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Article in press
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Omalizumab in Chronic Spontaneous Urticaria: Assessment of Response in Twenty-Five Patients
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Abstract [+]
Background
Omalizumab is a recombinant humanized monoclonal antibody against immunoglobulin E (IgE). It is approved for the treatment of chronic spontaneous urticaria (CSU) in patients ≥12-years of age.
Objective
We carried out a retrospective cross-sectional study in 25 patients with CSU to evaluate the characteristics of response of CSU to omalizumab treatment.
Method
A retrospective cross-sectional study of a convenient sample of all patients diagnosed as CSU who have been using omalizumab treatment during the study period from January 2018 to January 2020 in the Dermatology Department in King Abdulaziz Hospital, Makkah, Saudi Arabia.
Results
A total of 25 patients have participated in this study. The average age of patients was 40-years. Majority of the patients were female (52.0%, n=15). The average duration of illness was 1.32-years. Majority of the patients (72.0%, n=18) received two courses of omalizumab treatment. Minority of patients (28.0%, n=7) received one course of omalizumab treatment which was statistically significant (p value<0.01). Number of patients who have been using oral 2nd generation antihistamine during the first course and 2nd course was (72%, n=18 out of 25) and (50%, n=9 out of 18) respectively. Number of flare-ups during 2nd course (1.72 flares up per patient, n=31 flare-ups among 18 patients) was less than the number of flares-up during 1st course (2.96 flares-up per patient, n=74 flare-ups among 25 patients) which was statistically significant (p value<0.01). Number of patients who showed no flare-ups during the 1st and 2nd course of omalizumab treatment was (16%, n=4 out of 25 patients) and (27.77%, n=5 out of 18 patients) respectively. The average intensity of flares-up during 2nd course of omalizumab treatment was less than the average intensity of flares-up during first course of omalizumab treatment as the following; during 2nd course ( 33.33%, n=6 out of 18 patients), (27.77% n=5 out of 18 patients), (11.11%, n=2 out of 18 patients) mild, moderate and severe flares-up respectively and the severity during 1st course was (40.0%, n=10 out of 25 patients), (28.0%, n=7 out of 25 patients), (16.0%, n=4 out of 25 patients) mild, moderate and severe flares-up respectively. Conclusion According to expert’s guidelines, CSU of ≥3-years would be treated with omalizumab for a minimum of one-year. In our study, in spite of the short duration of CSU (average duration was 1.32-years), the majority of patients (72.0%, n=18) received omalizumab for 1-year (two courses of omalizumab treatment) suggesting that the majority of patients with CSU in general requires omalizumab ≥1-year. Our study also showed 5 patients who were free of any flare-up and they were not using 2nd generation antihistamines suggesting that omalizumab alone as monotherapy can be effective. Keywords Omalizumab; Urticaria; RCTs; Chronic spontaneous urticaria (CSU).
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Clinical Cases of Anterior Cervical Hypertrichosis
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Abstract [+]
Anterior cervical hypertrichosis (ACH) may be only an isolated aesthetic finding, but it may also be associated with other underlying conditions, including neurological and ocular disorders. In order to recognize this uncommon entity, it is imperative to provide detailed physical examination and clinical history to exclude the possible associated abnormalities in patients with ACH. In those cases that ACH represents only a cosmetic problem for the patient, laser hair removal is recommended. We hereby presented 2 cases of ACH in two young girls and discussed about all the differential diagnoses and how to rule out associated anomalies. The
most useful workout to rule out associated underlying conditions are described, and cosmetic treatment with laser hair removal devices is also commented.
Keywords
Hairy throat syndrome; Nevoid hypertrichosis; Dysraphism; Anterior cervical hypertrichosis; Congenital hypertrichosis.
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Application of Delayed Keystone Flap in Management of Post-Electrical Burn Squamous Cell Carcinoma
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Abstract [+]
Aim
The aim of the study is the application of delayed Keystone flap in the management of post-electrical burn squamous cell carcinoma.
Materials and Methods
In our study, a delayed staged type 3 keystone flap was performed as first stage procedure.
