Enayat Attwa

Psoriasis is a papulosquamous disorder that causes significant social and psychological trauma to the patient. It is characterized by the presence of erythematous, indurated plaques covered with silvery-white scales. Despite the availability of several systemic agents that have been approved for the treatment of psoriasis, usually there are some residual lesions and there is a need to treat them for cosmetic reasons or symptomatic control. 1. Treatment of resistant localized psoriatic plaques or residuals after systemic treatment. 2. Recently, some intralesional agents have been used successfully for the treatment of psoriatic plaques as 5-FU, methotrexate, and botulinum toxin type-A, and nearly for four decades, no study focused on the effect of intralesional corticosteroids in the treatment of these psoriatic plaques. We decided to highlight their role and compare intralesional Triamcinolone to intralesional 5-FU regarding efficacy and safety in the treatment of plaque psoriasis. This study included 24 patients with localized plaque psoriasis. Each patient was treated by split-body therapy where one psoriatic plaque was treated with intralesional 5FU and another plaque with intralesional TAC. A total of three injections were given at 2-week intervals and follow up was regularly every 2 weeks up to 12 weeks. There was a statistically significant difference between both groups (p = 0.008) as the response rate on 5-FU side was 12.5% with no response, 29.2% with a moderate response, 41.7% with an excellent response, and 16.7% with a complete clearance, while on the TAC side it was16.7% with a moderate response, 20.8% with an excellent response and 62.5% with a complete clearance. Hyperpigmentation was the most irritating side effect of 5-FU that occurred. Pain, during and after injection, was greater in 5-FU group. Hypopigmentation and atrophy only occurred in TAC group in some patients but it seems to be reversible and not disfiguring. 1-Intralesional TAC injection may have more efficacy and less side effects than 5-FU injection in the treatment of localized plaque psoriasis. Hyperpigmentation and pain were the most irritating side effects of 5-FU 2-Intralesional TAC can be effective in the treatment of localized psoriatic plaques with minimal side effects, especially in patients not suitable for systemic agents.

Background YKL‐40, a mammalian chitinase 3‐ like protein that was associated with multiple inflammatory and immune diseases. Previous studies have suggested a role for YKL‐40 in psoriasis based on its significantly higher levels in the serum of psoriatic patient compared to healthy controls. Aim The aim of this study was to determine the correlation between serum YKL‐40, psoriasis severity using PASI score and serum levels of IL‐17 before and after narrow‐band UVB therapy. Methods 28 patients with moderate to severe plaque psoriasis, as defined by PASI scores, were enrolled in this prospective cohort study. All cases received NB‐UVB phototherapy twice weekly for three month. Serum YKL‐40 and IL‐17 levels were evaluated before and after three months of treatment. Clinical photographs were taken both at baseline and after three month. Results There was a statistical positive correlation between serum levels of YKL‐40 and serum IL‐17 levels as well as PASI score in patients with moderate to severe psoriasis before and after treatment. Conclusion YKL‐40 represents a reliable marker for psoriasis severity estimated by PASI and positively correlated with IL 17 as an inflammatory marker in psoriasis.

Background: Microneedling is a valuable tool that can be used in transdermal drug delivery in vitiligo patients to improve drug permeability and efficacy with minor side effects.Aims: The aim of this study is to assess the effectiveness of using microneedling prior to application of topical 5‐FU in treatment of localized vitiligo and to compare its results with microneedling alone.Methods: Twenty‐seven patients with localized stable vitiligo are chosen. Two patches are determined in every patient: patch A treated with needling alone and patch B treated with needling followed by topical application of 5‐fluorouracil once every 2 weeks for three months. Repigmentation was accessed by grades ranging from G0; no response to G4; >75% repigmentation. Side effects were reported in every visit.Results: Microneedling followed by topical application of 5‐fluorouracil showed better response than needling alone with minimal side effects.Conclusion: Combining microneedling with topical drug application yields better results in treating localized vitiligo.

Psoriasis is a common inflammatory skin disorder with complex pathomechanisms. Methotrexate (MTX) is an antiproliferative and immunomodulating agent that control psoriasis. The aim of this study is to compare the efficacy of MTX and tolerability to MTX by oral route versus subcutaneous (SC) route. Twenty-eight cases were divided into two equal groups: Group I received a weekly dose of oral MTX and Group II received a weekly dose of SC MTX for 12 weeks. The starting dose was 7.5-10 mg and increased gradually by 2.5 mg every month till reaching 12.5-15 mg/week. Patients' clinical responses were evaluated according to Psoriasis Area and Severity Index (PASI) score. Results suggest that Group I patients showed reduction in PASI score of mean ± SD from 19 ± 7.4 before treatment to 11.2 ± 6.29 after treatment while Group II patients showed reduction from 23.4 ± 14.7 before treatment to 2.55 ± 2.6 after treatment with highly statistically significant difference between both groups. Clinical improvement was complete in 7.1% of Group I versus 57.1% of Group II. In conclusion, SC MTX has higher efficacy with lesser adverse effects and lower relapse rate when compared to oral form given by the same dose during the same duration.

