Can dietary furanocoumarin ingestion enhance the erythemal response during high-dose UVA1 therapy?

As phototoxic skin reactions caused by psoralen are induced by wavelengths within the UVA1 spectrum, we assessed the potential of the small amount of psoralen in a normal diet to provoke phototoxicity in volunteers with skin types I and II. Threshold erythema was unaffected by ingestion of a 200-g portion of parsnip.     

Does topical tacrolimus ointment enhance the efficacy of narrowband ultraviolet B therapy in vitiligo? A left–right comparison study

Background: Narrowband ultraviolet B (NB‐UVB) therapy has emerged as one of the most favored treatment options in patients with generalized vitiligo. The aim of combining topical agents is to improve the efficacy of NB‐UVB in causing repigmentation in vitiligo. Aims and objectives: The present study aims to study the effect of combining topical tacrolimus to NB‐UVB therapy in causing repigmentation in vitiligo lesions. Methods: This prospective single‐blind study was performed on 80 patients of generalized vitiligo above 12 years of age who had symmetrically distributed vitiligo lesions on the face, trunk or limbs. The patients applied topical tacrolimus 0.1% ointment twice daily on selected symmetrically distributed lesions on the left side of the body. No topical agent was applied on the corresponding lesions on the right side. The patients also received whole‐body NB‐UVB exposure three times every week on non‐consecutive days according to a set protocol. Lesions selected for the comparison analysis were photographed serially and assessed by a single‐blinded observer for the extent or repigmentation achieved. The extent of repigmentation achieved was calculated on the basis of VASI scoring. The time taken for the initial repigmentation to start, the overall repigmentation achieved as well as any adverse effects were noted down and compared between the selected lesions on the two sides. Results: Seventy‐four patients with 234 symmetrical vitiligo lesions were available for comparison analysis at the end of study period. The mean repigmentation achieved on the left‐sided study lesions was approximately 71% (VASI score of approximately 4.0) as compared with 60.5% on the symmetrically distributed right‐sided lesions (VASI score of 3.4). Moreover, the repigmentation started earlier on the study lesions on left side than on the right‐sided ones. No significant adverse events were reported with the combination treatment. Conclusions: Addition of topical tacrolimus increases the extent of overall repigmentation achieved with NB‐UVB therapy in vitiligo and also reduces the cumulative NB‐UVB dose needed to achieve a therapeutic benefit in affected patients.     

Is the efficacy of psoralen plus ultraviolet A therapy for vitiligo enhanced by concurrent topical calcipotriol? A placebo‐controlled double‐blind study

BACKGROUND: Encouraging results of previous uncontrolled trials suggest that calcipotriol may potentiate the efficacy of psoralen plus ultraviolet (UV) A (PUVA) therapy in patients with vitiligo. OBJECTIVES: We performed a placebo-controlled double-blind study to investigate whether the effectiveness of PUVA treatment could be enhanced by combination with topical calcipotriol in the treatment of vitiligo. METHODS: Thirty-five patients with generalized vitiligo enrolled in the study. Symmetrical lesions of similar dimensions and with no spontaneous repigmentation on arms, legs or trunk were selected as reference lesions. In this randomized left-right comparison study, calcipotriol 0.05 mg g(-1) cream or placebo was applied to the reference lesions 1 h before PUVA treatment (oral 8-methoxypsoralen and conventional UVA units) twice weekly. Patients were examined at weekly intervals. The mean number of sessions and the cumulative UVA dosage for initial and complete repigmentation were calculated. RESULTS: Twenty-seven patients (nine women, 18 men; mean +/- SEM age 29.8 +/- 13.5 years) were evaluated. The mean +/- SEM cumulative UVA dose and number of UVA exposures for initial repigmentation were 52.52 +/- 6.10 J cm(-2) and 9.33 +/- 0.65 on the calcipotriol side, and 78.20 +/- 7.88 J cm(-2) and 12.00 +/- 0.81 on the placebo side, respectively (P < 0.001). For complete repigmentation, respective values were 232.79 +/- 14.97 J cm(-2) and 27.40 +/- 1.47 on the calcipotriol side and 259.93 +/- 13.71 J cm(-2) and 30.07 +/- 1.34 on the placebo side (P = 0.001). Treatment with calcipotriol and PUVA resulted in significantly higher percentages of repigmentation for both initial (81%) and complete pigmentation (63%), compared with placebo and PUVA (7% and 15%, respectively). CONCLUSIONS: Our results have shown that concurrent topical calcipotriol potentiates the efficacy of PUVA in the treatment of vitiligo, and that this combination achieves earlier pigmentation with a lower total UVA dosage.     

