Bacterial Skin Dysbiosis in Darier Disease

INTRODUCTION

Darier disease is a rare inherited disease with dominant skin manifestations including keratotic papules and plaques on sebaceous and flexural areas. Secondary infection of skin lesions is common and Staphylococcus aureus commonly colonizes these lesions. The aim of the study was to characterize the bacterial microbiome of cutaneous Darier lesions compared to normal-looking skin and to disease severity.

METHODS

All patients with a history of Darier followed-up at Emek Medical Center were invited to participate in the study. Patients that did not use antibiotics in the past month and signed informed consent had four skin sites sampled with swabs: scalp, chest, axilla and palm. All samples were analyzed for bacterial microbiome using 16S rDNA sequencing.

RESULTS

Two-hundred and eighty microbiome samples obtained from lesional and non-lesional skin of the scalp, chest, axilla, and palm of 42 Darier patients were included in the analysis. The most abundant bacterial genera across all skin sites were Propionibacterium, Corynebacterium, Paracoccus, Micrococcus, and Anearococcus. Scalp and chest lesions featured a distinct microbiome configuration that was mainly driven by an overabundance of Staphylococci species. Patients with more severe disease exhibited microbiome alterations in the chest, axilla, and palm compared with patients with only mild disease, driven by Peptoniphilus and Moryella genera in scalp and palmar lesions, respectively.

CONCLUSION

Staphylococci were significantly associated with Darier lesions and drive Darier-associated dysbiosis. Severity of the disease was associated with two other bacterial genera. Whether these associations also hold a causative role and may serve as a therapeutic target remains to be determined and requires further investigation.

[TRANSLATIONAL MEDICINE IN DERMATOLOGY- FURTHER PROMOTING PSORIASIS RESEARCH]

INTRODUCTION

Psoriasis is a chronic inflammatory skin disorder that affects approximately 2-3% of the population worldwide. Translational medicine, which focuses on treating and analyzing diseases caused by translational factors, is becoming increasingly relevant in the field of psoriasis research. This review aims to display the current literature on the role of translational medicine in the treatment and understanding of psoriasis. We found that translational factors such as protein kinases and cytokines play a key role in the development and progression of psoriasis. Additionally, current treatments for psoriasis, such as biologics, target these translational factors to reduce inflammation and improve skin condition. Furthermore, studies have shown that genetic variations in translational-related genes can also contribute to the development of psoriasis. This highlights the importance of translational medicine in understanding the underlying mechanisms of psoriasis and developing increasingly effective treatments for this debilitating disease.

Ectopic presentation of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory disease involving primarily intertriginous skin areas. Ectopic HS lesions are a reported phenomenon that is not fully understood. We present a case report of a 66-year-old patient with painful symmetric ulcerated plaques on the posterior surface of the ankles and lower lip. In addition, we performed a systematic review on ectopic HS by conducting an electronic literature search to identify relevant contributions. Inclusion criteria included English-language and full texts only using PubMed, Embase, and the Cochrane Database. We found 22 eligible contributions reporting on a total of 58 patients. Most of the patients were men who had lesions on the head and neck region. The reviewed cases share common features with HS and may be considered disorders of follicular occlusion.

Acute Generalized Exanthematous Pustulosis: Clinical Features, Differential Diagnosis, and Management

Acute generalized exanthematous pustulosis (AGEP) is a rare, acute, severe cutaneous adverse reaction mainly attributed to drugs, although other triggers, including infections, vaccinations, ingestion of various substances, and spider bites, have also been described. AGEP is characterized by the development of edema and erythema followed by the eruption of multiple punctate, non-follicular, sterile pustules and subsequent desquamation. AGEP typically has a rapid onset and prompt resolution within a few weeks. The differential diagnoses for AGEP are broad and include infectious, inflammatory, and drug-induced etiologies. Diagnosis of AGEP depends on both clinical and histologic criteria, as cases of overlap with other disease processes have been reported. Management includes removal of the offending drug or treatment of the underlying cause, if necessary, and supportive care, as AGEP is a self-limited disease. This review aims to provide an overview and update on the epidemiology, pathogenesis, reported precipitating factors, differentials, diagnosis, and management of AGEP.

