Background: Treating lichen planopilaris (LPP) is challenging for dermatologists. Along with anti‐inflammatory agents, another goal of treatment is to improve hair thickness in unaffected areas to cover the scars. Aim: To evaluate the effectiveness and safety of adding low‐dose oral minoxidil (OM) to the standard anti‐inflammatory treatment of LPP. Method: A total of 37 patients with LPP were randomly assigned to receive either 15 mg/week methotrexate (MTX) plus topical clobetasol or 1 mg/day minoxidil in addition to MTX plus clobetasol for 6 months. The Lichen Planopilaris Activity Index (LPPAI), dermoscopy, and standard photography evaluated the treatment efficacy. Results: Both groups exhibited a significant improvement in LPPAI ( p < 0.001). The following signs/symptoms demonstrated notable improvements in frequency and/or severity in both groups: pruritus, anagen pull test, follicular prominency, scalp erythema, perifollicular erythema, milky red area, and pigmentation. However, pain, burning sensation, hair tufting, and spreading only improved in the MTX + low‐dose OM group. Elongated blood vessels did not improve in either group. In terms of hair thickness and density, there was no significant difference between the two groups. Conclusion: The addition of 1 mg/day minoxidil to the standard treatment of LPP was found to be safe but did not yield significant effects on LPPAI and hair density/thickness. Notably, two patients who received low‐dose OM (2/19, 10.5%) showed hair regrowth in scarring areas. Trials with higher doses of minoxidil may be promising. Trial Registration: Iranian Registry of Clinical Trials: IRCT20220528055005N1

Introduction:Mycosis fungoides (MF) represents the most prevalent form of cutaneous lymphoma, characterized by diverse histopathological patterns. However, recent comprehensive studies systematically evaluating the spectrum of histopathological patterns and changes associated with MF in patients within Iran are notably lacking. Method:This cross-sectional descriptive study analyzed 64 skin biopsy slides diagnosed with MF, archived from 2013 to 2023 at Al-Zahra Hospital and a private dermatopathology laboratory in Isfahan, Iran. Inclusion criteria included all slides with complete demographic data and a confirmed MF diagnosis. Patterns and finding of these slides were analyzed according to age, gender, and biopsy site. Data analysis was performed using SPSS Version 26.0, with significance set at p < 0.05. Results:The study included 31 females and 33 males, with a mean age of 44.64 ± 14.91 years. The most common biopsy site was the trunk (45.31%). The predominant histopathologic patterns observed were psoriasiform (33 cases), lichenoid (14 cases), and spongiotic (10 cases), with universal epidermotropism across all slides. Parakeratosis and cytological atypia were found in 37 and 31 cases, respectively. Notably, eosinophils were more frequent in males (p=0.016), and cytological atypia were significantly more common in males than females (p=0.044). Mild dermal infiltrate was the most prevalent, particularly in the 35-42 and 43-56 age groups, with a significant age-related variation (p=0.041). Conclusion:This study reveals that psoriasiform, lichenoid, and spongiotic patterns are the most common in MF, with epidermotropism present in all cases. Age and gender significantly influence certain features, but overall, histopathological patterns showed no significant variation by biopsy location or age group.

Background. Lichen planopilaris is the leading cause of cicatricial alopecia, and its management is challenging for dermatologists. It is a cell‐mediated autoimmune disorder in which activated T‐lymphocytes attack hair follicles. Aim. To compare the efficacy and safety of methotrexate versus azathioprine, two medications that affect lymphocyte function, in treating LPP. Methods. 32 LPP patients were randomly assigned to receive either 15 mg/week methotrexate or 2 mg/kg azathioprine for six months. Treatment efficacy was evaluated using the Lichen Planopilaris Activity Index (LPPAI), trichoscopy, and photography after 2, 4, and 6 months of treatment. Results. Both methotrexate and azathioprine groups showed significant improvements in LPPAI (P < 0.001) and perifollicular scaling on trichoscopy (P < 0.01). However, the two groups had no significant difference during the study. The azathioprine group significantly improved perifollicular erythema on trichoscopy (P = 0.002), but this was not significantly different from the methotrexate group (P = 0.69). Photographic assessment showed that more than 75% of patients in both groups improved without significant differences between the two groups. Conclusion. Methotrexate and azathioprine are two antilymphocyte medications which are both equally effective and well‐tolerated for managing LPP. This trial is registered with IRCT20191006045005N2.

