Livedoid vasculopathy: Clinical course and long‐term outcome in Asian patients with a review of the literature

Livedoid vasculopathy (LV) is an uncommon, chronic, and recurrent thrombo‐occlusive vascular disorder. Data specific to LV in Thai population remains scarce. This study aimed to evaluate the clinical course and treatment outcomes of LV in Thai patients, and to perform a literature review for studies that reported on anticoagulant treatment in LV. Seventy‐four patients with a mean age of 37.6 ± 14.7 years were included. The female to male ratio was 5.2:1, and the median follow‐up was 10.5 months. Most patients had primary LV disorder. Forty‐eight patients were improved with treatments, with a median duration of 11.4 months. Combination treatments were commonly used, including anti‐inflammatories, antiplatelets, and immunosuppressants. Add‐on therapy with anticoagulant or psoralen plus ultraviolet‐A (PUVA) led to disease improvement in a majority of the patients treated. Kaplan‐Meier analysis demonstrated that 38.5%, 53.7%, and 57.9% would have disease improvement at 1, 2, and 3 years, respectively. Of 39 studies (n = 219) that reported on anticoagulant treatment in LV, anticoagulant drug was used as monotherapy in 104 patients. The mean duration of anticoagulant treatment was 7.2 ± 3.8 months, which led to disease improvement in 97 patients (93.3%). Bleeding side effect was found in 9 patients (8.7%). The highest incidence of LV was found among females aged 30 to 40 years. Combination therapy with anti‐inflammatory drugs, antiplatelet drugs, and immunosuppressants led to disease improvement. The observed efficacy of add‐on PUVA or anticoagulant is promising and should be further investigated. Further studies are needed to guide the development of an LV management guideline.     

Quality of life in patients with facial steroid dermatitis before and after treatment

Background Improper long‐term, even low‐dose, topical corticosteroids, especially application to the face, could induce steroid dermatitis, which was refractory and detrimental to the quality of life. Objective To evaluate the quality of life in patients with facial steroid dermatitis before and after the treatment of doxycycline and indomethacin plus support therapy. Study design A prospective study. Setting Outpatients of the Department of dermatology, the Third Hospital of Hangzhou, from August 2, 2004, to April 20, 2005. Subjects Fifty consecutive outpatients completed the treatment. Intervention The intervention is doxycycline 10 mg twice a day and indomethacin 25 mg twice a day for 4 weeks, cetirizine or loratadine 10 mg daily if pruritic, topical white petroleum if feeling dry and wet dressing if burning and oedema, plus psychological support and health education. Main outcome measure The efficacy of the treatment was quantified using a 24‐point steroid clinical score. The detriment of the quality of life was quantified using a 30‐point Dermatology Life Quality Index. Results The steroid dermatitis clinical score decreased significantly from 15.06 ± 4.61 at baseline to 4.52 ± 3.39 at 2 weeks after the end of treatment (week 6; P < 0.001). Twenty‐one patients underwent a rebound phenomenon and the steroid dermatitis clinical score increased significantly from 13.71 ± 4.33 at baseline (week 0) to 19.24 ± 3.40 at 1 week after treatment (week 1; P < 0.001). Quality of life score decreased significantly from 13.76 ± 7.68 at baseline to 3.44 ± 2.57 at 2 weeks after the end of treatment (week 6; P < 0.001). Conclusions The quality of life was profoundly affected by facial steroid dermatitis. Doxycycline and indomethacin plus support therapy might be effective in patients with facial steroid dermatitis.     

Postoperative DAV‐IFN‐β therapy does not improve survival rates of stage II and stage III melanoma patients significantly