Result
In our study, by doing a delayed staged type 3 keystone flap we were able to successfully reduce the size of the defect by 40% without necrosis of the inset flap.
Conclusion
Delaying of the flap is a useful method when the vascularity of the keystone flap is doubtful especially in the case of post electrical burn.Keywords
Delayed keystone flap; Squamous cell carcinoma; Electrical burn.
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Current Issue
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Natural Honey as a Safe and Efficacious Alternative to Skin Grafting Post-Surgical Excision for Necrotizing Fasciitis at Primary Care Level: A Preliminary Study
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Abstract [+]
Necrotizing fasciitis is a soft tissue bacterial infection that spreads rapidly resulting in the destruction of muscles, skin, and underlying tissue. Necrotizing fasciitis is defined as a fast and progressive inflammatory infection of the fascia leading to secondary necrosis of the subcutaneous tissue moving along the facial plane. Fournier gangrene is a type of necrotizing fasciitis involving the scrotum and perineal area. Patients suffering from acute necrotizing fasciitis require an effective regimen which includes surgical removal of devitalized tissues, systemic antimicrobials and mitigating underlying systemic disease processes. The burden of treating wounds following surgical debridement, on the other hand, can be challenging especially in the third world where resources are scarce resulting in suboptimal wound coverage and function. At primary care level we had the opportunity of using natural honey in 5 patients with non-healing wounds in either the lower limb or scrotum due to acute necrotizing fasciitis. This natural noninvasive approach offers a cost-effective and efficacious alternative to dermatotraction, skin grafting and negative pressure wound therapy. In these patients, the use of natural honey led to the restoration of the appearance and function of the fasciotomy wound especially in patients with co-morbidities or those refusing skin grafting due to cost, religious factors, etc. The authors present the clinical results followed by a discussion on the therapeutic properties of natural honey. This case series demonstrates the efficacy of topical raw honey as a catalyst for speeding the healing process by secondary intention thereby offering a safe and efficacious
alternative for managing various wounds resulting from acute necrotizing fasciitis.
Keywords
Natural honey; Necrotizing fasciitis; Primary care; Wounds.
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Clinical Descriptive Study of Psoriasis in India: Triggers, Morbidities and Coincidences
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Abstract [+]
Background
Psoriasis is a T-cell mediated chronic inflammatory, a papulosquamous disease involving complex interactions between the innate and adaptive immune system and commonly manifested by skin lesions. It is characterized by hyperproliferation of keratinocytes and inflammatory infiltration in the epidermis and dermis. Chronic psoriasis can be a risk factor for developing comorbid diseases that share common immune pathophysiology and can be triggered by environmental factors in genetically susceptible individuals.
Aim
To study the clinico-demographic profile, determine the most common triggering factors and determine comorbidities’ coexistence in patients with psoriasis at a tertiary care centre.
Study Design
A cross-sectional study.
Methods
A teaching hospital-based cross-sectional study including 231 psoriasis patients visiting skin outpatient department (OPD) was conducted by the dermatology departmentat Sri Krishna hospital, Karamsad, India following acceptance of the study proposal by the human research ethics committee. This study was outcome of the dissertation topic of the author during dermatology residency. Total 5 qualified dermatologists working in the dermatology department and 3 resident doctors took part in the study as evaluators. After taking informed consent, detailed history regarding aggravating factors, progress and morbidities was taken with clinical examinations, and the diagnosis was purely clinical. Data were analysed using statistical package for the social sciences (SPSS).
Result
Our study revealed a peak incidence of psoriasis in the fourth and fifth decade of life with male preponderance (1.9:1). The most commonly found psoriasis type was psoriasis vulgaris, and chronic plaque psoriasis and the most common site of involvement was extensors and trunk. Pruritis was the most disabling complaint (91.34%), and the disease course was progressive. Aggravating factors included stress, winter season, implant insertion, smoking, alcohol consumption, tobacco chewing and obesity. Koebner phenomenon was commonly found with implant insertion in psoriasis patients (76.2%). Family history was one of the well established risk factors for developing psoriasis (14.2%). Our study’s most commonly found nail changes were pitting (35.49%) and dystrophic changes (18.61%). Palmoplantar keratoderma (4.76%) and vitiligo (4.76%) were the most commonly found dermatological condition with psoriasis and have been associated with various comorbidities such as cardiovascular disorder, metabolic syndrome, psoriatic arthritis and psychiatric disorders. As it was a cross-sectional study, no controls were used.