BACKGROUND:Frontal fibrosing alopecia (FFA) is a cicatricial alopecia with rapid epidemic growth. However, there is no agreement on the best therapeutic approach.AIMS:To compare the therapeutic effects of finasteride as a first-line systemic treatment of FFA versus hydroxychloroquine as a relatively safe and effective immunosuppressive drug.METHODS:Thirty-four female FFA patients were randomly assigned to receive either 400 mg/day of hydroxychloroquine or 2.5 mg/day of finasteride for 6 months. Topical treatments in both groups include pimecrolimus, mometasone, and minoxidil. Treatment efficacy was evaluated using the Frontal Fibrosing Alopecia Severity Score (FFASS), photography, and trichoscopy after 3 and 6 months.RESULTS:Both the finasteride and hydroxychloroquine groups showed significant improvements in FFASS and trichoscopic scores (p < 0.01). However, there was no significant difference between the two groups during the study. Photographic assessment showed that more than 60% of patients in both groups had improved without statistically significant differences between the two groups.CONCLUSIONS:Both finasteride and hydroxychloroquine are equally effective, safe, and well-tolerable for treating FFA patients.

BACKGROUND:Micro-focused ultrasound (MFU) is a technique for skin rejuvenation and lifting, targeting the facial SMAS-a fibrous network encompassing the platysma muscle and parotid fascia. OBJECTIVE:This study aims to propose a novel and cost-effective method (suggested by Fatemi) for Ultherapy, comparing its effectiveness with the conventional approach. MATERIALS AND METHODS:A prospective double-blind clinical trial was conducted with 30 female volunteers randomly assigned to two groups: The control group (conventional method) and the experimental group (new method). Ultherapy procedures utilized MFU technology with low energy and a higher frequency. RESULTS:Statistically significant differences in lifting effects and improvement in skin laxity were observed between the two groups. The new method, with a focus on the parotideal area of the SMAS, demonstrated superior outcomes and higher patient satisfaction. CONCLUSION:The parotideal region's accessibility, increased thickness, and safety profile make it an ideal target for Ultherapy. This not only reduces the risk of nerve injury but also yields effective collagen remodeling and skin-lifting results.

Lichen planopilaris (LPP) is the most common primary cicatricial alopecia defined by the follicular form of lichen planus.1 Histopathologic examination is considered the gold standard diagnostic method. However, it may not always be diagnostically reliable.2 When there is histological ambiguity, trichoscopy is a highly effective tool for diagnosis and monitoring treatment effectiveness.1 Frequently reported trichoscopic findings of LPP include the absence of follicular openings, perifollicular scaling, milky-red areas, and blue-gray dots in a target pattern. Perifollicular scaling (casts) is considered the most characteristic trichoscopic feature of LPP and frontal fibrosing alopecia (FFA).3 It varied between 38% and 100% (mean: 85%) of patients with LPP and 42%–90% (mean: 84%) of patients with FFA.1 Peripilar casts represent hyperkeratosis and lamellar fibrosis resulting from perifollicular lichenoid inflammation, hence, considered ideal sites for biopsy.1, 4 Although tubular type of hair casts was considered specific for LPP they were also observed in discoid lupus erythematosus (DLE) and folliculitis decalvance (FD). Contrary to LPP and FFA perifollicular scaling in FD is characterized by a yellowish color.3 However, diagnosis may be challenging in some cases. Considering perifollicular scaling as a frequent and specific dermoscopic feature of active LPP, recognition of its dermoscopic details might help improve the accuracy of clinical diagnosis of LPP and FFA from other diseases causing cicatricial-alopecia. Concerning patterns of tubular hair cast, if combined with minimum or absence of interfollicular scales has been described as a specific dermoscopic feature of LPP and FFA by Mathar et al.4 Herein we describe a new dermoscopic pattern of tubular scaling that we detected exclusively in patients with active LPP and FFA lesions. "Double ring sign" consists of two white-silvery rings of scaling around hair follicle and is identified on dry dermoscopy. The inner ring migrates along the hair shaft and forms a tubular structure that was previously described in the literature.3 The outer ring is a little far from the hair shaft and more delicate than the inner ring (Figure 1A,B). In our experience double ring sign is a helpful dermoscopic finding for differentiating LPP and FFA from other cicatricial alopecia. We evaluated the available dermoscopic images of 102 pathologically confirmed cicatricial-alopecia patients with clinically active disease. These include 45 cases of LPP, 36 cases of FFA, 13 cases of DLE, and 8 cases of FD. Double ring sign were observed only in 24 (53.3%) and 13 (36.1%) patients with LPP and FFA, respectively but not in DLE and FD. Among patients with LPP and FFA, those with severe perifollicular scaling (p < 0.001) and positive anagen pull test (p < 0.05) were more likely to have double ring sign (Tables 1 and 2). To correlate dermoscopic-pathologic features a 4-mm punch-biopsy specimen from the scalp area presenting double ring sign was obtained in three patients after informed consent. The main histopathological findings include lichenoid infiltrates involving infundibulum and isthmus causing reactive infundibular hyperplasia with compact hyperkeratosis extending outward from the follicles (Figure 1C). Regarding presence of white-silvery scaling in dermoscopy corresponding to parakeratosis in histopathology,5 concentric rings of white scaling in LPP have a parakeratotic nature which is created reactive to perifollicular inflammatory infiltrate. In other words, there are alternating circumferential parakeratosis and hyperkeratosis around the hair shaft (Figure 1C,D). This indicates that a control mechanism operates to a variable degree in LPP lesions leading to decreased perifollicular infiltration. Therefore, alternation of parakeratosis and orthokeratosis often occurs in lesions that have not been treated. When better understood, it is suggested this mechanism might be utilized in treating or preventing disease. Probably an intermittent course is an integral part of autoimmune diseases. For instance, alopecia areata presents with Pohl-Pinkus constrictions.6 We believe along with LPP, in other cicatricial alopecia like DLE or folliculitis decalvance, the same intermittent inflammation may occur. However, we suggest the simultaneous affection of epidermis or interfollicular spaces in such cases mask the dermoscopic feature of hypothetical perifollicular inflammation fluctuation if existing. In conclusion, double ring sign is a new specific dermoscopic feature of LPP and FFA observed in approximately one-third to half of active lesions. Rings of white-silvery scaling seem to be reactive to "waves" of disease activity related to perifollicular inflammation. It could be easily identified on dry dermoscopy and can benefit clinicians to differentiate LPP and FFA from other causes of cicatricial alopecia. This observation should be validated in future prospective works with a greater sample size. Mina saber involved in research design, project supervision, manuscript writing, and editing. Farahnaz Fatemi Naeini involved in patient recruitment, data collection, and manuscript writing. None. The authors have no conflict of interest to declare. This study has been approved by the ethics committee of the Isfahan University of Medical Sciences. Informed consent for the publication of medical images was obtained from the patients.