Background DAV‐interferon (IFN)‐β therapy is a combination chemotherapy of dacarbazine (D TIC), nimustine (A CNU) and vincristine (V CR) with local subcutaneous injection of IFN‐β that is widely employed as postoperative adjuvant chemotherapy to treat malignant melanoma in Japan. However, the efficacy of DAV‐IFN‐β therapy has not been confirmed by randomized controlled trials and the benefit of DAV‐IFN‐β therapy has not been established yet. This study evaluated the contribution of DAV‐IFN‐β therapy to improve survival of postoperative patients with cutaneous melanoma. Methods Patients with stage II or III cutaneous melanoma seen at Nagoya University Hospital from January 1998 to December 2009 were eligible for this study. Disease‐free survival rates and melanoma‐specific survival rates were evaluated. A propensity score was calculated to control for the effects of variables related to decisions regarding the application of DAV‐IFN‐β therapy. Results Eighty‐two stage II and 60 stage III melanoma patients were included. In the post‐matched stage II patients (17 matched pairs), the mean (±SE) disease‐free survival rates were 39.9±13.7% for DAV‐IFN‐β therapy and 73.1±11.7% for non‐use (hazard ratio for recurrence, 2.06; 95% CI, 0.63–6.69; P = 0.23), and the melanoma‐specific survival rates were 66.2±20.0% for DAV‐IFN‐β therapy and 86.2±9.1% for non‐use (hazard ratio for death, 1.09; 95% CI, 0.17–6.82; P = 0.93). In the post‐matched stage III patients (nine matched pairs), the disease‐free survival rates were 29.6±16.4% for DAV‐IFN‐β therapy and 33.3±15.7% for non‐use (0.69; 95% CI, 0.22–2.17; P = 0.53), and the melanoma‐specific survival rates were 55.6±16.6% for DAV‐IFN‐β therapy and 44.4±16.6% for non‐use (0.67; 95% CI, 0.18–2.50; P = 0.55). Conclusions DAV‐IFN‐β therapy brought no significant improvement in either disease‐free survival rates or melanoma‐specific survival rates of patients with stage II or III cutaneous melanoma. A randomized controlled trial would be required to further evaluate the efficacy of DAV‐IFN‐β therapy as an adjuvant chemotherapy.     

Modified Emmet's operation for ingrown nails using the Er:YAG laser

BACKGROUND: Ingrowing nails are a common problem. Standard procedure is surgery according to Emmet (a gycecologist) or Emmert (a surgeon) where postoperative pain, swelling and bleeding are major side effects and traumatic damage of the nail organ is not completely avoidable. Laser surgery may provide an alternative with less tissue damage.

METHODS: We compared 138 patients with 212 affected great toe nails (98 males, 40 females) were bloodless Emmet's operation was performed with digital nerve block with 11 patients (12 affected nails) using an Er:YAG laser for atraumatic nail plate removal. Pain was registered by a semiquantitative pain scale (ranging from “zero?–?no pain” to “10?–?maximum pain“). Swelling was scored from “0?–?absent” to “3?–?severe”. Side effects like bleeding, infection or relapse were registered.

RESULTS: Emmet's nail operation: Pain was scored 7.8±3.2 on the operation day (evening), 5.3±3.1 (day 1) and 3.8±4.0 (day 3). Swelling was scored 2.7±1.8 (operation day, evening), 2.1±1.9 (day 1) and 1.3±2.1 (day 3). Wound healing lasted 16.8±3.3 days. The infection rate was 2.4%, i.e. 5 of 212 nails. The relapse rate after 6 months was 12 of 212 nails (5.7%). Spicules were observed in 9 of 212 nails (4.2%). Laser procedure: Pain was scored 8.0±1.9 (operation day, evening), 4.1±1.5 (day 1) and 0.7±2.3 (day 3). The swelling was scored 2.4±1.8 (operation day, evening), 1.5±0.9 (day 1) and 0.9±1.3 (day 3). Wound healing was complete after 12.9±3.5 days. Infections and relapse were not observed. In one case spicules occurred after 5 months. No other side effects were noted.

CONCLUSIONS: The modified Emmet's operation for ingrown nails using the Er:YAG laser provides a safe method with increased efficacy that causes less pain and swelling, a faster healing and less complications.     

5‐Methoxypsoralen plus ultraviolet (UV) A is superior to medium‐dose UVA1 in the treatment of severe atopic dermatitis: a randomized crossover trial

Background Ultraviolet (UV) A1 and psoralen plus UVA (PUVA) are effective treatment options for severe atopic dermatitis (AD); however, their relative efficacy has not yet been determined in a head‐to‐head study. Objectives To compare UVA1 and oral 5‐methoxypsoralen (5‐MOP) plus UVA with respect to efficacy, tolerability and duration of response in patients with severe generalized AD. Methods Forty patients were included in this randomized observer‐blinded crossover trial. The patients received either 15 exposures to medium‐dose UVA1 as the first treatment and, in cases of relapse, another 15 exposures to 5‐MOP plus UVA as the second treatment, or vice versa. All patients were followed until 12 months after discontinuation of the last treatment. The SCORAD score was determined by a blinded investigator at baseline, after 10 and 15 treatments each and during the follow‐up period. In addition, all adverse events were recorded during the whole study period. Results Twenty‐three patients completed the crossover treatment. Both phototherapies resulted in clinical improvement; however, PUVA reduced the baseline SCORAD score to a significantly greater extent than UVA1 (mean ± SD 54·3 ± 25·7% vs. 37·7 ± 22·8%; P = 0·041). The median length of remission was 4 weeks (interquartile range 4–12) after UVA1 and 12 weeks (interquartile range 4–26) after PUVA therapy (P = 0·012). Conclusions PUVA provides a better short‐ and long‐term response than medium‐dose UVA1 in patients with severe AD.     

