Intralesional bivalent and quadrivalent human papillomavirus vaccines didn't significantly enhance the response of multiple anogenital warts when co-administered with intralesional Candida antigen immunotherapy. A randomized controlled trial

Treatment of anogenital warts (AGWs) is challenging. Candida antigen immunotherapy has been proven to be a safe and relatively effective therapeutic modality; nevertheless, some patients may experience a partial or no response. Combining Candida antigen with other immunotherapies has been proposed to improve the cure rate. Immunotherapy with human papillomavirus (HPV) vaccines has been tried with conflicting outcomes. This study aimed to  assess the efficacy and safety of intralesional Candida antigen, either alone or in combination with intralesional bivalent or quadrivalent HPV vaccines, for treating multiple AGWs. Eighty patients with multiple AGWs were included and randomly assigned to four equal groups: group A treated with intralesional Candida antigen only; group B treated with intralesional bivalent HPV vaccine (Cervarix) and Candida; group C treated with intralesional quadrivalent HPV vaccine (Gardasil) and Candida; and group D (control) treated with intralesional saline. Complete clearance of lesions was detected in 40%, 20%, and 60% of patients in Candida monotherapy, Cervarix/Candida, and Gardasil/Candida groups, respectively, whereas 40%, 60%, and 20% of patients in the three groups, respectively, showed partial response. Only 10% of the control group had a partial response. Therapeutic outcomes were significantly better in the three treatment groups compared to the control group, with no statistically significant difference between the Candida monotherapy group and the combination groups, but the response was significantly better in the Gardasil/Candida group than in the Cervarix/Candida group. No statistically significant difference was found between the studied groups regarding the development of side effects. Moreover, no recurrence was detected in any of the groups throughout the 3-month follow-up period.  Based on our results, combining intralesional HPV vaccines with Candida antigen immunotherapy may have no significant benefit for treating multiple AGWs. Candida antigen may be recommended as a relatively effective and inexpensive therapeutic modality. The combination of Gardasil and Candida was also effective but very expensive. The results of the Cervarix/Candida combination were unsatisfactory.  This clinical trial was registered and approved prospectively by the ethical review board at Faculty of Medicine, Zagazig University.

Intralesional versus intramuscular bivalent human papillomavirus vaccine in the treatment of recalcitrant common warts

BACKGROUND

Despite the availability of different therapeutic modalities, treatment of recalcitrant common warts is still challenging. Cervarix (GlaxoSmithKline, Brentford, UK), a recombinant bivalent human papillomavirus (HPV) vaccine, has shown promising efficacy in the treatment of warts.

OBJECTIVES

To evaluate the beneficial effects and tolerability of intramuscular versus intralesional bivalent HPV vaccine in the treatment of recalcitrant common warts.

METHODS

The study included 44 adult patients with multiple recalcitrant common warts; 22 patients received intramuscular injection of bivalent HPV vaccine at 0, 1, and 6 months or until complete clearance of warts, and the other 22 patients received intralesional injection of 0.1 to 0.3 mL of bivalent HPV vaccine into the largest wart at 2-week intervals until complete clearance or for a maximum of 6 sessions.

RESULTS

Complete clearance of warts was observed in 18 patients (81.8%) of the intralesional group and 14 patients (63.3%) of the intramuscular group; however, the difference was not statistically significant. Adverse effects were transient and insignificant, and no recurrence was reported in either group.

LIMITATIONS

Small study sample and different dosing schedules.

CONCLUSIONS

Bivalent HPV vaccine, particularly by intralesional injection, seems to be a potential therapeutic option for the treatment of multiple recalcitrant common warts.

Combination therapy versus monotherapy in the treatment of recalcitrant warts: A clinical and immunological study

BACKGROUND

Treatment of recalcitrant warts represents a continuing therapeutic challenge. Combination therapies can help improve treatment response, decrease adverse effects, and reduce recurrence.

OBJECTIVE

To compare the efficacy, safety and immunological effects of a combined acitretin-intralesional Candida antigen against acitretin alone and Candida antigen alone for intractable warts.

METHODS

Sixty adult patients with intractable warts were included in this study. Patients were subdivided into three groups, each containing 20 patients. Acitretin alone was taken by patients of group I, Candida antigen alone was injected in patients of group II, and group III received a combination of intralesional Candida antigen and acitretin. Serum cytokine levels of IL-10 and IFN-γ were measured before and after therapy in the studied groups.