Abstract Background Folliculotropic mycosis fungoides (FMF) is a rare variant of MF that involves hair follicles and requires a more aggressive treatment regime. Significantly, some patients with classic MF can eventually have some degree of follicular involvement. Objectives The aim of this study was to describe the dermoscopic features of FMF in nonscalp areas to facilitate early diagnosis and posttreatment monitoring. Methods The clinical and dermoscopic features in 11 FMF patients were analyzed and compared with the reports in the literature. Results Obliteration of hair follicles, loss of terminal hairs and hair loss were detected in all patients. Follicular accentuation, follicular dilation and broken hairs were found in almost all patients (90.9%). Other common follicular‐based dermoscopic features (<50%) were follicular plugging, perifollicular orange colour, perifollicular erythema and vessels, hyperpigmented halo around the follicle, follicular hyperkeratosis, comedo‐like lesions and perifollicular scales. The most frequent ‘dominant’ dermoscopic features were follicular accentuation with follicular plugging and dilation of follicular opening. Conclusions Identification of specific distinguishing dermoscopic patterns of FMF not only could be helpful in classifying MF patients but also could provide prognostic information regarding the disease course and aid in therapeutic decisions. In MF patients, dilation of follicular opening and spiky follicular keratosis are considered the most specific dermoscopic features of follicular involvement since they are uncommon in other conditions.

Background:Rosacea is a skin chronic inflammation with an unknown cause and cure. Environmental and genetic factors could not entirely explain the disease pathogenesis. Recently, infections like Chlamydia pneumoniae are of more attention in the rosacea progression. This study investigated the relationship between the C. pneumoniae seropositivity and the rosacea disorder. Materials and Methods:We aimed at a cohort of 100 patients with the rosacea disorder (60 active and 40 inactive) and from 100 sex- and age-matched healthy controls in Isfahan and determined the immunoglobulin M (IgM)/IgG antibodies titers to C. pneumoniae in the serum using the enzyme-linked immunosorbent assay method. The groups were compared using the analysis of variance procedure at the significant level of P < 0.05, statistically. Results:The mean of IgG in the controls was significantly higher than the levels in both the active and the inactive rosacea patients (p < 0.022). Also, the titer of serum IgM to C. pneumoniae in the controls was different, compared with the active (p < 0.019) and the inactive (p < 0.02) rosacea patients. In addition, the median titer of serum IgG (not IgM) to C. pneumoniae in the females with the inactive rosacea disorder was lower than the active rosacea disorder (p < 0.019) and controls women (p < 0.008). Furthermore, the serum level of IgG or IgM to C. pneumoniae in the controls males was higher than the males with the rosacea disorder (p < 0.05) and (p < 0.02), alternatively. Conclusion:C. pneumoniae seropositivity in the rosacea patients and controls was insignificant.