Adult Henoch-Schönlein Purpura: Comprehensive Assessment of Demographic, Clinical, and Histopathological Features as Predictors for Systemic Involvement

BACKGROUND

Henoch-Schönlein purpura (HSP) is a small-vessel IgA-predominant vasculitis. A major challenge in managing adult HSP is the difficulty assessing the risk of systemic involvement. There is currently a paucity of data in this area.

OBJECTIVE

The objective of this study was to determine demographic, clinical, and histopathological features associated with systemic involvement in adult HSP.

METHODS

In this retrospective study, we reviewed demographical features and clinical and pathology data of 112 adult HSP patients seen at Emek Medical Center between January 2008 and December 2020.

RESULTS

Of these patients, 41 (36.6%) had renal involvement, 24 (21.4%) had gastrointestinal tract involvement, and 31 (27.7%) had joint involvement. Age >30 years (p = 0.006) at diagnosis was an independent predictor of renal involvement. Platelet count (<150 K/µL) (p = 0.020) and apoptosis of keratinocytes on skin biopsy (p = 0.031) were also associated with renal involvement. History of autoimmune disease (p = 0.001), positive c-antineutrophil cytoplasmic antibody (p = 0.018), positive rheumatoid factor (p = 0.029), and elevated erythrocyte sedimentation rate (p = 0.04) were associated with joint involvement. Female sex (p = 0.003), Arab race (p = 0.036), and positive pANCA (p = 0.011) were associated with gastrointestinal tract involvement.

LIMITATIONS

This study is retrospective.

CONCLUSION

These findings may serve as a guide to stratify risk in adult HSP patients so that those at higher risk can be monitored more closely.

A Review of Bullous Dermatologic Adverse Events Associated with Anti-Cancer Therapy

The rapid evolution of anti-cancer therapy (including chemotherapy, targeted therapy, and immunotherapy) in recent years has led to a more favorable efficacy and safety profile for a growing cancer population, and the improvement of overall survival and reduction of morbidity for many cancers. Anti-cancer therapy improves outcomes for cancer patients; however, many classes of anti-cancer therapy have been implicated in the induction of bullous dermatologic adverse events (DAE), leading to reduced patient quality of life and in some cases discontinuation of life-prolonging or palliative therapy. Timely and effective management of adverse events is critical for reducing treatment interruptions and preserving an anti-tumor effect. Bullous DAE may be limited to the skin or have systemic involvement with greater risk of morbidity and mortality. We present the epidemiology, diagnosis, pathogenesis, and management of bullous DAE secondary to anti-cancer therapies to enable clinicians to optimize management for these patients.

Potential di-genic contribution to guttate leukoderma as the predominant feature of epidermolysis bullosa simplex

Inherited epidermolysis bullosa (EB) simplex is a heterogeneous group of skin fragility disorders caused by mutations in genes encoding cell-cell or cell-matrix adhesion proteins. A recently identified, rare subtype of EB simplex is due to bi-allelic mutations in the EXPH5 gene, which encodes exophilin5, an effector protein of the Rab27B GTPase involved in intracellular vesicle trafficking and exosome secretion. The EXPH5 EB subtype is characterized by early-onset skin blisters and scars, mainly on extremities, and varying degrees of pigmentary alterations. Here, we present a 31-year-old female with diffuse guttate hypopigmentation on the trunk and extremities since early childhood, with no apparent blisters or scars. We employed whole exome sequencing of germline DNA extracted from the patient's leukocytes to determine the genetic aetiology of the phenotype. A novel homozygous variant in EXPH5, c.1153C>T causing a premature stop codon at amino acid Glutamine 385, was identified. Histologic examination after skin pricking disclosed focal keratinocyte detachment typical to EB. Additionally, we identified a deleterious-predicted variant in ENPP1, a gene associated with disturbed transfer of melanosomes to keratinocytes in Cole disease. Our report expands the clinical spectrum of inherited EB simplex with a possible di-genic synergism contributing to co-presentation with guttate leukoderma.