The efficacy of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis: a systematic review and meta-analysis

Background Quantitative analysis of intravenous immunoglobulin (IVIg) treatment against toxic epidermal necrolysis (TEN) is lacking. Objectives To provide a meta‐analysis evidence‐based examination of IVIg efficacy against TEN. Methods A systematic review and meta‐analysis of literature published before 31 July 2011 was conducted. In observational controlled studies with at least eight patients with TEN receiving IVIg treatment, a pooled estimate of mortality risk was determined, comparing IVIg and supportive care. Statistical analyses were performed on raw data to compare the clinical differences between (i) high‐dose and low‐dose IVIg treatment in adult patients and (ii) paediatric and adult patients treated with IVIg. Results Seventeen studies met inclusion criteria. Overall mortality rate of patients with TEN treated with IVIg was 19·9%. The pooled odds ratio (OR) for mortality from six observational controlled studies comparing IVIg and supportive care was 1·00 [95% confidence interval (CI) 0·58–1·75; P = 0·99]. The pooled OR for mortality in patients treated with high‐dose IVIg vs. supportive care was 0·63 (95% CI 0·27–1·44; P = 0·27). Adults treated with high‐dose IVIg exhibited significantly lower mortality than those treated with low‐dose IVIg (18·9% vs. 50%, respectively; P = 0·022); however, multivariate logistic regression model adjustment indicated that IVIg dose does not correlate with mortality (high vs. low dose: OR 0·494; 95% CI 0·106–2·300; P = 0·369). Paediatric patients treated with IVIg had significantly lower mortality than adults (0% vs. 21·6%; P = 0·001). Conclusions Although high‐dose IVIg exhibited a trend towards improved mortality and children treated with IVIg had a good prognosis, the evidence does not support a clinical benefit of IVIg. Randomized controlled trials are necessary.     

A novel cosmetic approach for partial matricectomy in treating ingrown toenails

Background

Toenails play a great part in protecting toes and peripheral soft tissues, simultaneously playing a cosmetic role. The ideal treatment should result in a functional and aesthetic outcome.

Objective

To describe a novel, aesthetic and minimally invasive method to treat ingrown toenail.

Methods

We retrospectively analyzed 436 lesions of 395 ingrown toes in 353 patients with a mean age of 26.0 ± 13.4 (range 10–55) from June 2014 to March 2020 in our department. A novel cosmetic approach for partial matricectomy in treating ingrown toenails was undergone. The average follow-up time was 27.5 ± 2.8 months. The average period prior to work resumption, recurrence rate, and infection rate were measured. Mean pain Visual Analogue Scale (VAS) and Mean satisfaction VAS were used to evaluate the foot appearance.

Results

The average period prior work resumption was 2.2 ± 2.1 days (range, 0–7 days). The recurrence rate was 1.6% (7 lesions in 6 patients) at more than 2 years of follow-up. There was no critical complication except infection (0.46%). Mean pain VAS reduced from a preoperative score of 7.7 ± 1.5 points (range, 6–10 points) to a postoperative 3-day score of 2.2 ± 1.0 points (range, 1–4 points; p < 0.001) while Mean satisfaction VAS improved from 1.5 ± 1.3 points (range, 0–3 points) to 9.2 ± 0.6 points (range, 8–10 points; p < 0.001).

Conclusion

Our proposed approach is minimally invasive relative to conventional methods, which can achieve comparable efficacy to treat ingrown toenails with granulation tissue. Therefore, it can serve as another option to treat this specific type of ingrown toenails.     

A combination treatment of drug-laser-photon for melasma: A retrospective study of clinical cases

Background

Combinational therapy such as taking tranexamic acid while using laser treatment has been proved potential efficacy by many experiments. However, there is few research which contains large samples and consistent observations.

Objective

We evaluated clinical efficacy and safety of a new systemic treatment of drug-laser-photon therapy.

Methods

Retrospective and randomized investigator-blinded study of 75 patients with mixed type melasma was analyzed. At each visit, standardized photographs were taken using VISIA. Modified melasma area and severity index (mMASI) scores were marked using photographs by two dermatologists.