Conclusion
The study shows male preponderance and extensors, trunk as common sites of psoriatic lesion presentation. Aggravating factors included stress, winter season, implant insertion, smoking, alcohol consumption, tobacco chewing and obesity. Screening is
encouraged for symptoms of psoriatic arthritis, cardiovascular diseases and metabolic syndromes in psoriasis patients due to its predilection with systemic comorbidities.
Keywords
Psoriasis; Comorbidities; Cardiovascular disease; Metabolic syndrome; Risk factor; Triggers.
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A Case of Progestogen Hypersensitivity
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Progestogen hypersensitivity (PH) is a cyclical dermatosis that occurs in fertile women during the luteal phase of the menstrual cycle. The clinical presentation is variable and non-specific. We report the case of a 42-year-old woman with a 10-year history of itchy skin lesions that recurred monthly. Determined with her basal body temperature chart, her skin symptoms were related to progesterone surges. Skin examinations revealed multiple and extensive monomorphic red papules, mainly on her arms and legs, as well as on her chest and back. She had no history of associated fever or dyspnea. Her hair, nails and mucous membranes were normal. A blood test at the time of the worst skin eruption revealed mild elevation of serum thymus and activation-regulated chemokines and eosinophilia. Her total serum IgE level was normal. She showed a delayed skin reaction to progesterone. Ultra-low-dose combined oral contraceptives (COCs) improved her symptoms by suppressing ovulation. Accordingly, a diagnosis of progestogen hypersensitivity was made. A T-helper (Th)2 response rather than a Th1 response was suggested to be involved in this case. Atopic dermatitis (AD) can be classified into the major extrinsic type with high serum IgE levels and the minor intrinsic type with normal IgE levels. PH and AD share similarities in that they present with eczema, IgE-mediated sensitization and delayed hypersensitivity responses, and their pathophysiology remains to be fully elucidated because of their heterogeneous aspects. The symptoms of this case were in line with IgE-low AD rather than IgE-high AD, which implicates endogenous progesterone as a trigger.
Keywords
Progestogen hypersensitivity; Woman’s issues; Dermatitis; Diagnosis.
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The Dermoscopic “Chromosome Arms Sign” for Terra Firma-Forme Dermatosis
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Introduction
Terra firma-forme dermatosis (TFFD) belongs to the group of “dirty dermatoses” and represents a not well-known and surely underestimated skin condition.
Clinical cases
We present 2 cases of TFFD and present clinical and dermatoscopical findings.
Results
We present specific dermatoscopical findings of TFFD.
Conclusion
We propose the denomination “chromosome arms” sign for Terra firma-forme dermatosis.
Keywords
Terra firma-forme dermatosis; Dirtydermatoses; Dermatoscopy; Chromosome arms; Duncan’s dermatosis.
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Squamous Melanocytic Tumour at an Unusual Site: An Uncommon Case and Literature Review
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Hidradenoma Papilliferum
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Photobiomodulation in Cells’ Repair
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Lupus Erythematosus Affecting the Genitalia: An Unusual Site
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Previous Issue
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The Skinny on Moisturizers: A Brief Report
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Abstract [+]
Objective
To compare the effectiveness of 5 different skin moisturizers using JELL-O® as a model for the human skin.
Methods
In this study five different moisturizers (Equate®, Burt’s Bees®, Suave®, Aveeno® and Vaseline®) were applied to equivalent samples of JELL-O®. Observations were made over a 12-day period and data was collected at 15 different time intervals. The primary outcome was the height (cm) and weight (g) of the JELL-O® sample at each time interval. The study was an ex vivo experiment conducted in a home laboratory. No Institutional Review Board (IRB) approval was required since the research does not involve living organisms.