Could colorimetric method replace the individual minimal erythemal dose (MED) measurements in determining the initial dose of narrow‐band UVB treatment for psoriasis patients with skin phototype III–V?

Background Assessment of minimal erythemal dose (MED) for individual patients has been used to guide the narrowband Ultraviolet B (NB‐UVB) phototherapy, which sometimes causes discomfort and additional time. The L* value (the lightness of color in Commission Internationlale de l’Eclairge L*a*b* color scale) measured by colorimeter was shown to be useful for predicting sensitivity to NB‐UVB irradiation. Objective To compare the efficacy and safety of NB‐UVB phototherapy between 50% of MED and colorimetric L* value starting dose regimens for skin phototype III–V Korean patients with psoriasis. Method Twenty seven patients determined starting doses based on colorimetric L* value, and 27 patients based on 50% of MED. Since correlation analysis showed that L* value had the most significant association with MED compared with skin phototypes, a*, and b* values, we designated starting doses of L* value regimen as follows: 300 mJ/cm² (L* >66), 400 mJ/cm² (62 < L*≤66), and 500 mJ/cm² (L*≤62). Results There was no significant difference between two groups in clinical efficacy including response rate, mean number of sessions, duration of treatment, maximum dose and cumulative dose until achieving the state of near clearance. The proportion of adverse effects was not also significantly different. Conclusions NB‐UVB starting dose determination based on colorimetric L* value was comparable with conventional MED based regimen in efficacy and safety for skin phototype III–V patients. Since it provides much convenience and ease for both patients and physicians, colorimetric L* value could partly substitute the MED checking methods in NB‐UVB phototherapy.     

Can rituximab be used in the treatment of pemphigus vulgaris during the COVID‐19 pandemic?

Rituximab is a monoclonal antibody that targets CD20, a B‐lymphocyte antigen; that leads to a decline in the B‐cell counts for at least a year. The patients who have received rituximab treatment in the previous 5 years with the diagnosis of pemphigus group of diseases at Cerrahpa?a Medical Faculty were questioned for COVID‐19 infection. A total of 48 patients were included in this study; only one male patient had COVID‐19 infection which had a mild course. There is no significant difference in the total number of lymphocytes between patients who have received rituximab within the previous 5 years or last year. The number of lymphocytes is independent of the number of courses of rituximab treatment received. Therefore, we suggest that all pemphigus patients who have received rituximab treatment within the previous 5 years should be careful of the preventive measures against the COVID‐19 infection irrespective of the number of treatment courses or the number of years which has passed since the treatment. The disease course was mild in the only infected patient. Thus, rituximab may be used in the treatment of pemphigus vulgaris during the COVID‐19 pandemic if its use is necessary.     

Can the response of port‐wine stains to laser treatment be reliably assessed using subjective methods?