Results

The mMASI score decreased significantly from 6.92 to 3.84 after the treatment. The VISIA analyze right cheek data shows: Spots (from 49.67 ± 3.43 to 56.09 ± 3.31), UV spots (from 41.39 ± 24.45 to 44.56 ± 25.86), and Brown spots (from 23.97 ± 17.89 to 28.16 ± 21.28) are statistically increased (p = 0.035, p = 0.018, p = 0.07). All patients feel varying degrees of improvement, about 10.17% felt very much improved, 30.51% felt much improved (51%–75%), 45.76% felt moderately improved (26%–50%), and 13.56% felt little improved (1%–25%).

Limitations

This study was no control group.

Conclusion

The efficacy and safety profile of the combination of drug-laser-photon therapy systemic treatment in melasma patients has been proved. It has potential possibility to become a new, reliable, widely suitable therapy strategy.     

Efficacy and tolerability of short contact therapy with tretinoin,clindamycin, and glycolic acid gel in acne: A randomized,controlled, assessor‐blinded two‐center trial: The MASCOTTE study

Retinoids and antibiotics topical treatments are commonly used as first line therapy in mild to moderate acne. However, irritant contact dermatitis is a common side effect of topical retinoids. A strategy to increase local tolerability is the “short contact therapy” (SCT) approach, consisting in the application of the product with the complete removal after 30 to 60 minutes using a non‐aggressive cleanser. A gel containing tretinoin 0.02%, clindamycin 0.8%, and glycolic acid 4% in polyvinyl alcohol (MP‐gel) has shown to be effective as monotherapy in mild to moderate acne with a tolerability profile similar to other topical retinoids. So far, no trials have been performed with this gel comparing the tolerability profile of SCT with standard application therapy (SAT). We conducted a 2‐center randomized parallel groups, controlled, assessor‐blinded study, comparing MP‐gel applied as SCT in comparison with MP‐gel used as SAT (The “MASCOTTE” trial). Forty‐six subjects (nine men and 37 women, mean age 23 ± 4 years, range 18‐31 years) with mild‐to‐moderate acne were enrolled, after their written informed consent in a randomized, parallel groups controlled, assessor‐blinded 8‐week trial. Twenty‐three were assigned to MP‐gel once daily (evening application) using the SCT approach (ie, complete removal of product after 1 hour using a gentle cleanser), and 23 were randomized to the SAT approach with the same gel. The primary endpoint was the evolution of the tolerability score (TS) assessed evaluating four items: erythema, dryness, stinging, and burning, using a 4‐point score scale (from 0: no symptom to 3: severe symptom). Secondary endpoints were the evolution of global acne grading system (GAGS) score (range: from 0 to >39) and the investigator global assessment (IGA of acne severity) score (range from 0 to 4). TS was evaluated at 2, 4, and 8 weeks. GAGS and IGA scores were evaluated at baseline and at week eight. At week eight, an efficacy global score (EGS) (from 1: no efficacy to 4: very good efficacy) and a tolerability global score (TGS) (from 1: very low tolerability to 3: very good tolerability) evaluation were also done. All the evaluations were performed by an investigator unaware of treatment groups allocation (SCT or SAT). Thirty‐eight subjects (83%) completed the 8‐week treatment period. Eight subjects (two in the SCT group and six in the SAT group) dropped out prematurely due to low skin tolerability. In the SCT the TS at week two was 1.3 ± 1.7, in the SAT group TS was significantly higher (3.1 ± 1.7) (P = .028). TS was significantly lower in SCT group vs SAT also at weeks four and eight (P = .01; ANOVA test). The GAGS score at baseline was 19 ± 7 in the SCT group and 23 ± 4 in the SAT group (NS). At week 8 the GAGS score in SCT was significantly reduced to 8.5 ± 2.8 (?55%) (P = .001 vs baseline) and was also significantly lower in comparison with SAT group (8.5 vs 15; P = .0054). The IGA scores at baseline were 1.9 ± 0.6 in SCT and 2.4 ± 0.7 in SAT group. At week eight, in comparison with baseline values IGA score was reduced significantly by 48% in SCT and by 30% in SAT. EGS and TGS were significantly higher (better clinical efficacy and better tolerability) in SCT in comparison with SAT (3.6 ± 0.5 and 2.9 ± 0.3 vs 2.7 ± 0.6 and 1.5 ± 0.7; respectively). This tretinoin, clindamycin, glycolic acid gel, applied as SCT, has shown a better skin tolerability and at least a comparable clinical efficacy in comparison with the standard application modality in the treatment of mild‐to‐moderate acne. The SCT therefore could be an effective treatment strategy which could improve subjects' compliance and adherence.     

