsy technique.BACKGROUND Demodex folliculorum has been reported in rosacea in a number of clinical studies. As the Demodex mite is also present in many healthy individuals, it has been suggested that the mite may have a pathogenic role only when it is present in high densities. Moreover, some authors have proposed that a mite density above 5/cm2 may be a criterion for the diagnosis of inflammatory rosacea. In this study, the possible role of D. folliculorum and the importance of mite density in rosacea were investigated using a skin surface biopsy technique. METHODS Thirty-eight patients with rosacea and 38 age-and-sex-matched healthy subjects entered the study. With the skin surface biopsy technique, we obtained samples from three facial sites. We then determined the mite positivities, the mean mite counts in both study groups, the mean mite densities at each facial site and in the rosacea subgroups, and the mite densities above 5/cm2. RESULTS The mean mite count in the rosacea group (6,684) was significantly higher than that in controls (2,868; p < 0.05). The cheek was the most frequently and heavily infested facial region. Ten rosacea patients and five normal subjects had mite densities over 5/cm2; the difference was not statistically significant (p > 0.05). CONCLUSIONS Rosacea is a disease of multifactorial origin, and individual properties may modify the severity of the inflammatory response to Demodex. We suggest that a certain mite density is not an appropriate criterion in the diagnosis of the disease; nevertheless, large numbers of D. folliculorum may have an important role in the pathogenesis of rosacea, together with other triggering factors.

Childhood bullous pemphigoid following hepatitis B immunization.

Bullous pemphigoid (BP) is an acquired autoimmune bullous disorder which predominantly affects the elderly. It is very rare in children. There are approximately 50 reported cases of childhood BP. Although the cause of childhood BP is unknown, drug intake and vaccination have been incriminated in some cases. A total of 13 patients with BP (10 adults and 3 infants) have been described to be related to various vaccines and tetanus toxoid booster. However, no case related to hepatitis B vaccination has previously been reported. Our case of childhood BP developed one week after hepatitis B immunization in a Turkish caucasian child. This case suggests that the hepatitis B surface antigen can function as the triggering factor for BP by inducing a nonspecific immune reactivation which unmasks subclinical BP or by stimulating a specific antibody production that may cross–react with BP antigens.

Rapid improvement of human orf (ecthyma contagiosum) with topical imiquimod cream: report of four complicated cases

Orf is a zoonosis caused by an epitheliotropic DNA parapox virus. Human orf is a generally benign, self‐limiting condition that usually regresses in 6–8 weeks without specific treatment. However, it may be accompanied by local symptoms including pain, pruritus, lymphangitis and axillary adenitis, or less frequently by systemic symptoms such as fever or malaise. Furthermore, it may be complicated by erythema multiforme, Stevens‐Johnson syndrome, erysipelas, generalized mucocutaneous eruption, toxic erythema, eyelid oedema and giant, persistent or recurrent lesions in immunocompromised patients. Imiquimod, a potent topical immune response modifier, enhances both the innate and acquired immunity by stimulation of immune system cells resulting in local antiviral, antitumour and immunoregulatory activity. We present, for the first time, four complicated cases of orf successfully treated by topical imiquimod resulting in rapid regression of both orf and associated lesions. Two of the cases were complicated with erythema multiforme, one with recurrent eyelid oedema, and another had giant orf associated with axillary lymphadenitis. We suggest that topical imiquimod may be an effective and safe therapy for complicated orf cases.

Multiple NSAID Intolerance in Chronic Idiopathic Urticaria Is Correlated with Delayed, Pronounced and Prolonged Autoreactivity

Autologous serum skin test (ASST) reactivity is positive in up to 60% of patients with chronic idiopathic urticaria (CIU). About 21 to 30% of patients with CIU have intolerance to acetyl salicylic acid (ASA) and/or other chemically unrelated non‐steroidal anti‐inflammatory drugs (NSAIDs). To investigate the relationship between ASA/NSAID intolerance and ASST reactivity, a case‐control study was performed in 110 patients with CIU and 60 healthy controls. A positive ASST was defined as an erythematous wheal with a diameter of ≥ 5 mm more than the saline‐induced response. Patients were assessed at 10‐minute intervals for a minimum of three hours. ASA/NSAID intolerance was ascertained by a placebo controlled‐provocation test with offending drug (s). Forty‐two patients with CIU (38.2%) had autoreactivity whereas only two of the controls (3.3%) displayed early and weak skin responses (P<.0001). ASA/NSAID intolerance was demonstrated in 30 (27.3%) patients with CIU. The prevalences of autoreactivity were 93.3% (28/30) and 17.5% (14/80) in patients with and without ASA/NSAID intolerance, respectively (P<.001). Thirteen of the 25 ASST‐positive patients (52%) who had single (n: 7) or multiple (n: 6) NSAID intolerance showed early (before or at 30 min) and mild autoreactivity of short duration, whereas 15 of the remaining 17 ASST‐positive patients (88.2%) who all had multiple NSAID intolerance showed delayed (later than 30 min) and prolonged autoreactivity (P<.05). These findings suggest that a common mechanism may be responsible for the pathogeneses of both delayed autoreactivity and multiple NSAID intolerance in CIU. It might be further speculated that delayed, prolonged, and pronounced autoreactivity may be a possible predictor for multiple NSAID sensitivity in CIU.