Assessing the results of laser treatment of port-wine stains (PWS) is very subjective. Most publications use scoring systems that physically describe the change in PWS after treatment. For results derived from such an analysis to be meaningful, the observers must be able to produce results that not only have a small interobserver variability but are also reproducible. Previous studies have addressed the former but not the latter. The present study was undertaken to investigate this area of concern. Six professionals, experienced in laser work, blindly assessed the response to laser treatment of 20 PWS, on two occasions, 1 month apart. Twenty pairs of comparable clinical photographs (one pretreatment and one post-treatment) were assessed using three different scoring systems commonly used in previous publications. Intrarater concordance between the two sessions was then assessed. Our results demonstrated that the judges could only consistently score results at the extremes of outcome. There was little agreement in the assessment of results lying between these. The judges were, however, consistently able to place a similar proportion of patients in each outcome category. We conclude that, as yet, there is no satisfactory method of monitoring the progress of an individual's PWS following laser treatment. However, the scoring systems examined would seem to be reasonable for presenting the data from patient series.     

Can the brain inhibit inflammation generated in the skin? The lesson of α‐melanocyte‐stimulating hormone

The neuro-immuno-cutaneous-endocrine network is not a simple construct featuring organ systems intimately involved in the bridge between body and mind. Mind-body influences are bi-directional and the skin should be considered an active neuroimmunoendocrine interface, where effector molecules of neuropeptides act as common words used in a dynamic dialogue between brain, immune system and skin. Gamma-melanocyte stimulating hormone (gamma-MSH), one of the principal neuroimmunomodulating peptides, seems to exercise some control on the cutaneous inflammatory process, through a central action mediated by descending anti-inflammatory neural pathways and via local direct influence on inflammatory cells infiltrating the dermis, such as monocytes, macrophages and neutrophils. Gamma-MSH down-regulates the production of proinflammatory cytokines, while the production of the anti-inflammatory cytokine IL-10 is stimulated by gamma-MSH. Finally, gamma-MSH seems to regulate the expression of surface molecules in immunocompetent cells. Thus, further studies may lead to the use of gamma-MSH as an important anti-inflammatory agent in clinical dermatology.     

Rate of growth—A novel surrogate marker for high‐risk cutaneous squamous cell carcinoma? A case report and review of the literature

Cutaneous squamous cell carcinoma (cSCC) is one of the most common nonmelanoma skin cancer worldwilde, with a more invasive growth pattern and higher potential to metastatize than basal cell carcinoma. Although several risk factors have been linked to a high metastatic potential of cSCC, no widely accepted classification system for this common subtype of cancer exists. Herein we report an emblematic case of rapidly growing and metastatic cSCC and discuss the rate of growth of the tumour (ROG) as novel prognostic high risk surrogate marker.     

Is occupational solar ultraviolet irradiation a relevant risk factor for basal cell carcinoma? A systematic review and meta‐analysis of the epidemiological literature

Summary Background The most important risk factor for basal cell carcinoma (BCC) is ultraviolet (UV) radiation. It is reasonable to assume that outdoor workers with a long history of work‐related UV exposure are at increased risk of developing BCC. Objectives To analyse systematically the epidemiological literature concerning the evidence of an association between occupational UV exposure and BCC risk in outdoor workers. Methods Systematic literature review of cohort studies and case–control studies providing data on occupational UV exposure and BCC occurrence. PubMed (up to 28 January 2011) was searched, supplemented by hand searching and consultation of experts in the field. The association between occupational UV exposure and BCC risk is presented as odds ratios (ORs). A random‐effects meta‐analysis and sensitivity analysis including meta‐regression on study‐specific covariates were performed. Results Twenty‐four relevant epidemiological studies (five cohort studies, 19 case–control studies) were identified. Twenty‐three studies reported sufficient data to be included in the meta‐analysis. The pooled OR for the association between outdoor work and BCC risk was 1·43 (95% confidence interval 1·23–1·66; P = 0·0001). Studies adjusting for sex (P < 0·0001) and individual nonoccupational UV exposure (P = 0·014) showed a significantly stronger association of occupational UV exposure and BCC risk. Meta‐regression revealed a significant inverse relationship between occupational UV radiation exposure and BCC risk with latitude (P = 0·015). Conclusions Published epidemiological literature indicates that outdoor workers are at significantly increased risk for BCC. This finding is highly relevant for health policy to stimulate the implementation of effective prevention strategies.     