A randomized, multicentre study of directed daylight exposure times of 1½ vs. 2½ h in daylight-mediated photodynamic therapy with methyl aminolaevulinate in patients with multiple thin actinic keratoses of the face and scalp

Background Actinic keratoses (AKs) are common dysplastic skin lesions that may differentiate into invasive squamous cell carcinomas. Although a superior cosmetic outcome of photodynamic therapy (PDT) is advantageous compared with equally effective treatments such as cryotherapy and curettage, the inconvenience of clinic attendance and discomfort during therapy are significant drawbacks. Daylight‐mediated PDT could potentially reduce these and may serve as an alternative to conventional PDT. Objectives To compare the efficacy of methyl aminolaevulinate (MAL)‐PDT with 1½ vs. 2½ h of daylight exposure in a randomized multicentre study. Methods One hundred and twenty patients with a total of 1572 thin AKs of the face and scalp were randomized to either 1½‐ or 2½‐h exposure groups. After gentle lesion preparation and application of a sunscreen of sun protection factor 20, MAL was applied to the entire treatment area. Immediately after, patients left the clinic and exposed themselves to daylight according to the randomization. Daylight exposure was monitored with a wristwatch dosimeter and patients scored their pain sensation during treatment. Results The mean lesion response rate at 3 months was 77% in the 1½‐h group and 75% in the 2½‐h group (P = 0·57). The mean duration of daylight exposure was 131 and 187 min in the two groups. The mean overall effective light dose was 9·4 J cm^?2 (range 0·2–28·3). Response rate was not associated with effective daylight dose, exposure duration, treatment centre, time of day or time of year during which the treatment was performed. Treatment was well tolerated, with a mean ± SD maximal pain score of 1·3 ± 1·5. Conclusions Daylight‐mediated MAL‐PDT is an effective, convenient and nearly pain‐free treatment for patients with multiple thin AKs. Daylight‐mediated PDT procedures were easily performed and 2 h of daylight exposure resulted in uniformly high response rates when conducted in the period from June to October in Nordic countries.     

Increasing topical anesthetic efficacy with microneedle application

Introduction: Since topical anesthetics alone seldom provide adequate analgesia for laser resurfacing procedures, injectable forms of anesthesia are often required. However, their application is uncomfortable for the patient. In this study, it is investigated whether microneedle application would enhance the efficacy of topical anesthetics. Methods: Forty-seven patients participated in the study. Topical anesthetic agent EMLA was applied to the whole face of the patients. Microneedle treatment was applied to one side of the face with a roller-type device. Whole-face carbon dioxide laser resurfacing therapy was carried out then. The pain that patients experienced was assessed by using visual analog scale (VAS) method. VAS scores of two sides of the face were compared by using Wilcoxon signed-rank test. Results: The mean of VAS score of the microneedle treated side was 2.1 ± 1.1 while that of the untreated side was 5.9 ± 0.9 and this difference was statistically significant (Wilcoxon signed-rank test, the Z-value is ? 5.9683 and the p-value is < 0.001). Summary: This study revealed that microneedle application, with a roller-type device, is a safe and easy procedure in providing sufficient anesthesia for facial laser resurfacing without the need for supplementary nerve blocks or injections.     

Use of intravenous immunoglobulin therapy during pregnancy in patients with pemphigus vulgaris

Background Pemphigus vulgaris (PV) is a potentially fatal autoimmune disease characterized by the presence of in vivo deposition of antibodies against cell surface antigens desmoglein 1 and desmoglein 2 in the epidermis. Objectives To report the treatment outcomes in pregnant PV patients treated with intravenous immunoglobulin (IVIg) therapy. Methods Eight patients with active disease during pregnancy were treated. Patients were treated with a dose of 2 g/kg/cycle. Seven patients were treated for 2 months on post‐partum basis. Main Outcome Measures were as follows: (i) pregnancy outcome; (ii) presence of neonatal pemphigus; (iii) post‐partum flare; (iv) effect of IVIg on present and future pregnancies; (v) immediate and long‐term side‐effects in the mother and child. Results Patients ages ranged from 20 to 43 years (mean 29.6). All patients had severe and widespread disease involving the skin and multiple mucous membranes. Patients one to seven responded to IVIg therapy and did not have a post‐partum flare. Patient eight could not tolerate IVIg because of intense headaches and significant post‐partum flare. None of the neonates had pemphigus. Three patients who completed the IVIg protocol had normal second pregnancies. One patient who did not complete the protocol had a miscarriage during the second pregnancy. Since last observation, none of the patients have had a recurrence of the disease or another pregnancy. Conclusions The data suggests that IVIg can be useful and safe in treating pregnant patients with PV. No long‐term adverse effects of IVIg in the mother or in the child were observed based on a long‐term follow‐up.     

