Area Of Skin Involvement Research Articles

Method of Assessing Skin Cancerization and KeratosesTM (MASCK™): development and photographic validation in multiple anatomical sites of a novel assessment tool intended for clinical evaluation of patients with extensive skin field cancerization.

SummaryBackgroundA range of ‘field‐directed’ treatments is available for the management of extensive skin field cancerization (ESFC), but to date, the only validated objective quantitative tools are limited to assessment of actinic keratoses (AKs) affecting the head.AimsTo develop a versatile quantitative instrument for objective clinical assessment of ESFC and perform initial internal validation across multiple anatomical zones.MethodsThe study comprised instrument development, pilot testing and instrument refinement and two rounds of reliability and inter‐rater validation testing. The study was noninterventional and used a convenience sample of de‐identified patient photographs selected based on preset criteria. An expert panel developed the instrument and scoring system via a modified Delphi voting process. A sample of 16 healthcare professionals from multiple specialties undertook the pilot testing, and a panel of seven dermatologists were involved in validation testing. Validation was determined by assessment of overall inter‐rater agreement using Gwet chance‐corrected agreement coefficients (ACs).ResultsThe instrument produced, called the Method for Assessing Skin Cancer and Keratoses™ (MASCK™), comprises the Skin Field Cancerization Index (SFCIndex), derived from area of skin involvement and AKs (number and thickness), a global assessment score and a cancer‐in‐zone score, and uses Likert scales for quantitative scoring. The SFCIndex is a composite score comprising the number and thickness of AKs multiplied by area of skin involvement. ACs for the SFCIndex components, the overall SFCIndex score and the global assessment score were > 0.80 (rated ‘almost perfect’) while the AC for the cancer‐in‐zone metric was lower (0.33, rated ‘fair’). Internal consistency was demonstrated via positive correlation between the overall SFCIndex score and the global assessment score.ConclusionsOur study found near‐perfect agreement in inter‐rater reliability when using MASCK to assess the severity of ESFC in multiple anatomical sites. Further validation of this novel instrument is planned to specifically assess its reliability, utility and feasibility in clinical practice.

Efficacy and Safety of Continuous Risankizumab Therapy vs Treatment Withdrawal in Patients With Moderate to Severe Plaque Psoriasis

Risankizumab selectively inhibits interleukin 23, a cytokine that contributes to psoriatic inflammation. To evaluate the efficacy and safety of risankizumab vs placebo and continuous treatment vs withdrawal in adults with moderate to severe plaque psoriasis. Multinational, phase 3, randomized, double-blind, placebo-controlled trial conducted from March 6, 2016, to July 26, 2018. A total of 507 eligible patients had stable moderate to severe chronic plaque psoriasis for 6 months or longer, body surface area involvement greater than or equal to 10%, Psoriasis Area and Severity Index (PASI) greater than or equal to 12, and a static Physician's Global Assessment (sPGA) score greater than or equal to 3. Intention-to-treat analysis was conducted. Patients were randomized (4:1, interactive response technology) to risankizumab, 150 mg, subcutaneously, or placebo at weeks 0 and 4 (part A1). All patients received risankizumab at week 16. At week 28, patients randomized to risankizumab who achieved an sPGA score of 0/1 were rerandomized 1:2 to risankizumab or placebo every 12 weeks (part B). Co-primary end points for the part A1 phase included proportions of patients achieving greater than or equal to 90% improvement in PASI (PASI 90) and sPGA score of 0/1 at week 16. The PASI measures severity of erythema, infiltration, and desquamation weighted by area of skin involvement over the head, trunk, upper extremities, and lower extremities; scores range from 0 (no disease) to 72 (maximal disease activity). The sPGA assesses average thickness, erythema, and scaling of all psoriatic lesions; scores range from 0 (clear) to 4 (severe), with 0/1 indicating clear or almost clear. Primary and secondary end points in part B included proportion of rerandomized patients achieving an sPGA score of 0/1 at week 52 (primary) and week 104 (secondary). Of 563 patients screened, 507 were randomized to risankizumab (n = 407) or placebo (n = 100). Most patients were men (356 [70.2%]); median age was 51 years (interquartile range, 38-60 years). At week 16, 298 patients (73.2%) in the treatment group vs 2 patients (2.0%) receiving placebo achieved a PASI 90 response, and 340 patients (83.5%) receiving risankizumab vs 7 patients (7.0%) receiving placebo achieved sPGA 0/1 scores (placebo-adjusted differences: PASI 90: 70.8%; 95% CI, 65.7%-76.0%; sPGA 0/1: 76.5%; 95% CI, 70.4%-82.5%; P < .001 for both). At week 28, 336 responders were rerandomized to risankizumab (n = 111) or treatment withdrawal (n = 225). At week 52, the sPGA 0/1 score was achieved by 97 patients (87.4%) receiving risankizumab vs 138 patients (61.3%) receiving placebo. At week 104, the sPGA 0/1 score was achieved by 90 patients (81.1%) receiving risankizumab vs 16 patients (7.1%) receiving placebo (placebo-adjusted differences: week 52: 25.9%; 95% CI, 17.3%-34.6%; week 104: 73.9%; 95% CI, 66.0%-81.9%; P < .001 for both). Rates of treatment-emergent adverse events were similar between risankizumab (186 [45.7%]) and placebo (49 [49.0%]) in part A1 and remained stable over time. Risankizumab showed superior efficacy compared with placebo through 16 weeks and treatment withdrawal through 2 years. Risankizumab was well tolerated, with no unexpected safety findings during the 2-year trial. ClinicalTrials.gov Identifier: NCT02672852.