Hepatosplenisches T‐Zell‐Lymphom unter Therapie mit TNF‐α‐inhibierenden Biologics: (k)ein Risiko für Patienten mit Psoriasis?

Tumor necrosis factor (TNF)‐α antagonists have considerably improved the therapeutic approach to chronic inflammatory disorders including psoriasis vulgaris. Recently, some cases of highly aggressive hepatosplenic T‐cell lymphoma (HSTCL) have developed in patients with inflammatory bowel diseases (IBD) being treated with infliximab or adalimumab. Analysis of the published data suggests that the emergence of HSTCL is favored by the combination of purine analogues and infliximab or adalimumab in the therapy of a granulomatous inflammation involving Vδ1⁺γδ T cells. Because psoriasis vulgaris is different from IBD in regard to the type of inflammation, the concomitant therapies used and the tissue‐specific subsets of γδ T cells, the use of infliximab or adali‐mumab in psoriasis may not necessarily be associated with an increase in the risk of HSTCL.     

Chronic unremitting urticaria: is the use of antihistamines above the licensed dose effective? A preliminary study of cetirizine at licensed and above‐licensed doses

Recently, several authors have suggested an off-label increase of antihistamine dosage should be given to patients with chronic urticaria (CU) not responding to the usual, recommended doses, in order to gain better control of the disease. However, this recommendation is not evidence-based. The objective of this study was to assess the effectiveness of increased doses of antihistamines in patients with CU showing poor control at recommended doses. In total, 22 adult patients with moderate/severe CU not controlled with the usual antihistamine doses were studied. These subjects recorded urticaria severity on a visual analogue scale (range 0-10) for 2 weeks. During the first week, they were treated with cetirizine at the licensed dose (10 mg/day), and with a three-fold increased dose (10 mg x 3/day) during week 2. Only 1 patient (5%) responded satisfactorily to the increased dosage of antihistamine; in the remaining 21 subjects, urticaria scores did not change, and these patients had to be treated with steroids, ciclosporin, and in 1 case with cyclophosphamide. Disease control was eventually gained in all cases. This study suggests that the proportion of patients with severe CU that may gain a better control of their disease with high, off-label doses of antihistamines is probably small, and that most patients will eventually have to undergo more aggressive treatments.     

Do the filarial lymphoedema patients’‘3 months recall’ on acute dermato‐lymphangio‐adenitis (ADLA) correlate with streptococcal serology?

Aim The aim of this study was to know the correlation of patients’ 3 months recall on acute dermato‐lymphangio‐adenitis (ADLA) with anti‐streptolysin O (ASO) serology and its application as a tool to know the burden of ADLA in the community. Methods Fifty‐nine lymphoedema (LE) patients and 27 age matched controls were clinically assessed for LE and the occurrence of ADLA during the previous 3 months was obtained by recall. After obtaining the informed consent, 2 mL of venous blood sample was collected and ASO was quantified in Olympus AU400 auto‐analyzer. Results When the results were computed as two groups, controls and LE patients with no reported ADLA and LE patients with reported ADLA (by 3 months recall), the ASO positivity and ASO titre was significantly higher in the later group (P < 0.05). When the results were computed as three groups, controls with no reported ADLA, LE patients with no reported ADLA and LE patients with reported ADLA, the ASO titre was significantly higher in LE patients reported ADLA (P < 0.05). Conclusion As ASO was measured in post‐infection phase, we relied on the ASO titre for making conclusion. Patients’ 3 months recall on ADLA correlates with the ASO titre and therefore, it could be considered as a tool to measure the burden of ADLA in the community. Multicentre community‐based studies are needed to ascertain the findings.