Phototherapy for Generalized Pruritus of Unknown Origin: Single-Center Experience

OBJECTIVE

Phototherapy is a well-established therapy in dermatology. However, there is limited evidence regarding phototherapy for the treatment of generalized pruritus of unknown origin (GPUO). The objective of this study was to assess the efficacy and safety of narrowband ultraviolet B (NB-UVB) phototherapy in patients with GPUO.

METHODS

Researchers conducted a retrospective review of the treatment outcomes of patients with GPUO who were treated with NB-UVB between 2004 and 2019 at their facility.

RESULTS

Investigators included 67 patients diagnosed with GPUO treated with NB-UVB. Complete remission was achieved in more than 70% of the patients. No serious adverse events were documented.

CONCLUSIONS

For patients with GPUO, NB-UVB may be a safe and effective treatment option.

Acral peeling in Nagashima type palmo-plantar keratosis patients reveals the role of serine protease inhibitor B 7 in keratinocyte adhesion

Acral peeling skin syndrome (APSS) is a heterogenous group of genodermatoses, manifested by peeling of palmo-plantar skin and occasionally associated with erythema and epidermal thickening. A subset of APSS is caused by mutations in protease inhibitor encoding genes, resulting in unopposed protease activity and desmosomal degradation and/or mis-localization, leading to enhanced epidermal desquamation. We investigated two Arab-Muslim siblings with mild keratoderma and prominent APSS since infancy. Genetic analysis disclosed a homozygous mutation in SERPINB7, c.796C > T, which is the founder mutation in Nagashima type palmo-plantar keratosis (NPPK). Although not previously formally reported, APSS was found in other patients with NPPK. We hypothesized that loss of SERPINB7 function might contribute to the peeling phenotype through impairment of keratinocyte adhesion, similar to other protease inhibitor mutations that cause APSS. Mis-localization of desmosomal components was observed in a patient plantar biopsy compared with a biopsy from an age- and gender-matched healthy control. Silencing of SERPINB7 in normal human epidermal keratinocytes led to increased cell sheet fragmentation upon mechanical stress. Immunostaining showed reduced expression of desmoglein 1 and desmocollin 1. This study shows that in addition to stratum corneum perturbation, loss of SERPINB7 disrupts desmosomal components, which could lead to desquamation, manifested by skin peeling.

Concomitant variants in NF1, LZTR1 and GNAZ genes probably contribute to the aggressiveness of plexiform neurofibroma and warrant treatment with MEK inhibitor

Neurofibromatosis 1 (NF1) is caused by germline mutations in the NF1 gene and manifests as proliferation of various tissues, including plexiform neurofibromas. The plexiform neurofibroma phenotype varies from indolent to locally aggressive, suggesting contributions of other modifiers in addition to somatic loss of NF1. In this study, we investigated a life-threatening plexiform neurofibroma in a 9-month-old female infant with NF1. Germline mutations in two RASopathy-associated genes were identified using whole-exome sequencing-a de novo pathogenic variant in the NF1 gene, and a known pathogenic variant in the LZTR1 gene. Somatic analysis of the plexiform neurofibroma revealed NF1 loss of heterozygosity and a variant in GNAZ, a gene encoding a G protein-coupled receptor. Cells expressing mutant GNAZ exhibited increased ERK 1/2 activation compared to those expressing wild-type GNAZ. Taken together, we suggest the variants in NF1, LZRT1 and GNAZ act synergistically in our patient, leading to MAPK pathway activation and contributing to the severity of the patient's plexiform neurofibromatosis. After treatment with the MEK inhibitor, trametinib, a prominent clinical improvement was observed in this patient. This case study contributes to the knowledge of germline and somatic non-NF1 variants affecting the NF1 clinical phenotype and supports use of personalized, targeted therapy.

