Vulvar verrucous lesions include a wide spectrum of differential diagnoses, with condyloma accuminata (CA) being the most common cause, while vulvar lymphangioma circumscriptum (LC) represents a rare cause. Herein, we report a case of giant unilateral vulvar LC that first developed during pregnancy in a 23-year-old female who had a primary lymphedema of the ipsilateral lower limb as well. Lesions were initially misdiagnosed as condyloma accuminata clinically and as fibroepithelial polyps histologically. Dermoscopic, histopathological, and ultrasound examinations confirmed the diagnosis of vulvar LC. The patient was referred for surgical excision.
Chronic prurigo (CPG), particularly prurigo nodularis, is a highly burdensome skin disease that is characterized by the presence of chronic pruritus and hyperkeratotic, pruriginous papules and nodules. CPG demands accurate diagnostic and individualized therapeutic strategies. Clinically, CPG is primarily diagnosed through physical examination, assessing the quantity and severity by using validated tools like the Prurigo Activity and Severity score and the Investigator’s Global Assessment. Further diagnosis includes an assessment of the lesion type, underlying causes, comorbidities, and potential systemic issues through additional radiological diagnostics. Therapeutically, CPG requires a multimodal strategy that is tailored to patient-specific, individual factors. Besides therapy, options like topical treatments and phototherapy and systemic therapies like small molecules and biologics offer significant clinical improvements. Currently, dupilumab is the only Food and Drug Administration and europäische arzneimittelagentur-approved systemic treatment for adult chronic nodular prurigo patients. Emerging therapies include monoclonal antibodies like nemolizumab and vixarelimab and Janus Kinase inhibitors like ruxolitinib and tofacitinib, showing promising results in clinical trials enhancing the quality of life for affected patients. This review aims to highlight that ongoing research is focused on expanding the range of validated diagnostic tools and the spectrum of approved therapy options and discuss historical and modern research trends.
Background Alopecia areata (AA) is a common hair loss disorder. Despite the availability of various treatment options, no single agent consistently cures this condition. Vitamin D, with its immunomodulatory effects, emerges as a promising treatment avenue for AA. Objective To assess the safety and efficacy of intralesional vitamin D3 compared with intralesional triamcinolone acetonide (TAC) in AA. Also, the treatment response should be analyzed according to serum vitamin D3 levels. Patients and methods This randomized controlled trial involved 40 patients aged 12 years and older with patchy active AA involving less than 50% of the scalp. The patients were randomized into two groups: group A received intralesional TAC, and group B received intralesional vitamin D3. Each patient underwent four treatment sessions and two follow-up sessions at monthly intervals. Serum vitamin D3 levels were assessed at the baseline. The regrowth score (RGS) was used to assess clinical improvement. Results Both groups showed significant improvement in mean RGS at the 16th and 20th weeks compared with the fourth week (P<0.001; for both groups at the 16th and 20th weeks). By the 20th week, the mean RGS reached 3.05 in group A and 2.55 in group B (P=0.398). No significant difference was found between good and poor responders regarding vitamin D levels. Trichoscopic signs of activity improved significantly in both groups, and both treatment modalities were safe, with minor side effects. Conclusion Intralesional vitamin D is comparable in efficacy and safety to intralesional TAC in patchy AA of the scalp. Also, the response to treatment was insignificantly influenced by the level of serum vitamin D.
Sudoriferous grover’s disease is a rare subtype of Grover’s disease with only nine cases reported to date. It presents by itchy erythematous papules and vesicles due to acrosyringial acantholysis. Pachyonychia congenita is a rare genodermatosis with mutation in keratin that can affect the nails, skin, oral mucosa, hair and teeth. Here we report a 38-year-old female patient with sudoriferous grover’s disease proved by histopathological examination associated with pachyonychia congenita of the nails since birth, To the best of our knowledge, this is the first reported case of sudoriferous grover’s disease to be associated with pachyonychia congenita.
Epidermolysis Bullosa Acquisita is a rare, chronic autoimmune blistering disorder characterized by vesicles and bullae on the skin and mucous membranes. This condition, presenting typically in adulthood, is caused by autoantibodies against type VII collagen. Conventional treatments, including systemic corticosteroids and immunosuppressants, often fail to achieve long-term remission. Biologic agents like rituximab have shown promise in managing refractory cases. This report presents a case of a 27-year-old female with recalcitrant epidermolysis bullosa acquisita successfully managed after starting rituximab therapy.