BackgroundMelasma is a hyperpigmentary disorder causing cosmetic disfigurement. We aimed to compare the efficacy and safety of tranexamic acid (TXA) microinjections with TXA mesoneedling for facial melasma. MethodsThis randomized assessor-blind split-face controlled trial included patients with symmetric facial melasma. One side of the face received TXA (100 mg/ml) mesoneedling and the other side intradermal TXA microinjections. The interventions were repeated three times with 4-week intervals (weeks 0, 4, and 8). The primary outcome was improvement in modified Melasma Area and Severity Index (mMASI) 4 weeks after the final treatment session. Secondary outcomes were complications and patient satisfaction with the treatments evaluated by a visual analog scale (VAS). ResultsAll 27 patients included in the study were female (mean age: 44.22 +/- 8.39 years). Both groups were comparable in terms of mMASI scores before and after treatment (standardized mean difference [SMD] = 0.32, 95% confidence interval [CI] -0.22; 0.85, p = 0.248 and SMD = -0.13, 95% CI -0.66; 0.40, p = 0.633, respectively). The mMASI score change from baseline was not different (SMD = -0.39, 95% CI -0.93; 0.15, p = 0.157). However, patient satisfaction was significantly higher with TXA mesoneedling (SMD = 0.77, 95% CI 0.21; 1.32, p = 0.007). Post-inflammatory hyperpigmentation occurred in one patient in the TXA mesoneedling group. Erythema, scaling, and edema were significantly higher with TXA mesoneedling (p < 0.001). ConclusionsTXA mesoneedling was comparable with TXA microinjection in the treatment of facial melasma, while patient satisfaction was significantly higher with TXA mesoneedling; however, the high frequency of complications occurring with this treatment should be taken into account.

Objective Mycosis fungoides (MF) is a condition of the lymphatic tissues that mostly affects the skin (primary cutaneous T cell lymphoma), the most prevalent form of T-cell skin lymphoma. Central lymph node and other organs involvement are very poor prognostic factors that can gradually affect the quality of life of these patients. Therefore, in this study, we aimed to examine the quality of life in patients with MF. Methods In this descriptive study, a demographic questionnaire including age, gender, duration of MF, stage of the disease, and location of the lesion was completed. All participants were tested for quality of life using the SF36 questionnaire. Results There was a significant difference between different stages of the disease as well as the duration of the disease with respect to the overall quality of life score and its subscales, so that with increasing stage and duration of the disease, the quality of life decreased (P <0.05). The quality of life was lower in patients with sun-exposed areas than in those with other affected areas (P <0.05). Conclusion MF disease is correlated with reduced quality of life and the extent of which is inversely related to the duration of the disease as well as the stage of the disease. Additionally, patients with affected areas that are exposed to sunlight have a lower quality of life than those with other affected areas.

Background:Lichen planopilaris (LPP) is a rare inflammatory disorder of the scalp that causes cicatricial alopecia. No therapeutic approach has been approved for this disease due to the rare frequency. Methotrexate and corticosteroid are commonly considered second- or third-line therapy. The efficacy of a combination of methotrexate and corticosteroid has been reported in some dermatological and immunological diseases. However, the efficacy of this combination in LPP is not clear. Therefore, this study aimed to compare the impact of methotrexate alone and in combination with corticosteroid on LPP.Materials and Methods:This randomized clinical trial was performed on 28 patients who referred to the dermatology clinic affiliated with Isfahan University of Medical Sciences, Isfahan, Iran during February 2015-December 2016, and 24 of them completed the trials. Fourteen patients received 15 mg methotrexate per week alone and the other fourteen subjects received 200 mg prednisolone plus 15 mg methotrexate per week. The primary outcome was Lichen planopilaris activity index (LPPAI) score. Moreover, we evaluated photographic changes and symptoms during the study.Results:The mean of LPPAI in both groups decreased during the follow-up with a similar pattern of LPPAI changes in both groups. No statistically significant difference was found between the two intervention groups regarding the LPPAI score. We found no difference in the symptoms and photographic assessments in methotrexate and combination therapy groups during follow-up. In both groups, exclusively one adverse effect was reported.Conclusions:Our results showed that methotrexate therapy with and without corticosteroids had similar efficacy and safety.