Parental mosaic cutaneous-gonadal GJB2 mutation: From epidermal nevus to inherited ichthyosis-deafness syndrome

Ichthyosis and deafness syndrome is a group of devastating genodermatoses caused by heterozygous mutations in GJB2, encoding the gap junction protein connexin 26. These syndromes are characterized by severe skin disease, hearing loss, recurrent infections, and cutaneous neoplasms. Cutaneous somatic mutations in the same gene are associated with porokeratotic eccrine ostial dermal duct nevus. Here we report a family in which a parent presented with localized epidermal nevus and his child suffered with hystrix-like ichthyosis with deafness. Histologic examination of the parent's cutaneous lesion revealed verrucous epidermal nevus without features of porokeratotic eccrine ostial dermal duct nevus. Genetic analysis identified the same pathogenic variant, GJB2 c.148G>A (p.D50N), in DNA extracted from the parent's cutaneous lesion and the child's leukocytes, but not in the parent's leukocytes. This study expands the phenotypic heterogeneity of GJB2 mosaic variants in addition to porokeratotic eccrine ostial dermal duct nevus, and emphasizes the importance of molecular diagnosis of mosaic skin diseases considering the risk of severe inherited diseases in the offspring.

Ophthalmic Assessment in Patients With Darier Disease

PURPOSE

To assess the prevalence of ophthalmic findings in patients with Darier disease, an autosomal dominant genetic skin disorder, in an effort to evaluate the need for eye examinations in the management of the disease.

DESIGN

Prospective observational case series.

METHODS

Thirty-six individuals with Darier disease were evaluated by both ocular assessment questionnaire and a comprehensive ophthalmic examination (visual acuity, refraction, external examination, and slit-lamp examination) with emphasis on the eyelids, conjunctiva, and cornea. In addition, questionnaire-based medical interview and skin examination were conducted.

RESULTS

According to the medical questionnaire, 39% of patients reported eye problems, 36% dry eye, and 42% eye fatigue after prolonged reading. Ocular examination revealed Darier disease lesions on the eyelids in 55% of the patients, blepharitis in 44%, conjunctival hyperemia in 28%, and short tear film break-up time in 83%. There was no significant relationship between any of these ophthalmic findings and systemic retinoid therapy, sex, or age.

CONCLUSIONS

The high prevalence of blepharitis and dry eye highlights the importance of ophthalmologic evaluation of patients with Darier disease.

Skin and soft tissue infections in biological therapy for psoriasis-A case report and systematic review of the literature

BACKGROUND

Biological therapies are widely used for moderate to severe chronic plaque psoriasis owing to their high efficacy and safety profile. However, skin and soft tissue infections (SSTIs) have been reported in association with biological treatment in psoriasis.

METHODS

We report a case of necrotizing fasciitis in an 18-year-old psoriasis patient with a history of severe combined immunodeficiency treated with secukinumab and conducted a systematic literature review of SSTIs associated with biological therapy for psoriasis. The literature review related to biological therapies for psoriasis between the years 1990 and 2020: Medline (PubMed), Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) were searched for psoriasis, biological treatment, and skin and soft tissue infections.

RESULTS

Over 1,300 titles were found, 24 of which met the inclusion criteria for our study: nine retrospective studies, nine randomized controlled trials, and six prospective studies. The data covered 10 biological treatments. More than 40,000 patients receiving biological treatment were included, and nearly 1,000 cases of SSTIs were documented.

CONCLUSIONS

We present the available records regarding SSTIs among chronic plaque psoriasis patients given biological treatment. Most reported SSTIs were related to psoriasis patients treated with TNF-α inhibitors. In view of the presented data, biological treatment appears to be a safe mode of therapy for this aspect of psoriasis.

An Update on the Cutaneous Manifestations of Darier Disease

BACKGROUND

Knowledge about the clinical features of Darier disease, an orphan autosomal-dominant genetic disorder, is sparse and has been evaluated only in few studies.