Background The pathogenesis of nonsegmental vitiligo (NSV) and alopecia areata (AA) overlap in several aspects. In AA, the anagen hair follicle (HF) undergoes a collapse of immune privilege (IP). No previous studies assessed the IP of the HF in NSV. Objective To assess the IP in NSV compared with AA. Patients and methods Twenty NSV with scalp lesions and 20 scalp AA patients were included in this prospective comparative study. Clinical assessment and immunohistochemical examination of punch biopsies from lesional and nonlesional scalp were done for interferon gamma (IFN-γ), transforming growth factor beta 1 (TGF-β1), major histocompatibility complex (MHC)I, and MHCII in the HF and epidermis. Results In AA, there was upregulation of IFN-γ and MHCI and downregulation of TGF-β1 denoting impaired IP in lesional compared with nonlesional HF. In NSV, no difference in IFN-γ was found between lesional and nonlesional HF. MHCI and MHCII were upregulated in lesional HF, while TGF-β1 was significantly lower in lesional HF. A significantly higher expression of IFN-γ and MHCI was detected in lesional epidermis compared with lesional HF in NSV patients. Lesional HF in AA showed significantly higher expression of IFN-γ and MHCI and significantly lower expression of TGF-β1 than lesional HF in NSV, denoting preserved IP in NSV. Conclusion IP is preserved in HF in NSV compared with AA, protecting the follicular melanocytes from autoimmune attacks.
Porokeratosis is a rare distinct acquired or congenital skin disease of unknown origin, characterized by abnormal keratinization. A rare form of porokeratosis known as punctate porokeratosis is distinguished by raised lesions on the palms and soles that resemble seeds. Punctate porokeratosis might resemble other dermatoses that affect the palms and soles, such as punctate keratoderma, spiny keratoderma, arsenical keratosis, lichen nitidus, and nevus comedonicus. Here, a case of isolated plantar punctate porokeratosis in the skin of colour is shown along with the dermoscopic characteristics that help identify it from other dermatological differential diagnoses.
Background Treatment of vitiligo targets controlling immunological pathways, stimulating melanocyte regeneration, and decreasing oxidative stress. Insulin can increase the synthesis of multiple growth factors when applied topically. It regulates re-epithelization, inflammatory responses, increases angiogenesis, regulation of inflammatory reactions, and decreases reactive oxygen species. Fractional carbon dioxide laser (fractional CO2) can increase the absorption of topically applied medications, as it forms microscopic, coagulated columns within the intact skin. Objective To assess the efficacy and safety of insulin applied topically with assisted delivery using fractional CO2 laser in the treatment of vitiligo. Patients and methods In this controlled study, 60 vitiligo patients were included; they were divided into two groups., both underwent a weekly session of fractional CO2 laser for 12 weeks. Group 1 applied insulin topically postsession once/day until the next session. The evaluation was done using Vitiligo Extent Score for Target Area before the treatment and at 6 then 12 weeks. Results Vitiligo extent score for a target area score showed improvement after 6 weeks in group 1 with no improvement in group 2 with P value less than 0.0001 and after 12 weeks there was marked improvement in group 1 with median range 62 (0–100) while in group 2 it was 10 (0–70) with a statistically significant P value less than 0.001. Conclusion Topically applied insulin combined with fractional CO2 laser may have a safe and effective role in the treatment of vitiligo.
Background Human papillomavirus (HPV) infection is common across the world’s population, with millions of new cases reported each year. An increasing number of disorders are being linked to dysregulated microRNA (miRNA) expression, particularly when high-risk human papillomavirus infection is present. Objective To investigate the miR-3654 expression level in male patients with anogenital warts (AGWs) to develop a new patho-physiolological era in the genital wart. Patients and methods A total of 25 male patients with AGWs were consecutively enrolled in this case control study. MiR-3654 expressions in lesional skin and nonlesional skin were detected by quantitative PCR. Results Diseased tissue had a significantly lower median of miR-3654 level than normal healthy skin. There was no significant correlation between diseased tissue miR-3654 level with patient’s age, number of lesions, and average size of lesions. Conclusion It was found that diseased tissue miR-3654 was downregulated in warts compared with normal skin. Given its predicted targets and functions, the current study findings point out that miR-3654 could be a potential disease biomarker and may play a regulatory role in pathogenesis of AGWs.