Medium-dose ultraviolet (UV) A1 vs. narrowband UVB phototherapy in atopic eczema: a randomized crossover study

Background Ultraviolet (UV) A1 and narrowband (NB)‐UVB have been reported to be effective treatments for atopic eczema (AE). Objectives We aimed to compare the efficacy of medium‐dose UVA1 and NB‐UVB mono‐phototherapy in patients with AE. Methods A randomized double‐blind controlled crossover trial (ClinicalTrials.gov Identifier: NCT00419406) was conducted in which patients with AE received a 6‐week course of both medium‐dose UVA1 and NB‐UVB. Clinical efficacy was assessed using the Six Area, Six Sign, Atopic Dermatitis (SASSAD) score and a visual analogue scale for pruritus. Assessment of health‐related quality of life was performed using the Skindex‐29. Total immunoglobulin E (IgE) and eosinophilic cationic protein (ECP) were evaluated at baseline and after each phototherapy course. Results Twenty‐eight patients who completed both UVA1 and NB‐UVB phototherapy courses on an intention‐to‐treat basis were analysed according to the crossover design. Both interventions were associated with significant clinical improvement but there was no significant difference between treatments with respect to the mean ± SD relative reduction (RR) of the clinical scores (SASSAD, 43·7 ± 31·4% vs. 39·4 ± 24·1%, P = 0·5; pruritus score, 16 ± 61·8% vs. 25·2 ± 30·5%, P = 0·5, respectively). There was no significant difference in the mean ± SD RR of the Skindex‐29 after UVA1 and NB‐UVB phototherapy (12·7 ± 18·8% vs. 16·5 ± 17·6%, P = 0·1). Changes in the total IgE and ECP levels following UVA1 and NB‐UVB did not differ significantly (P = 0·3 and P = 0·9, respectively). Conclusions A 6‐week course of NB‐UVB and UVA1 phototherapy of AE resulted in significant clinical improvement. With regard to efficacy and tolerability, both phototherapeutic modalities may be considered comparably good.     

Efficacy and safety of mycophenolate mofetil vs. methotrexate for the treatment of chronic plaque psoriasis

Background Methotrexate (MTX) is a well‐known systemic drug for moderate to severe chronic plaque psoriasis. Recently, mycophenolate mofetil (MMF) has been recommended for psoriasis. Objective To compare the efficacy and safety of MMF vs. MTX for the treatment of chronic plaque psoriasis. Methods Thirty‐eight consecutive patients with Psoriasis Area and Severity Index (PASI) >10 were randomly assigned for 12 weeks of treatment with either MTX (18 patients; initial dose, 7.5 mg/week) or MMF (20 patients; dose; 2 g/day) and were followed for 12 weeks after discontinuing the treatment. The differences between the two groups were analysed at the end of treatment and follow‐up comparing with baseline values. Results After 12 weeks of treatment, the mean ± SD score for the PASI decreased from 16.46 ± 5.29 at baseline to 3.17 ± 2.35 among 15 patients treated with MTX, whereas the score decreased from 17.43 ± 7.42 to 3.97 ± 5.95 among 17 patients treated with MMF (P > 0.05). Twelve weeks after discontinuing the treatment, the scores were 4.77 ± 3.52 and 5.94 ± 4.27, respectively (P > 0.05). PASI ‐75 were achieved in 58.8% of patients in MMF group and 73.3% in MTX group (P > 0.05). Three months after discontinuing the treatment, PASI‐75 remained in 33.3% of patients in MMF and 53.3% of MTX group (P > 0.05). Both drugs were well tolerated and side‐effects were minor and transient. Conclusions No significant differences in efficacy were found between MTX and MMF groups. MMF may represent a good alternative for the treatment of psoriasis in patients who are unable to take MTX or other available drugs due to contraindication or toxicity.     