OBJECTIVES

To investigate the clinical features of a large group of patients with Darier disease, and to explore for associations between disease characteristics and severity of the disease.

METHODS

Seventy-six individuals with Darier disease were evaluated utilizing a structured questionnaire-based interview, a physical examination, and a retrospective assessment of their medical records.

RESULTS

The most frequent locations of lesions were hands (99%) and fingernails (93%). Wart-like lesions on the hands were more visible after soaking them in water for 5 minutes, we therefore named this phenomenon the "wet hand sign". Oral involvement was found in 43% of patients, while 48% of women and 16% of men showed genital lesions. Patients with severe Darier disease had a tenfold greater risk of developing genital lesions than those with mild disease (P = .01). Most patients (88%) in our study exhibited a combination of the four types of the disease patterns of distribution (flexural, seborrheic, nevoid, and acral).

CONCLUSIONS

Documentation of disease on the hands and fingernails provides a highly sensitive means to aid in the diagnosis of Darier disease. It is important to evaluate mucosal lesions including genital and oral mucosa.

Retrospective Study of Patients With SJS/TEN Treated at a Tertiary Burn Unit in Canada: Overview of 17 Years of Treatment

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are adverse drug reactions.

OBJECTIVES

To learn about the clinical characteristics of patients with SJS/TEN including treatments provided, outcomes, and mortality.

METHODS

We conducted a retrospective chart review of patients who were hospitalized with the diagnosis of SJS/TEN at the Ross Tilley Burn Center between the years 1999 and 2015.

RESULTS

A total of 43 patients were identified with a mean age of 54 ± 19 (58, 18-85). The most common offending medications were allopurinol and carbamazepine. The overall mortality rate in our study is 21% with the most common causes of death being multiorgan failure and sepsis. The majority of our patients had oral (84%), ocular (79%), and genital (60%) involvement during hospitalization. Our data revealed that combination treatment involving oral corticosteroids with intravenous immunoglobulin (IVIG) had the highest mortality rate in our study since 55% (6/11) of patients who were treated in this manner passed away compared to 11% (2/18) of patients passing away who were treated with solely IVIG and 33% (1/3) who were treated with only supportive care. Our study also demonstrates the addition of etanercept and cyclosporine treatment in the second time period we studied: 2008-2015 versus the earlier time period of 1999-2007. None of the patients in our study who were treated with therapies including cyclosporine and/or etanercept passed away.

CONCLUSIONS

Our study sheds light on a possible beneficial role of cyclosporine and etanercept for the treatment of SJS and TEN and reinforces the necessity of a multidisciplinary care team for patients.

[PIGMENTED BASAL CELL CARCINOMA AND IONIZING RADIATION]

AIMS

This study aimed at demonstrating whether the histological and clinical manifestations of pigmented basal cell carcinoma are different among those who were previously treated with ionizing radiation for ringworm infection.

BACKGROUND

Ionizing radiation is known to cause increased morbidity among those who are chronically exposed. Basal cell carcinoma in known to be related to ionizing radiation however, the characteristics of pigmented BCC in relation to ionizing radiation are poorly described.

METHODS

The study included the demographics and characteristics of 23 patients with pigmented BCC who were treated for ringworm with ionization radiation and a control group of 21 patients that had not been treated with ionizing radiation. All the cases treated between the years 2005-2015 were included in the study. The data was analyzed with a SPSS program.

RESULTS

Among the patients who were treated with ionizing radiation the percentage of the tumors that were well differentiated was 34.8%, much higher than those who were not treated with ionizing radiation - 14.3%. In addition, the average age for those who were treated with ionizing radiation was 66 compared to 73 in the group that weren't treated with radiation.

DISCUSSION

Pigmented basal cell carcinoma is a rare variant of BCC and it has characteristics that are quite dissimilar among patients treated with ionizing radiation. However, more studies are needed in order to strengthen the results.