Results
Overall, the JELL-O® sample that had the Vaseline® applied on it had the lowest loss of height and weight. The height stayed at 100% of its original value and the weight only decreased to 97.2% of the original value by the end of the observation period. In contrast, the sample which had Suave® applied to the surface its height and weight decrease the most (42% and 28% respectively). The other moisturizers had effects intermediate between these two extremes.
Conclusion
Based on this ex vivo head to head study using JELL-O® as a model for the human skin the 5 moisturizers examined had widely differing levels of effectiveness with Vaseline® appearing to be the most protective against evaporative losses and Suave® appearing to be the least.
Keywords
Moisturizers; Dry skin; Different moisturizers; Skin lotions; Vaseline® effectiveness.
Squamous Melanocytic Tumour at an Unusual Site: An Uncommon Case and Literature Review
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We herein present a case report of a 60-year-old male patient diagnosed with squamous-melanocytic tumour (SMT) in his anal region, comprised of two intermingled different phenotypic lesions. This dual tumour is quite uncommon and could potentially be challenging on both diagnose and also management. It is the first case reported on this location, moreover, the lack of consensus for these lesions makes it difficult to classify them. We reviewed the literature of similar SMT’s and discussed its histogenesis. As they are rare, their biological behavior and potential metastasis remain unclear. Therefore, close follow-up is advised.
Keywords
Combined neoplasia; Squamous-melanocytic tumour; Uncertain; Anal canal.
Hidradenoma Papilliferum
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Photobiomodulation in Cells’ Repair
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Photobiomodulation is a non-invasive treatment modality acting at different biological levels through the non-thermal transfer of photons to the living matter via a photoelectric effect, inducing photochemical reactions in treated cells. The objectives of this article is to review the literature on Photobiomodulation, its different fields of application and mechanisms of action, for establishing a comprehensive summary of evidence. The search strategy initially run searches in scientific databases MEDLINE,
PubMed, EMBASE and Cochrane registries from 1990 up to March 2020, with entries Photobiomodulation, LLLT-LEDT, PDT, Photobiology, Cytochrome c Oxidase. Selection criteria was based on preferably inclusion of randomized clinical trials (RCTs), systematic reviews (SR) and studies providing qualitative and quantitative data with the best consistency, in a field where heterogeneity of light parameters is often a difficulty to comparison of findings. Publised expert opinions were also considered. A total of 80 publications were reviewed out of a thousand obtained from databases, among which were retained 9 RCTs, 6 systematic reviews, 3 meta-analysis and 2 case-reports. Differences were found in treatment parameters as wavelength, dosage, energy output, treatment length, performances of light-sources, quantity of diodes and single power of these, which may explain the paucity of high-level body of evidence in Cochrane databases. However, numerous state-of-the- art researches are also found, led by dedicated research teams paving the way to standardized methods of evaluation and comprehension of light-biological-tissues interaction and optimization of outcomes in a promising field.
Keywords
PhotoBioModulation; Low-Level-Laser-Therapy (LLLT); Light emitting diodes (LED); Biophotons-mitochondria; Adenosine-triphosphate (ATP); Inflammation-pain-skin rejuvenation; Photo dynamic therapy (PDT); Photobiology.
Lupus Erythematosus Affecting the Genitalia: An Unusual Site
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Cutaneous lupus erythematosus classically affects sun-exposed areas. It’s rarely affects the genitalia, and there are few cases reported in the literature. Thus, we report the different genital manifestations observed in a patient with lupus erythematosus affecting the genital area.
Keywords
Genitalia; Cutaneous lupus erythematosus; Systemic lupus.
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Associate Editors
Hashim Mohamed, MBBch
Assistant Professor
Weill Cornell Medicine Qatar
Senior Consultant Family Medicine
Education City, Al Luqta St, Ar-Rayyan, Qatar
Assistant Professor Weill Cornell Medicine Qatar Senior Consultant Family Medicine Education City, Al Luqta St, Ar-Rayyan, Qatar