High-frequency ultrasound-based differentiation between nodular dermal filler deposits and foreign body granulomas.

The number of procedures involving dermal filler injection is still on the rise. Although their safety is improving, not all complications can be avoided. The late complications manifesting as nodules or granulomas pose a particular diagnostic and therapeutic challenge, due to the lack of uniform standards or guidelines. High-frequency, ultrasound imaging appears to be a useful method for distinguishing between granulomas and nodular dermal filler deposits. The aim of the paper was to evaluate the utility of high frequency ultrasound imaging for distinguishing between foreign body granulomas and nodular dermal filler deposits. Eleven females aged 21-66years (mean age of 43.6years old) who had soft tissue fillers injected were enrolled. All patients had a high-frequency ultrasound scan of the involved skin area performed. The shape, margins, area, location and echogenicity of the lesions were assessed. Additionally, the lesions were evaluated histologically and photographs were taken. The analysis indicated differences between the ultrasound image of granulomas and dermal filler deposits. Characteristic ultrasound features of granulomas include oval shape and blurred, irregular outer edges. Small hyperechoic areas were seen inside the granulomas. The deposits were anechogenic, with sharp, regular borders. High-frequency ultrasound imaging enables distinguishing between granulomas and nodules-dermal filler deposits, which form after dermal filler injections.

Inpatient Mortality Resulting from Dermatological Disorders at a Tertiary Care Center in Eastern India: A Record-based Observational Study.

Background:Contrary to popular perception, several dermatological conditions may be associated with lethal outcome in the absence of timely intervention or due to complications.Aims:The aim was to estimate the number of deaths and analyze their causes due to skin disorders at a tertiary level inpatient dermatology ward.Materials and Methods:We conducted a retrospective, record-based observational study involving 538 patients spanning over 4 years (2013–2016) at our dermatology indoor setup.Results:There were 45 deaths (male:female = 1.5:1), accounting for 8.4% or total admissions, occurring mostly in patients in their 7th decade. Vesiculobullous disorders were the most frequent cause of mortality (57.8%), followed by drug reactions accounting for 17.8% of cases. In the former group pemphigus vulgaris accounted for most deaths (31.1%) followed by bullous pemphigoid (17.8%) and pemphigus foliaceus (8.9%), whereas toxic epidermal necrolysis was the most frequent cause of death from drug reactions (8.9%). Almost half of all deaths (48.9%) occurred due to septicemia followed by cardiopulmonary complications (40%). Most of the cases presented to us at an advanced state of the disease previously being treated inappropriately.Conclusion:Prompt diagnosis and treatment of such dermatological conditions are mandated, preferably in an intensive care set-up, to reduce mortality rates. Advanced age, the area of skin involvement, mucosal involvement, and septicemia were adverse prognostic factors in these patients.

Diagnosis and Management of Cutaneous B-cell Lymphoma.

The diagnosis of primary cutaneous B-cell lymphoma (CBCL) requires that the search for a more widespread lymphoma has been negative. The clinical presentation, outlook, and treatment options of the common types of CBCLs, with emphasis on differences or similarities to their nodal counterparts, are discussed. Treatment may range from observation to topical therapies to systemic therapies, depending on the histology, degree and area of skin involvement, patient performance, and comorbidities. Rare lymphomas, such as intravascular large B-cell lymphoma and Epstein-Barr virus-positive cutaneous lymphoproliferations that are associated with immunodeficiency, are also briefly described.