COVID-19 effect on phototherapy treatment utilization in dermatology

Background: At the end of 2019, an innovative coronavirus caused an outbreak of pneumonia cases in Wuhan, a city Hubei Province of China. Despite the direct effect on the routine of all life aspects, there are no clinical guidelines regarding phototherapy treatment during COVID-19 pandemic and as a result, phototherapies units continued to deliver this therapy for patients worldwide.Objective: We wish to explore the phototherapy utilization among dermatologic patients.Methods: We marked all patients that continue to arrive and being treated during COVID-19 pandemic.Results: From March more than 50% of patients stopped arriving to treatments due to the fear of COVID-19 infection.Conclusions: COVID-19 has a major implication on chronic dermatology treatments such as phototherapy.

Cutaneous manifestations of COVID-19: Report of three cases and a review of literature

BACKGROUND

Various cutaneous manifestations have been observed in patients with COVID-19 infection. However, overall similarities in the clinical presentation of these dermatological manifestations have not yet been summarized.

OBJECTIVE

This review aims to provide an overview of various cutaneous manifestations in patients with COVID-19 through three case reports and a literature review.

METHODS

A literature search was conducted using PubMed, OVID, and Google search engines for original and review articles. Studies written in the English language that mentioned cutaneous symptoms and COVID-19 were included.

RESULTS

Eighteen articles and three additional cases reported in this paper were included in this review. Of these studies, 6 are case series and 12 are case report studies. The most common cutaneous manifestation of COVID-19 was found to be maculopapular exanthem (morbilliform), presenting in 36.1% (26/72) patients. The other cutaneous manifestations included: a papulovesicular rash (34.7%, 25/72), urticaria (9.7%, 7/72), painful acral red purple papules (15.3%, 11/72) of patients, livedo reticularis lesions (2.8%, 2/72) and petechiae (1.4%, 1/72). Majority of lesions were localized on the trunk (66.7%, 50/72), however, 19.4% (14/72) of patients experienced cutaneous manifestations in the hands and feet. Skin lesion development occurred before the onset of respiratory symptoms or COVID-19 diagnosis in 12.5% (9/72) of the patients, and lesions spontaneously healed in all patients within 10 days. Majority of the studies reported no correlation between COVID-19 severity and skin lesions.

CONCLUSION

Infection with COVID-19 may result in dermatological manifestations with various clinical presentations, which may aid in the timely diagnosis of this infection.

[SYSTEMIC REVIEW OF EOSINOPHILIC DERMATOSES PATIENTS TREATED WITH TNF-Α INHIBITORS AND USTEKINUMAB]

AIMS

This study aims to critically review the pros and cons of biological drugs as treatments and triggers of eosinophilic dermatoses.

BACKGROUND

Eosinophilic dermatoses syndromes are rare diseases with a prominent eosinophilic infiltration mechanism. These syndromes have several known treatments with limited success. Several physicians worldwide suggested possible advantages of using specific biological drugs, which are different from eosinophil targeted biotherapies as treatments for eosinophilic dermatoses syndromes. Others considered these drugs as possible triggers.

METHODS

Articles published in the last 30 years containing relevant key words were reviewed using PubMed and Medline. Associations between Infliximab, Adalimumab, Etanercept, TNF alpha inhibitors and Ustekinumab to Eosinophilic Dermatoses syndromes were reviewed.

RESULTS

Our search revealed an association between 17 eosinophilic dermatoses patients and the drugs of interest. Out of 5 Wells' syndrome cases, four patients had an outbreak of the disease following treatment and one improved by the treatment. Six cases of Eosinophilic Fasciitis mostly had a positive reaction to the treatment. More associations were found among 4 cases of Churg-Strauss syndrome, one case of Granuloma Faciale and 1 case of Eosinophilic Pustular Folliculitis.

CONCLUSIONS

TNF alpha inhibitors and Ustekinumab may have a role in the treatment of eosinophilic dermatosis syndromes. These drugs may act as triggers among Wells' syndrome patients. Further investigation is needed.