Could azathioprine be considered as a therapeutic alternative in the treatment of alopecia areata? A pilot study

Alopecia areata is an autoimmune disease resulting in partial or total nonscarring hair loss and the treatment of severe alopecia areata is difficult. The aim of this study was to evaluate the efficacy and safety of azathioprine as a systemic monotherapy for moderate to severe alopecia areata. A total of 20 patients [14 men (70%) and six women (30%)] with minimum 6 months history of alopecia areata were included. The extent of scalp hair regrowth during and after the completion of the 6 months treatment was evaluated by the Severity of Alopecia Tool (the SALT score). The daily drug intake was calculated as 2 mg/kg of body weight. Mean duration of current episode of scalp hair loss was 26.4 (26.4 ± 17) months. Mean regrowth percentage was 52.3% (52.3 ± 38.4). Mean hair loss percentage before treatment was 72.7% (72.7 ± 28.3) compared with 33.5% (33.5 ± 30.7) after 6 months of azathioprine treatment. This showed a highly significant statistical difference (Paired t‐test, CI 95% = 21.5–54.1). Mean hair loss score (S₀–S₅) before treatment was 3.9 (3.9 ± 1.6) and after 6 months of azathioprine treatment was 1.8 (1.8 ± 1.3). Assessment showed significant difference from baseline score (sign test, P < 0.0001). No significant statistical difference was observed with respect to gender before and after azathioprine treatment. Treatment with azathioprine as a systemic monotherapy clinically produces relevant improvement in moderate‐to‐severe alopecia areata. Generally azathioprine is a low‐cost and well‐tolerated drug and with controlled studies on larger number of patients, long‐term efficacy and safety of this treatment should be investigated.     

Left ventricular systolic asynchrony: an important sign for cardiac involvement in plaque‐type psoriasis

Psoriasis is associated with cardiovascular diseases (CVD). The purpose of this study was to evaluate the relationship between Left Ventricular (LV) asynchrony and psoriasis. Asynchrony was assessed in 31 patients with psoriasis without evidence of CVD and 25 healthy subjects. All the patients and controls were subjected to tissue synchronization imaging (TSI), and conventional and tissue Doppler echocardiography. The time to regional peak systolic tissue velocity (Ts) in LV by the six‐basal‐six‐midsegmental model was measured on ejection phase TSI images, and four TSI parameters of systolic asynchrony were computed. C‐reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels in psoriatic patients were measured. All TSI parameters of LV asynchrony increased in psoriatic patients compared to the controls: the standard deviation (SD) of the 12 LV segments Ts (37.3 ± 14.8 vs. 24.6 ± 11.1, P = 0.002); the maximal difference in Ts between any two of the 12 LV segments (112.7 ± 39.8 vs. 83.1 ± 38.1, P = 0.01), the SD of the six basal LV segments (36.2 ± 17.3 vs. 23.2 ± 14.5, P = 0.008); and the maximal difference in Ts between any two of the six basal LV segments (91.3 ± 43.5 vs. 60.5 ± 37.3, P = 0.01). LV asynchrony was observed in 67.7% of psoriatic patients. Higher CRP (1.9 ± 1.3 vs. 0.92 ± 1.4, P = 0.04) and ESR (34.8 ± 17.3 vs. 20 ± 15.3, P = 0.03) levels were determined in patients with LV asynchrony. Regression analysis showed LV systolic asynchrony (P = 0.02), Tei index (P = 0.03), EF (P = 0.04), and E/A ratio (P = 0.04) were independently associated with psoriasis. LV asynchrony firstly described in patients with psoriasis may be an important finding of cardiac involvement in psoriasis.     

Importance of concomitant topical therapy in moderate‐to‐severe atopic dermatitis treated with cyclosporine

Cyclosporine (CS) is widely used in patients with refractory atopic dermatitis (AD). During CS treatment, many patients have a tendency to decrease their adherence to topical agents as their disease improves. Our aim was to compare the efficacy and relapse rate of CS treatment combined with topical therapy and CS monotherapy. This prospective, randomized, 6 month study involved 60 patients with moderate‐to‐severe AD who were randomly assigned to two groups, one receiving CS and topical agents and the other, CS only. Clinical outcomes were based on investigators’ global assessment (IGA) scores, eczema areas and severity index scores, and trans‐epidermal water loss. If a patient achieved treatment success (IGA score ≤2) during the study period, CS was stopped. Relapse rate and time to relapse were evaluated during the 3 months after discontinuation of CS. The treatment success rate was significantly higher in the combination group (p = 0.028). The combination group had a shorter median time to response (p = 0.040), a lower cumulative dose (p = 0.041), and a longer time to relapse (p < 0.01) than the monotherapy group. Although CS monotherapy is effective against AD, topical agents should be used concomitantly.     