RESULTS

Total resolution of warts was achieved in 8 patients (40%) of the acitretin alone group, 9 patients (45%) of the Candida antigen alone group and 15 patients (75%) of the combination therapy group. The therapeutic response was statistically higher in the combined acitretin-Candida antigen group as compared with either agent alone. Adverse effects were non-significant in the three groups. There were no statistically significant differences in the serum levels of IFN-γ and IL-10 between responders and non-responders after therapy in the three studied groups.

CONCLUSION

The combination therapy of acitretin + Candida antigen is superior to either agent alone. Serum cytokine levels of IL-10 and IFN-γ were not associated with clearance or persistence of warts in any of the studied groups.

Topical silymarin versus hydroquinone in the treatment of melasma: A comparative study

BACKGROUND

Melasma is a highly prevalent hyperpigmentation disorder with a high relapsing rate and a negative impact on the psychological state of the affected patients. The exact pathogenesis of melasma is not completely elucidated; however, ultraviolet induced oxidative stress has an important role in its pathogenesis. Silymarin, antioxidant drug, reduces the harmful effects of solar ultraviolet radiation such as inflammation, immune responses, DNA damage, and pigmentation.

OBJECTIVES

To assess the efficacy and safety of topical silymarin with different concentrations (0.7% and 1.4%) versus hydroquinone 4% in the treatment of melasma.

METHODS

Forty-two adult female patients with melasma were assigned to three equal groups each containing 14 patients; group1 was treated by silymarin 0.7% cream, group 2 was treated by silymarin 1.4% cream and group 3 was treated by hydroquinone 4% cream. The duration of treatment was 3 months.

RESULTS

MASI score was significantly reduced in all groups at the end of third month; however, there were no significant differences in the therapeutic response between the three studied groups. No side effects were recorded with silymarin, while hydroquinone was associated with significant adverse effects.

CONCLUSIONS

Silymarin cream might serve as an effective and safe treatment modality for melasma.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Lichen myxedematosus: diagnostic criteria, classification, and severity grading

BACKGROUND

Lichen myxedematosus (LM) is a rare, chronic idiopathic disorder characterized clinically by waxy, closely set papules and histopathologically by diffuse dermal mucin deposition and fibroblast proliferation. The most recent classification of LM was proposed in 2001; however, it seems to be complex, confusing, and imprecise. Herein, we present seven cases of LM to evaluate the validity of the current classification, to propose new diagnostic criteria and classification, and to suggest a clinically relevant severity grading system for this rare disorder.

MATERIALS AND METHODS

The study included seven patients with different presentations and severities of LM. All patients were subjected to thorough dermatological and systemic examination, routine laboratory tests, evaluation of thyroid function, protein electrophoresis, and detailed investigations to detect systemic involvement.

RESULTS

The current classification does not meet the requirements of proper diagnosis of different presentations of LM. Subtyping of the studied patients differs greatly according to the old classification and the newly proposed one. New diagnostic criteria, classification, and grading are consequently suggested.

CONCLUSIONS

We propose two sets of diagnostic criteria to define the disease more precisely and to avoid confusion associated with the other classification. The first set comprises constant clinical and histopathological features that are always present in every case, and the second set includes associated features that were variably reported in some patients. LM is then subclassified according to the presence or absence of systemic manifestations into a systemic severe form (scleromyxedema) and a non-disabling, pure cutaneous form.

Platelet-rich plasma versus CROSS technique with 100% trichloroacetic acid versus combined skin needling and platelet rich plasma in the treatment of atrophic acne scars: a comparative study

BACKGROUND

Platelet-rich plasma (PRP) is an autologous preparation of platelets in concentrated plasma that may be beneficial in the treatment of atrophic acne scars by promoting collagen deposition. Skin needling is a technique that uses a sterile dermaroller to puncture the skin and release growth factors. The combination of skin needling and PRP could enhance the efficacy of both modalities. Chemical reconstruction of skin scars technique consists of focal application of high concentration of trichloroacetic acid (TCA) on the acne scars to stimulate collagen production.

OBJECTIVE

To evaluate the efficacy and safety of intradermal injection of PRP, 100% focal TCA, and combined skin needling plus topical PRP in the treatment of atrophic acne scars.