Hidradenitis suppurativa on Facebook: thematic and content analyses of patient support group

Online support groups present a sheltered and partially anonymous zone where patients can unload that which disturbs and preoccupies them. In this qualitative study, we explored the use of a Facebook support group for Hidradenitis Suppurativa (HS) patients, and analyzed the contents of shared posts. By evaluating the post's themes, we aim to contribute a deeper understanding of HS patients' needs and possible ways of engaging them. We analyzed more than 730 posts and 8500 comments posted on the "Hidradenitis Suppurativa Israel'' Facebook group. Content analysis was performed, categorizing all posts into 20 topics, assembled into 5 main themes. The most popular theme among all posts was requests for treatment information. The most commented on theme was posts with emotional text, particularly pessimistic ones. Annual activity was analyzed by month, and peaks were found in some months. This article demonstrates that online social networks can lead to the identification of unmet requirements.

The Role of Desmoglein 1 in Gap Junction Turnover Revealed through the Study of SAM Syndrome

An effective epidermal barrier requires structural and functional integration of adherens junctions, tight junctions, gap junctions (GJ), and desmosomes. Desmosomes govern epidermal integrity while GJs facilitate small molecule transfer across cell membranes. Some patients with severe dermatitis, multiple allergies, and metabolic wasting (SAM) syndrome, caused by biallelic desmoglein 1 (DSG1) mutations, exhibit skin lesions reminiscent of erythrokeratodermia variabilis, caused by mutations in connexin (Cx) genes. We, therefore, examined whether SAM syndrome-causing DSG1 mutations interfere with Cx expression and GJ function. Lesional skin biopsies from SAM syndrome patients (n = 7) revealed decreased Dsg1 and Cx43 plasma membrane localization compared with control and nonlesional skin. Cultured keratinocytes and organotypic skin equivalents depleted of Dsg1 exhibited reduced Cx43 expression, rescued upon re-introduction of wild-type Dsg1, but not Dsg1 constructs modeling SAM syndrome-causing mutations. Ectopic Dsg1 expression increased cell-cell dye transfer, which Cx43 silencing inhibited, suggesting that Dsg1 promotes GJ function through Cx43. As GJA1 gene expression was not decreased upon Dsg1 loss, we hypothesized that Cx43 reduction was due to enhanced protein degradation. Supporting this, PKC-dependent Cx43 S368 phosphorylation, which signals Cx43 turnover, increased after Dsg1 depletion, while lysosomal inhibition restored Cx43 levels. These data reveal a role for Dsg1 in regulating epidermal Cx43 turnover.

Mortality and risk factors among Israeli bullous pemphigoid patients

There are differences concerning reported mortality rates and prognostic factors of bullous pemphigoid (BP) patients in different studies. Our objectives were to evaluate the mortality rates and prognostic factors among Israeli BP patients compared to matched control subjects. Three age- and sex-matched patients without BP (n = 261) who were treated in our clinic were selected and compared to BP patients (n = 87). Mean survival period of the BP group was 4.1 years (95% CI: 3.3-4.8 years) and 5.9 years among the non-BP group (95% CI: 5.6-6.3 years). The 1-year mortality rate was 24.1% for the BP group and 6.5% for the control group. In multivariate analysis, age above 80 was a significant risk factor for mortality [HR 3.22 (95% CI, 1.15-8.96), p = 0.03], while statins intake had a protective role [HR 0.36 (95% CI, 0.15-0.88), p = 0.03]. In univariant analysis, dementia [HR 2.44 (95% CI, 1.02-5.99), p = 0.04] was a risk factor. In conclusion, BP patients' mortality is correlated to increasing age at diagnosis, dementia, and statins use. Statins' protective role is newly discussed in the literature.

Severe Physical Complications among Survivors of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

INTRODUCTION

Few studies have reported the physical complications among Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) survivors.

OBJECTIVE

The aim of this study was to comprehensively characterize the physical complications among SJS/TEN survivors and to learn about patients' perspectives of surviving SJS/TEN.