Background Psoriasis and unstable atherosclerotic plaques share common inflammatory pathways. Little is known about the effects of psoralen ultraviolet A (PUVA) photochemotherapy on cardiometabolic risk factors and atherosclerotic plaques in patients with psoriasis. Objective To investigate the effects of 36 sessions of PUVA on several cardiometabolic biomarkers in patients with psoriasis with and without atherosclerosis. Patients and methods A comparative clinical trial screened 91 patients with chronic plaque psoriasis for eligibility. Fifty patients and 15 individuals for control of laboratory values were included. In all, 27 patients were allocated to either atherosclerosis (A) or nonatherosclerosis group (B) based on duplex ultrasonography. Psoriasis area and severity index (PASI), BMI, waist circumference, arterial blood pressure, high-sensitive C-reactive protein, oxidized low-density lipoprotein, lipid profile, and fasting/postprandial blood glucose were assessed before and after 36 sessions of PUVA. Results Before–after treatment comparison revealed that, in group A, three biomarkers improved along with PASI: triglycerides, cholesterol, and systolic blood pressure, while in group B, PASI was the only parameter that significantly improved. PASI percent reduction correlated positively with both systolic blood pressure, cholesterol percent reduction, and low-density lipoprotein percent change in group A. Atherosclerotic plaques in group A showed no significant change after treatment. Conclusion PUVA photochemotherapy can have an added benefit in patients with psoriasis and atherosclerosis in comparison with patients without atherosclerosis. Testing the atheroprotective potential of different ultraviolet wavelengths in long-term studies is warranted.
Background Lichen planus (LP) is a chronic autoimmune skin disease that affects the skin, mucous membranes, and skin appendages. Inhibin βA is a member of the transforming growth factor beta family having various immunological functions. Objective To assess the tissue expression levels of inhibin βA in both nonlesional and lesional skin of cutaneous LP patients as a trial to evaluate its role in LP pathogenesis. Patients and methods This case control study comprised thirty patients with cutaneous LP and thirty normal controls. The assessment of LP severity was done through LP severity index score (LPSI). The skin biopsies were taken from the nonlesional and lesional skin of LP patients and the healthy skin of normal subjects for assessing the skin levels of inhibin βA by ELISA and Western blot techniques. Results There was a statistically significant increase of inhibin βA tissue expression levels (in both nonlesional and lesional skin; 2.86±0.57 and 4.76±1.15, respectively) of LP patients in comparison with normal subjects (1.01±0.01) (P˂0.001). Also, there was a statistical significant rise of inhibin βA tissue expression levels in the lesional skin in comparison with the nonlesional skin of LP patients (P˂0.001). Conclusion Inhibin βA tissue expression levels were upregulated in LP patients proposing a possible effect of inhibin βA in LP pathogenesis.
Introduction Pathogenesis of atopic dermatitis (AD) is complex and includes several aspects, such as genetics and environmental exposure. Recently, several research studies have highlighted the effect of oxidative stress (OS) in different dermatological diseases such as psoriasis, AD, and alopecia areata. Objective To investigate the role of human advanced glycation end products (AGEs) and human advanced oxidation protein products (AOPPs) as markers of OS and inflammation in patients with AD. Patients and methods In the present case control study, serum levels of human AGEs and human AOPPs were measured in 30 patients with AD and in 30 controls. Results The level of OS markers was significantly higher in patients compared with controls (P<0.001). Patients with severe AD had significantly higher levels of OS markers compared with patients with moderate AD (P=0.020 and 0.025, respectively). Both can significantly predict the severity of AD with high sensitivity and specificity. Conclusion Human AGEs and human AOPPs function as useful markers of OS, and are elevated in patients with AD, and can be used for assessing disease severity.
Secukinumab is an IL-17A antagonist, approved by the FDA for the treatment of adult and pediatric (≥6 years) psoriasis, psoriatic arthropathy, and hidradenitis suppurativa. Of late, secukinumab has been found to be beneficial in pityriasis rubra pilaris, pyoderma gangrenosum, lichen planus, and Behçet’s disease. This review will throw light on secukinumab’s utility in psoriasis, as well as other dermatologic conditions.
Background Determining the status of nonsegmental vitiligo is crucial in initiating the management plan, especially when planning for surgery. Serum biomarkers can serve as an additive tool, to clinical examination and history-taking, in differentiating active from stable vitiligo. Objective To assess serum levels of calprotectin (CP) in nonsegmental vitiligo, and to compare these levels among active and stable cases. Patients and methods Serum samples were taken from 42 vitiligo patients and 42 healthy controls, and CP levels were measured by ELISA technique. Results Although the serum CP levels were not significantly higher in patients (median = 33.6) in comparison with controls (median = 33.5) (P=0.28), CP was significantly elevated in active vitiligo cases when compared with stable patients (P=0.010) and had a positive correlation with vitiligo disease activity score (r=0.400, P=0.009). Conclusion Serum CP can potentially help in differentiating active from stable vitiligo.