PATIENTS AND METHODS

Forty-five patients with atrophic acne scars were randomly assigned to 3 equal groups; Group A received intradermal injection of PRP, Group B received chemical reconstruction of skin scars technique with TCA 100%, and Group C was treated by combined skin needling and PRP. Each patient underwent 3 sessions at 2-week interval.

RESULTS

All the patients completed the study. The 3 groups showed statistically highly significant improvement in the degree of acne scars after treatment (p < .001). No major adverse effects were observed in the studied groups.

CONCLUSION

This is the first study to use intradermal injection of PRP alone for the treatment of atrophic acne scars. The 3 modalities showed a promising efficacy and safety in the treatment of atrophic acne scars.

Generalized eruptive keratoacanthoma: proposed diagnostic criteria and therapeutic evaluation

Generalized eruptive keratoacanthoma (GEKA) of Grzybowski is a sporadically occurring, extremely rare variant of keratoacanthoma characterized clinically by severely pruritic, generalized eruption of numerous small follicular papules, often with a central keratotic plug, and histologically by typical features of solitary keratoacanthoma. Despite the continuous addition of new case reports, no definite diagnostic criteria have been established, and an optimum treatment is not yet determined. Herein, we review the different aspects of this rare entity, including pathogenesis, clinical and histopathological features, differential diagnosis, course and prognosis. Different therapeutic approaches and their impact on the course and prognosis of the disease are also evaluated and presented. We propose two sets of diagnostic criteria to define the disease more precisely and to avoid overlapping and confusion with other types of multiple keratoacanthoma. The first set comprises constant clinical and histopathological features that almost always present in every case and the second set includes variable features that were reported in some patients, and to which any emerging finding could be added to avoid missing cases. Although different therapeutic options have been used, either as single agents or in combinations, there is no standard therapy for GEKA and the disease still represents a therapeutic challenge.

Intralesional antigen immunotherapy for the treatment of warts: current concepts and future prospects

Many destructive and immunotherapeutic modalities have been used for the management of warts; however, an optimal treatment with high efficacy and absent or low recurrence has not been explored to date. Recently, the use of intralesional immunotherapy with different antigens has shown promising efficacy in the treatment of warts. We review the different aspects of this new modality, including candidates, types of warts treated, dosage, number and interval between treatment sessions, mode of action, efficacy, adverse effects, recurrence rate, advantages, disadvantages, current place and future prospects. A literature review revealed that healthy immune subjects are the best candidates, and a pre-sensitization test is usually done before the start of therapy. The dosage, the number and interval between sessions, and the success rates varied among the different studies. The mode of action is still uncertain, but is essentially mediated through stimulation of T helper-1 cell cytokine response. Adverse effects are mild and generally insignificant, and the recurrence rate is absent or low. Intralesional antigen immunotherapy seems to be a promising, effective and safe treatment modality for viral warts. Future well-designed and controlled studies would help to more clearly define its place in the challenging field of wart therapy.

Paederus dermatitis in Egypt: a clinicopathological and ultrastructural study

BACKGROUND

Outbreaks of paederus dermatitis (PD) have been observed in different parts of the world, yet the histopathological and ultrastructural changes and their relationship to pederin toxin have not been described.

OBJECTIVE

To describe the clinical presentations of PD in Egypt and to study the effects of pederin toxin on the skin by evaluating the histopathological and ultrastructural changes of some representative cases.

METHODS

One hundred and thirteen patients with PD were studied clinically and epidemiologically. Skin biopsies were taken from 40 patients for histopathological examination and from 20 patients for electron microscopic (EM) examination.

RESULTS

Clinically, the most common presentation comprised erythematous plaques with micropustules. Blisters exhibited a linear configuration in 40% of the patients and kissing lesions were observed in 13%. Multiple lesions occurred in 78% of the patients and the face was the most commonly involved site (48%). The insect was identified as Paederus alfierii. Histopathological examination revealed features of acute irritant dermatitis in the upper epidermis. Mitotic figures and apoptotic changes such as chromatin condensation and DNA fragmentation were identified in the basal and suprabasal layers. These features were confirmed by EM.

CONCLUSIONS

Clinical, histopathological and, for the first time, ultrastructural characteristics of paederus dermatitis are described. The pathological abnormalities of the upper epidermis are caused by the irritant effect of pederin toxin. The presence of apoptosis within the lower epidermis can be related to this toxin, a point that needs further research, hoping for its future implications in the management of hyperproliferative disorders.