Psoriasis is a chronic inflammatory skin disease with unknown etiology and a wide spectrum of clinical presentations. We report the first case of dermatomal psoriasis in a 62-year-old patient in addition to an unusual presentation of psoriasis as a solitary plaque on the ear of a 38-year-old patient.

Acute generalized exanthematous pustulosis (AGEP) is an exanthematous condition, predominantly occurring as a result of drug reactions. We, hereby, present the first case of AGEP following treatment with remdesivir in a patient with COVID-19, without hydroxychloroquine use, which serves as a reminder to consider remdesivir as a possible causative agent when dealing with AGEP presentation in COVID patients.

Background Facial papules reflecting the lichenoid inflammation of facial vellus hair follicles can occur in the backgrounds of frontal fibrosing alopecia, lichen planopilaris (LPP), or even alone. In the present study, we aimed to compare systemic and topical isotretinoin in the treatment of facial LPP. Method In a prospective randomized trial, 26 patients with facial LPP were randomly allocated to receive either 20 mg/day oral isotretinoin or isotretinoin 0.05% gel every night for 6 months. Global Aesthetic Improvement Scale (GAIS) and patient's satisfaction questionnaire were used at 1, 3, and 6 months after treatment to evaluate the outcomes. Results In both oral and topical isotretinoin groups, facial papules were significantly improved at all follow-up visits, resulting in statistically significant improvements (p = 0.005 and p = 0.007, respectively, for oral and topical groups) in GAIS score mean difference from month 1 to month 6. Overall levels of patient satisfaction were high in both groups, and no significant difference was observed between two groups (p = 0.107). However, the mean GAIS score at 3 and 6 months after treatment showed significantly greater improvements in oral isotretinoin group compared to topical group (1.85 +/- 0.62 vs. 1.03 +/- 0.49 at month 3, p = 0.004; 2.45 +/- 54 vs. 1.59 +/- 0.62 at month 6, p = 0.008). Overall, patients could well tolerate the treatments; however, topical therapy was associated with fewer side effects. Discussion Both oral and topical isotretinoin were found to be effective in improving facial papules; however, oral isotretinoin was significantly more efficacious. Considering safety profile of topical isotretinoin, it can be administrated as maintenance therapy for patients with facial LPP.

We hereby, present the first case of Acute generalized exanthematous pustulosis (AGEP) following treatment with remdesivir in a patient with COVID-19 without hydroxychloroquine use which serves as a reminder for considering remdesivir as a possible causative agent when dealing with AGEP presentation in COVID patients.

Mycosis fungoides (MF) is the most common form of cutaneous T-cell lymphomas and interferon α is one of the treatment modalities for MF patients. So far, various side effects have been reported in connection with interferon use, including lupus-like reaction, which is relatively rare and classified as an injection-site reactions (ISR). We report a 38-year-old female with history of MF for 2 years who developed cutaneous lesions at the sites of interferon α-2b injections. There are few reports of lupus-like reaction due to therapy with interferon in malignant melanoma and multiple sclerosis (MS) patients, but there is no report in the literature about this side effect among patients with MF.

Background: Bullous pemphigoid (BP) is a widely recognized autoimmune blistering disease (AIBD) linked with a high incidence of morbidity and mortality. The aim of this study was to evaluate the available findings of randomized clinical trial studies to update interventions for Bullous pemphigoid. Methods: This article provides an updated overview of interventions for BP. A literature search was performed using Cochrane Central Register of Clinical Trials, MEDLINE, Scopus, and Web of Science from August 2010 to December 2020. All randomized clinical trials (RCTs) were done on adults and investigated the effectiveness of administered topical or systemic medications versus placebos or controls included in the current systematic review. Three RCTs comprising 363 patients were included in the systematic review. One of the eligible studies was placebo-controlled. All of the included studies used various interventions including, methylprednisolone plus azathioprine versus methylprednisolone plus dapsone, doxycycline versus prednisolone, and intravenous immunoglobulin (IVIG). Results: Following their potentials in disease control, no difference was observed between dapsone and azathioprine; although, dapsone had a higher corticosteroid-sparing potential. The evaluation of the effect of doxycycline in short-term blister control in comparison to corticosteroids showed that the medication was not inferior to prednisolone, although it had a higher long-term safety. Conclusion: Therapeutic outcome of IVIG for steroid-resistant patients was satisfactory. Moreover, the effectiveness and reliability of various immunosuppressive drugs and tetracyclines are investigated by blinded RCTs for the treatment of BP.

The data that support the findings of this study are available from the corresponding author upon reasonable request.