Vitiligo is a common, acquired pigmentary disorder of unknown etiology with great impact on patient’s appearance and quality of life. It presents a therapeutic challenge to many dermatologists. Photochemotherapy using psoralen and ultraviolet A (UVA) therapy, topical and oral immunosuppresants, as well as cosmetic camouflage are also commonly employed with varying clinical efficacy. Phototherapy is a popular treatment option, which includes both of the generalized ultraviolet B (UVB) therapies, broadband UVB and narrowband UVB (NB-UVB). It has been used favorably, both alone as well as in combination with other agents like topical calcineurin inhibitors, vitamin-D analogs. Combination therapies are useful and may provide quicker regimentation and treat vitiligo with an additive mechanism of action than UVB phototherapy. Advances in technology may lead to the continuing use of UVB phototherapy as a treatment for vitiligo through the development of sophisticated devices and delivery systems as well as innovative application methods. These will provide increased therapeutic options for all vitiligo patients, particularly those with refractory disease. In this article, I have reviewed the available data pertaining to efficacy and safety issues for NB-UVB as monotherapy, its comparison with psoralen plus UVA and other modes of phototherapy, combination regimens that have been tried and future prospects of NB-UVB in vitiligo.

Melasma is a common pigmentary disorder that remains resistant to available therapies. The aim of the present study was to evaluate the efficacy of erbium:YAG lasers in the treatment of refractory melasma and investigate the histopathological and ultrastructural changes between melasma skin and adjacent control skin before and after surgery. Fifteen Egyptian female patients with melasma unresponsive to previous therapy of bleaching creams and chemical peels were included in this study. Full-face skin resurfacing using an erbium:YAG laser was performed. Clinical parameters included physician and patient assessment, and melasma area and severity index score were done. Adverse effects after laser resurfacing were recorded. Biopsies of lesions and adjacent healthy skin were stained using hematoxylin-eosin, immunohistochemically marked for Melan-A, and evaluated by electron microscopy. The amount of melanin, staining intensity, and number of epidermal melanocytes are increased in melasma lesions as compared to normal skin. Electron microscopic analysis revealed an increased number of mature melanosomes in keratinocytes and melanocytes, with more marked cytoplasmic organelles in melasma skin than in biopsy specimens from normal skin, suggesting increased cell activity. After surgery, the number of melanocytes and concentration of melanin decreased in melasma skin, and the mean melasma area and severity index score decreased dramatically. Erbium:YAG laser resurfacing effectively improves melasma; however, the almost universal appearance of transient postinflammatory hyperpigmentation necessitates prompt and persistent intervention.

There is a growing evidence that cytokines are important in the depigmentation process of vitiligo, however, the exact mechanism is not fully understood. The aim of this work was to study the possible role of the tumor necrosis factor-α (TNF-α) cytokine in the depigmentation process of the disease. Twenty patients with generalized vitiligo were exposed to narrow-band ultraviolet B (NB-UVB) therapy thrice weekly for a total of 60 sessions. Immunohistochemical examination was done, to assess the TNF-α expression in lesional and perilesional skin as compared to normal control skin, before and after therapy. At baseline, positive lesional TNF-α expression was detected in 60 % of patients which was significantly higher as compared to perilesional skin (20 %) and negative expression in healthy control skin. Post-treatment, a statistically significant increase in TNF-α expression was detected in both lesional (90 %) and perilesional skin (70 %) as compared to baseline (P < 0.05). The significant increase of TNF-α in vitiligo lesions compared with perilesional and healthy skin suggests a possible involvement of this cytokine in the depigmentation of vitiligo. The increase in TNF-α expression after NB-UVB phototherapy suggests another role in repigmentation.

Background  Cowden’s syndrome is a rare, autosomal dominant condition characterized by hamartomas of the gastrointestinal tract and cancer of the breast and thyroid. This study describes the clinical, immunological, and histopathological status of four Cowden’s syndrome cases from two different families.Methods  Biopsies were taken from different skin, mucous membrane, and intestinal lesions in all patients. Blood samples from patients and their parents were also examined.Results  Two brothers in the first family had more flexural distribution of papular and warty skin lesions as well as other manifestations of the syndrome, including recurrent pyogenic and fungal infections. Flow cytometric study revealed decreased total T and B‐cell percentages and abnormal helper : suppressor ratios in these patients. The other two patients from the second family showed the classical picture of the syndrome and normal immunological parameters. Histopathologically, most skin lesions of the face showed trichilemmomas, and all oral and some of the other skin lesions showed benign fibromas with giant cells (Cowden’s fibroma). Examination of intestinal biopsies revealed hamartomatous and hyperplastic polyps.Conclusions  Some cases of Cowden’s syndrome may be associated with prominent flexural skin lesions, recurrent pyogenic and fungal skin infections, decreased total T and B‐cell counts, and an abnormal helper : suppressor ratio.

Background  Psoriasis is a chronic and recurrent inflammatory skin disease, known as an oxidative stress condition. Smoking augments the risk of development of psoriasis. Although the relative importance of potential mechanisms of smoking‐induced psoriasis is unknown, direct delivery of oxidants has been implicated in the pathogenesis of smoking‐induced psoriasis.Objectives  This study aimed to investigate the smoking‐induced oxidative stress in psoriatic patients and its correlation with the severity of the disease.Methods  The levels of malondialdehyde (MDA) and superoxide dismutase (SOD) were measured in 25 psoriatic patients (10 smokers, 10 non‐smokers and 5 ex‐smokers) and 20 healthy control subjects (10 smokers and 10 non‐smokers). Clinical severity of psoriasis was determined according to the Psoriasis Area Severity Index (PASI) score.Results  Our results showed a significant increase in serum MDA and decrease in the blood SOD levels in psoriatic patients compared with those in control subjects and those in smokers compared with those in non‐smokers. The concentrations of MDA and SOD were significantly correlated with PASI score. There was a significant increase in PASI score in smoker patients compared with that in non‐smokers and it increased with increasing the pack‐years of smoking.Conclusions  Our results indicate that smoking‐induced oxidative damage resulting from increased reactive oxygen species production along with insufficient capacity of antioxidant mechanisms may be involved in the pathogenesis of psoriasis.