The prevalence of hepatitis C virus infection in patients with lichen planus in Gaziantep region of Turkey

The purpose of this case–control study was to investigate the association between lichen planus (LP) and hepatitis C virus (HCV) infection in Gaziantep region of Turkey. Seventy-three patients with LP and a control group of patients (n: 73) with a dermatological disorder other than LP were detected for HCV infection using a third generation enzyme-linked immunosorbent assay (ELISA). A serological positivity for HCV was found in five of LP patients (6.84%), whereas it was positive for only one patient of the control group (1.36%). A statistically significant difference was found between LP and control groups (p < 0.05). We conclude that the coexistence of the two diseases is probably more than coincidental.

A prospective epidemiologic survey on the prevalence of onychomycosis and dermatophytosis in male boarding school residents.

Dermatophyte infections and onychomycosis are not usually serious in term of mortality; however, they may have significant clinical consequences such as secondary bacterial infections, chronicity, therapeutic difficulties and esthetic disfigurement in addition to serving as a reservoir of infection. Our aim was to determine the prevalence of onychomycosis and dermatophytosis in a selected high risk group, consisting of male boarding school residents. A total of 410 males inhabiting two houses were evaluated by two dermatologists. In cases of clinical suspicion, appropriate samples were taken for direct microscopy and culture. The results showed that the prevalences of tinea pedis (athlete’s foot) and pure pedal onychomycosis were 51.5% (n:211) and 4.4% (n:18), respectively. Thirty cases of those with tinea pedis were complicated by toenail onychomycosis. Tinea cruris was present only in five cases with tinea pedis. Interestingly 71.1% of those with tinea pedis and 45.8% of those with onychomycosis, associated with or without tinea pedis were unaware of their diseases. The most common fungal isolate was Trichophyton rubrum (76.6%) followed by Epidermophyton floccosum (11.6%), T. interdigitale (10.55%). Approximately one third of the cultures from nail specimens yielded pure growths of nondermatophyte moulds or Candida albicans. In conclusion, we found unexpectedly high prevalences of occult athlete’s foot and toenail onychomycosis among the male residents of student houses. Our results indicate that health-care workers of such common boarding-houses should be more aware of clinical and subclinical dermatophyte infections and onychomycosis, and have more active approaches to educational measures and management strategies to prevent further infections. To our knowledge, this is the first epidemiologic study on the prevalences of dermatophytosis and onychomycosis in boarding-houses from Turkey.

High incidence of demodicidosis in eyelid basal cell carcinomas

Background Although UV radiation is the major cause of basal cell carcinoma (BCC), local factors, such as chronic trauma, irritation, or inflammation, may also have some role in its etiopathogenesis. The pilosebaceous follicle mites, Demodex folliculorum and D. brevis, inhabit most commonly and densely certain facial skin areas, including the nose and periorbital regions, where BCC also develops most frequently.

Topical Therapy for Dermatophytoses

AbstractDermatophytoses, commonly known as ringworm or tinea, represent superficial fungal infections caused by dermatophytes, which are among the most common infections encountered in medicine. The use of corticosteroid-containing combinations in dermatophyte infections that are usually treated with topical medications is still a much-debated issue. The addition of a corticosteroid to local antifungal therapy may be of value in reducing local inflammatory reaction and thus carries the theoretical advantage of rapid symptom relief in acute dermatophyte infections associated with heavy inflammation. However, the use of such combinations requires caution as they have some potential risks, especially with long-term use under occlusive conditions. Corticosteroid-induced cutaneous adverse effects have been reported primarily in pediatric patients due to inappropriate application of these preparations on diaper areas. Additionally, the corticosteroid component may interfere with the therapeutic actions of the antifungal agent, or fungal growth may accelerate because of decreased local immunologic host reaction, such that underlying infection may persist, and dermatophytes may even acquire the ability to invade deeper tissues.Analysis of the literature documenting clinical study data and adverse reactions related to combination therapy, drew the following conclusions: (i) combination products containing a low potency nonfluorinated corticosteroid may initially be used for symptomatic inflamed lesions of tinea pedis, tinea corporis, and tinea cruris, in otherwise healthy adults with good compliance; (ii) therapy should be substituted by a pure antifungal agent once symptoms are relieved, and should never exceed 2 weeks for tinea cruris and 4 weeks for tinea pedis/ corporis; and (iii) contraindications for the use of these combinations include application on diaper or other occluded areas and facial lesions, as well as in children <12 years of age and in immunosuppressed patients for any reason.

Deep dermatophytoses in association with atopy and diabetes mellitus: Majocchi's granuloma tricophyticum or dermatophytic pseudomycetoma?

Two patients presenting with subcutaneous nodules, plaques, papules and ulceration caused by dermatophytes are described in this report. The first case was atopic and had used low dosesystemic corticosteroids intermittently for his asthma. The second case was a poorly controlled and long-standing diabetic patient. The diagnoses were suspected after direct microscopical examinations of the discharge materials which revealed the presence of hyaline hyphae and spores, and histological examination which showed an inflammatory infiltrate with fungal elements in the dermis. Cultures of puncture materials and skin biopsies confirmed the diagnosis identifyingTrichophyton rubrumand T. mentagrophytes var interdigitale,in the first and second case respectively. Antifungal therapy with itraconazole was successful in both patients. The cases are presented to emphasize the possibility of this unusual condition in association with atopy and diabetes mellitus as in profoundly immunosuppressed cases. The nomenclature concerning this type of dermatophyte infections is also discussed.

Human arylamine N-acetyltransferase 2 polymorphism and susceptibility to allergic contact dermatitis.

Background  N‐acetyltransferase 2 (NAT2) polymorphism may be involved in the pathogenesis of allergic contact dermatitis.