METHODS

SJS/TEN survivors older than 18 years of age were assessed by different methods: a medical interview; a questionnaire assessing patients' perspectives; thorough skin, oral mucous membrane, and ophthalmic examinations; and a retrospective assessment of medical records.

RESULTS

Our cohort consisted of 17 patients with a mean time of 51.6 ± 74.7 months (median 9, range 1-228) following SJS/TEN. The most common physical complications identified in the medical examination were post-inflammatory skin changes (77%), cutaneous scars (46%), dry eyes (44%), symblepharon, and chronic ocular surface inflammation (33% each). Novel physical sequelae included chronic fatigue (76%) and pruritus (53%). We also found a novel association between the number of mucous membranes affected in the acute phase of SJS/TEN and hair loss during the 6 months following hospital discharge; hair loss was reported in 88% of the group of patients who had three or more mucous membranes affected versus 29% of patients who had less than three mucous membranes involved (p = 0.0406). Following hospital discharge due to SJS/TEN, 59% of patients were followed by a dermatologist, although 88% had dermatological complications; 6% were followed by an ophthalmologist, even though 67% had ophthalmological complications; and 6% of female survivors were followed by a gynecologist, even though 27% had gynecological complications.

CONCLUSION

Survivors of SJS/TEN suffer from severe physical complications impacting their health and lives that are mostly under recognized and not sufficiently treated by medical professionals.

Bullous pemphigoid and neurological disorders among a Jewish population

A retrospective case control study included data regarding 65 Jewish bullous pemphigoid (BP) patients diagnosed in a tertiary medical center and a control group consisting of 182 matched Jewish patients. The study indicates that Jewish patients with BP suffer from a higher prevalence of neurological diseases compared to patients with no BP, similarly to previous reports showing high prevalence of neurological diseases among BP patients from different ethnic groups.

[BULLOUS PEMPHIGOID RESISTANT TO CORTICOSTEROIDS]

Bullous pemphigoid is the most common autoimmune bullous disease, treated with low dosage local or systemic corticosteroids. This is a case report of a 65 years-old female patient with a month long history of a bullous disease before admission to the dermatology department with a generalized bullous rash. Clinical examination and histopathology revealed bullous pemphigoid. She was treated according to the established protocol with systemic corticosteroids. The amount of prednisone was raised to 100mg per day for 8 weeks without any noticeable improvement, instead there was a worsening of her symptoms. In light of the treatment failure we carried out an adrenocorticotropic stimulation hormone test with a normal result. The patient was diagnosed as being resistant to corticosteroids and the treatment with prednisone was immediately terminated. Treatment was initiated with cyclophosphamide with an immediate improvement in her symptoms, and the patient was discharged after complete recovery. Discussion: Resistance to corticosteroids is a rare occurrence that has been reported in the literature on pulmonary and gastric disease. In dermatology, there is a single case report on atopic dermatitis that was treated locally. Awareness of the possibility will allow for a prompt diagnosis and appropriate treatment. Conclusion: We presented the case of a 65 year old female with bullous pemphigoid resistant to corticosteroids that has not been previously reported in the dermatologic literature.

[CUTANEOUS T CELL LYMPHOMA: UNILESIONAL MYCOSIS FUNGOIDES]

Unilesional mycosis fungoides is a rare cutaneous T cell lymphoma that warrants either radiation therapy or surgical excision. Benign characteristics result in misdiagnosis, delayed tissue biopsy and subsequently delayed provision of adequate treatment. A young patient presented with a history of 18 months of eczematous benign - appearing single lesion restricted to her index finger. Local electron-beam radiation following tissue diagnosis resulted in full recovery.

Black Urine and Black Pleural Fluid: A Distinctive Presentation of Metastatic Melanoma

Metastatic melanoma is an uncommon clinical entity which can have an unusual presentation. We describe a patient with metastatic melanoma who presented with diffuse melanosis cutis, black urine and black pleural effusion. Very few medical conditions can cause black discoloration of body fluids, so this should prompt physicians to search for a number of potential underlying causes.