Dear editor, Double nails, also described as rudimentary or accessory nails, are uncommon and underdiagnosed anomalies and are mostly reported in the toes [1]. These are mostly incidental findings, and the true incidence of this peculiar anomaly is difficult to know as many cases may remain undiagnosed due to the lack of clinical symptoms. In the fingers, the potential cosmetic concern and subsequent consultation appear more likely as compared to the toes. But the description of double nails in fingers is extremely rare [1,2]. A 48-year-old female was referred to us with a history of a nail-like structure protruding next to the right thumbnail on the radial aspect for the last 5 years. There was no history of trauma or similar features in other fingers or toes. On clinical examination, the structure looked like a human nail and appeared to arise from the same nail bed as the thumbnail. There was associated prominence over the nail bed area corresponding to the prominent nail bed for the accessory nail. There were minimal clinical problems associated with it except for occasional pain when manually pressed over the affected nail bed prominence. Cosmesis was the primary concern, and the patient wished for its removal. The structure was approached under wrist block through an incision entered over the structure, and the offending lesion was separated from the native nail tissue. The root was completely excised from the nail bed, followed by chemical matricectomy with phenol. No postoperative or remote complication or recurrence was noted in the follow-up of 6 months. The biopsy of the specimen confirmed the structure to be a human nail appendage. Double nails present like a widened nail, which on closer inspection revealed to consist of two parts divided by a longitudinal split, the nail may be symmetrical on the contralateral side, but more pronounced on one side. Our case, however, had unilateral involvement. Histology reveals the presence of a shorter but normal nail with less developed nail structures and is reported to be autosomal dominant with variable expression [2]. There is, however, no hereditary or antecedent traumatic event associated with these lesions in most cases. Females are commonly affected, and usually no underlying bony abnormality is found [3]. Only one case has been previously reported, having a double nail of the second toe with an underlying bone involvement on ultrasound and plain radiographs [4]. Treatment includes selective matrix phenolization with liquefied phenol or segmental excision of the entire nail with matrix, proximal fold, and hyponychium. We also used phenol as an adjunct to adequate rexcision along with the affected nail bed. The double nails in fingers are rare entities, and few differential diagnoses may require exclusion. The important differentials are: traumatic double nail, ectopic nail, and a nail spiculum left after incomplete extirpation of the lateral matrix. This short case snippet aims to highlight a rare case for educational purposes in primary care facilities. As the report of the double or accessory nail in the thumb has not been described to the best knowledge of the author, this case may enrich the medical literature and educate students and practitioners alike (Fig. 1).Figure 1: The clinical image showing a nail-like structure adjacent to the normal thumbnail with associated swollen nail-bed area (a, b). The excised accessory nail tissue after the surgery (c, d) that measured about 2.5 cm.Acknowledgements Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Data availability statement: data is available upon request.
Background Although the immune dysregulation caused by Helicobacter pylori has been linked to the pathogenesis of many dermatological diseases, the link between H. pylori infection and pityriasis versicolor (PVC) has not been largely verified. Objective To study the probable association between active H. pylori infection and PVC prevalence and clinical parameters. Patients and methods The present case control study included 65 male patients with PVC (group A) and 65 dermatologically free patients (group B). Active H. pylori infection was detected in both groups using H. pylori stool antigen test (SAT). In group A, patients who tested SAT positive were subjected to measurement of anti-H. pylori immunoglobulin (Ig)G and IgA and interleukin (IL)-10 serum levels. Results The frequency of H. pylori was equal (61.5%) in both study groups. The various clinical parameters of PVC did not significantly differ between SAT-positive and SAT-negative patients. In group A, H. pylori-infected patients had elevated IgG and IgA serum titer, while IL-10 level was in most cases (65%) low. No significant relation was detected between the H. pylori serological markers and the PVC clinical parameters. Conclusion Active H. pylori infection did not impact the prevalence or clinical features of PVC. Elevated H. pylori IgG and IgA levels did not vary differentially in relation to PVC clinical features. Moreover, serum IL-10 level in active H. pylori-infected patients with PVC was not elevated. Accordingly, its role as a systemic immunosuppressive cytokine predisposing for PVC was unverified in this study.
Knuckle pads are under reported benign well-defined thickened skin plaques usually overlying the extensor aspect of the small joints of the hands. Primary knuckle pads are a fibromatous disease that may be seen in several inherited fibromatosis and keratoderma syndromes. Secondary knuckle pads are distinctly different from primary knuckle pads, acquired by repetitive trauma, and dermoscopy may aid in diagnosis. We hereby report a case of a female patient with recalcitrant knuckle pads for 8 years, that were confused with psoriasis or erythrokeratoderma. However, after repeated consultations, they were found to be due to body-focused repetitive behaviour of recurrent skin biting, denoting dermatodaxia. After the condition was explained, the patient consciously refrained from biting her knuckles with improvement within a few weeks.