Nonmutilating palmoplantar and periorificial kertoderma: a variant of Olmsted syndrome or a distinct entity?

BACKGROUND

Olmsted syndrome is a rare keratinization disorder characterized by mutilating palmoplantar and periorificial keratoderma as the two major diagnostic features. Some authors believe that atypical cases without this standard combination may not really belong to Olmsted syndrome. Herein, we describe two familial cases with congenital nonmutilating palmoplantar and periorificial keratoderma, and discuss their similarities and differences with Olmsted syndrome.

PATIENTS

The study included two sisters who presented with focal and punctate nonmutilating palmoplantar keratoderma (PPK), periorificial hyperkeratotic plaques, and widely distributed keratotic lesions. Fragile denuded areas of the skin were found in sites exposed to trauma. Fingernails showed a characteristic form of leukonychia.

RESULTS

Histopathology of plantar keratoderma showed psoriasiform hyperplasia with marked compact hyperkeratosis, while vicinity of denuded skin revealed thin parakeratotic zone and dissolution of the granular cell layer. Immunohistochemistry demonstrated suprabasal staining pattern for acidic keratin (AE1) and uniform positivity, starting four to six layers above the basal layer, for cytokeratin 10. Electron microscopy showed defective keratinization. Cytogenetic studies revealed normal karyotype and no chromosomal breakage.

CONCLUSION

Our cases share Olmsted syndrome in the early onset, and the presence of symmetrical PPK, periorificial keratoderma and keratotic lesions. However, the striking nonmutilating nature of PPK and the presence of unique features in our patients suggest a newly described keratinization disorder.

Juvenile hyaline fibromatosis and infantile systemic hyalinosis: a unifying term and a proposed grading system

BACKGROUND

It has been suggested that juvenile hyaline fibromatosis and infantile systemic hyalinosis represent different severities of the same disease.

OBJECTIVE

We sought to redefine these disorders clearly to establish a common inclusive terminology.

PATIENTS

The study included two children with early onset of similar pink papulonodular skin lesions and marked gingival hyperplasia. The first case was characterized by flexion contractures of the large joints, fractures, persistent diarrhea, recurrent chest infections, and retarded physical growth. The second patient had large swellings on the scalp and knees without systemic involvement.

RESULTS

Radiologic examination revealed fractures and osteolytic bone lesions in the first case, and soft tissue masses in the second case. Laboratory tests showed anemia in both cases, and hypogammaglobulinemia, hypoalbuminemia, and electrolyte imbalance in the first case. Histopathological and ultrastructural evaluation demonstrated hyalinized fibrous tissue in the dermis in both cases.

LIMITATIONS

Genetic studies were unavailable.

CONCLUSION

Juvenile hyaline fibromatosis and infantile systemic hyalinosis share many common features that strongly support consideration of these conditions as different expressions of the same disorder. We propose a common term, "hyaline fibromatosis syndrome," which can be divided into mild, moderate, and severe subtypes.

Necrolytic acral erythema: a variant of necrolytic migratory erythema or a distinct entity?

BACKGROUND

Hepatitis C is a major health problem in Egypt. Necrolytic acral erythema (NAE) is a recently described necrolytic erythema that has a distinctive acral distribution and a uniform association with hepatitis C. Some authors believe that NAE is a distinct entity and others consider it as a variant of necrolytic migratory erythema (NME).

METHODS

Five patients with clinical features consistent with NAE were included in this study. The patients were subjected to skin biopsy examination, CT scan of the pancreas and a liver biopsy. Liver function tests, serum glucagon, glucose, amino acids and zinc were measured. All patients were tested for hepatitis C by enzyme-linked immunosorbent assay (ELISA) and by polymerase chain reaction (PCR).

RESULTS

Three patients presented with early (acute) lesions and two patients with chronic lesions. The distribution of the lesions was almost exclusively on the dorsae of the feet. Histopathological findings were similar to those of other necrolytic erythemas. Hepatitis C virus was uniformly detected in all patients. Serum glucagon was high in two patients, serum glucose was high in four patients, serum amino acids were low in three cases and serum zinc and albumin were low in two cases. Little or no improvement was reported after oral amino acid supplementation, while the response to oral zinc sulfate was moderate to good.

CONCLUSION

Necrolytic acral erythema is closely associated with hepatitis C infection. Many findings indicate that NAE seems to be a variant of NME rather than a distinct entity. Hence, an alternative proposed term could be acral NME.