Non‐ablative 1550‐nm erbium‐glass and ablative 10 600‐nm carbon dioxide fractional lasers for acne scars: a randomized split‐face study with blinded response evaluation

Background Non‐ablative 1550‐nm erbium‐doped fractional photothermolysis systems (FPS) and 10 600‐nm carbon dioxide fractional laser systems (CO₂ FS) have been effectively used to treat scars. Objective We compared the efficacy and safety of single‐session treatments of FPS and CO₂ FS for acne scars through a randomized, split‐face, evaluator‐blinded study. Methods Eight patients with acne scars were enrolled in this study. Half of each subject’s face was treated with FPS and the other half was treated with CO₂ FS. We used a quartile grading scale for evaluations. Results At 3 months after the treatment, the mean grade of improvement based on clinical assessment was 2.0 ± 0.5 for FPS and 2.5 ± 0.8 for CO₂ FS. On each side treated by FPS and CO₂ FS, the mean duration of post‐therapy crusting and scaling was 2.3 and 7.4 days respectively and that of post‐therapy erythema was 7.5 and 11.5 days respectively. The mean VAS pain score was 3.9 ± 2.0 with the FPS and 7.0 ± 2.0 with the CO₂ FS. Conclusion We demonstrated the efficacy and safety of single‐session acne scar treatment using FPS and CO₂ FS in East Asian patients. We believe that our study could be used as an essential reference when choosing laser modalities for scar treatment.     

The management of livedoid vasculopathy focused on direct oral anticoagulants (DOACs): four case reports successfully treated with rivaroxaban

Livedoid vasculopathy (LV) is a thrombotic skin disease characterized by episodic painful ulcerations of the distal aspects of the legs. Its healing process typically leaves small porcelain‐white scars called atrophie blanche as a result of the occlusion of cutaneous microcirculation. The main goals of the treatment are pain management and the prevention of ulceration and of progressive scarring in the malleolar area. The therapeutic management is still a challenge, however, and most treatments were based on anecdotal off‐label protocols. Over such context, direct oral anticoagulants (DOACS) arise as a potential treatment for this disease. This class of medications became an alternative from initial large studies applied on different pathologic scenarios regarding thromboembolic events. In that line, recent case series using DOACS, including rivaroxaban, started to emerge in the literature related to LV and reported successful prevention of cutaneous infarctions and ulcerations, providing physicians with a new promising alternative. The current report describes four cases of long‐term recalcitrant LV, in which rivaroxaban monotherapy effectively reduced pain and cutaneous ulcerations in a few weeks of treatment without relevant side effects. The authors also review therapy management of the disease, focused on DOACS, and suggest a step‐by‐step approach to treat these patients, taking into consideration different resource profiles of each level of local health centers, the gravity of the cases, and risks/benefits for patients.     

Effect of climate therapy at Gran Canaria on vitamin D production, blood glucose and lipids in patients with psoriasis

Background Climate therapy (heliotherapy) of psoriasis is an effective and natural treatment. Ultraviolet radiation (UVB) from the sun improves psoriasis and induces vitamin D₃ synthesis. Objective The aim of the study was to investigate the effect of climate therapy on vitamin D₃ synthesis, blood glucose, lipids and vitamin B12 in psoriasis patients. Methods Twenty Caucasian patients (6 women and 14 men; mean age, 47.2 years; range, 24–65) with moderate to severe psoriasis [mean Psoriasis Area and Severity Index (PASI) score 9.8; range, 3.8–18.8] received climate therapy at the Gran Canarias for 3 weeks. Blood samples were drawn before and after 15 days of sun exposure. In addition, the patients’ individual skin UV doses based on UV measurements were estimated. Results Sun exposure for 15 days lead to a 72.8% (± 18.0 SD) reduction in the PASI score in psoriasis patients. Although no direct correlation was observed between PASI score improvement and UVB dose, the sun exposure improved the vitamin D, lipid and carbohydrate status of the patients. The serum concentrations of 25‐hydroxyvitamin D [25(OH)D] increased from 57.2 ± 14.9 nmol/L before therapy to 104.5 ± 15.8 nmol/L (P < 0.0001) after 15 days of sun exposure; the serum levels of 1,25‐dihydroxyvitamin D [1,25(OH)₂D] increased from 146.5 ± 42.0 to 182.7 ± 59.1 pmol/L (P = 0.01); the ratio of low‐density lipoprotein cholesterol and high‐density lipoprotein cholesterol decreased from 2.4 to 1.9 (P < 0.001); and the haemoglobin A₁c (HbA₁c) levels decreased from 5.6 ± 1.7% to 5.1 ± 0.3% (P < 0.0001). Conclusion Climate therapy with sun exposure had a positive effect on psoriasis, vitamin D production, lipid and carbohydrate status.