Solar burn reactivation reaction: an unusual side effect of methotrexate

To the Editor,Methotrexate (Mtx) is an immunosuppressive andantimitotic agent that terminates deoxyribonucleic acid(DNA) synthesis by inhibiting the enzyme dihydrofolatereductase. The spectrum of clinical usage and the sideeffects are quite common. Reactivation of radiation der-matitis, generalized maculopapular rash, stomatitis, andexacerbation of acne lesions can be associated with the useof Mtx (1). Phototoxicity is a direct tissue damage that iscaused by phototoxic agents and UV light via inflamma-tory mediators (2).Sunburn reactivation is a rare and specific UV recalldermatitisthatisseeninpatientspreviouslysufferingfromsunburn (3). This phenomenon is quite different fromother cytotoxic drug-induced radiation recall dermatitis.Low dose Mtx given to psoriasis patients does not appeartocausethisrecallreaction.Thismaybeatime-anddose-relatedreaction(1).Somepointswillbeemphasizedinthispaper to avoid this side effect.A45-year-oldmalewhowasreceivingMtxtreatmentforpsoriasis developed an erythematous, painful, andedematous rash on the chest, abdomen, and extremities.He went to the shore for swimming and sunbathing onSunday and had a moderate erythema on sun-exposedareas. Three days after sunbathing, he took 16 tablets ofMtx (2.5 mg tablets, a total of 40 mg) by mistake, eventhough he was prescribed to take 10 mg a week. Twenty-four hours after receiving high-dose Mtx, the patientnoticed burning and increased redness on his skin at siteswhere he had sun-induced erythema previously. Thedermatologic examination revealed erythema on the sun-exposed areas of his upper back, chest, arms, and legs.There was erythematous to violaceous and edematousplaques with hyperemia and pain in involved skin areas(Fig. 1a, b). Patient was hospitalized, and Mtx therapy isceased. It was revealed from the patient’s history that hehas been taking Mtx 40 mg/week since 6 weeks, and hispsoriasiswasinremission.Completebloodcountandbio-chemical values were in normal range. Histopathologicalexamination revealed epidermal spongiosis, intraepi-dermal apopitotic keratinocytes, and vesiculation, whichwas consistent with phototoxic reaction. Symptomatictreatment with wet dressings and antihistaminics resultedinarapidresolutionofthelesions.Hewasfreeofpsoriasislesions when he was discharged from the hospital but hadrecurrence after 6 weeks.Mtx is an antimitotic and immunosuppressive agentused for the treatment of cancer, psoriasis, andrheumatologic disorders. The well-known side effectsinclude mucosal ulceration, hepatotoxicity, pulmonaryfibrosis,myelosuppression,alopecia,andrenaltoxicity(1).

The levels of soluble ST2 in sera and bullous fluid from patients with bullous pemphigoid

Soluble ST2 (sST2) is a soluble form of the transmembrane receptor for interleukin (IL)-33, ST2L, and is a member of the IL-1 receptor family. sST2 antagonizes IL-33-ST2L signaling by competing with ST2L as a decoy receptor for IL-33. We investigated the sST2 and IL-33 levels in the sera and bullous fluid of bullous pemphigoid patients and compared these with the corresponding levels in normal healthy controls. As controls, we used the bullous fluid of burn patients and that from suction blisters induced in normal healthy volunteers. The serum sST2 concentrations of bullous pemphigoid patients were higher than those of healthy controls. Serum sST2 levels correlated with the area of skin involvement and serum lactate dehydrogenase levels, suggesting that serum sST2 levels reflect disease severity. The sST2 concentrations in bullous fluid from bullous pemphigoid patients were higher than those from controls. The concentration of IL-33 ligand was below the detectable limits in all enzyme-linked immunosorbent assay samples. Thus, our study suggested that the serum sST2 level may be a useful marker of disease severity and that sST2 functions as a negative regulator in the pathophysiology of bullous pemphigoid.

Ramsay Hunt syndrome

Ramsay Hunt syndrome is defined as herpes zoster oticus associated with an acute peripheral facial nerve paresis and quite often with other cranial nerve lesions. The combination of motor, sensory and autonomic involvement leads to a variety of neurological damage patterns, i. e. facial muscle paresis, hearing and balance disorders, sensory problems and disturbances of taste as well as lacrimal and nasal secretion. Additional variability of the clinical picture of Ramsay Hunt syndrome is produced by varying patterns of skin involvement explained by individual anastomoses between cranial and cervical nerves. Knowledge of these findings and an early diagnosis of Ramsay Hunt syndrome are important as prognosis of cranial nerve damage depends on the time at which acyclovir-corticosteroid therapy is started.

Dermal fibroblasts from acute inflamed atopic dermatitis lesions display increased eotaxin/CCL11 responsiveness to interleukin-4 stimulation

The presence of eosinophils and/or eosinophil-derived products in the dermis is characteristic for involved skin of patients with atopic dermatitis and contributes to the observed tissue injury. CCL11 is a potent chemoattractant and activator of human eosinophils and interleukin (IL)-4 is a potent inducer of CCL11 expression in dermal fibroblasts. As increased fibroblast CCL11 expression may explain eosinophilic infiltration of involved skin areas in atopic dermatitis, we asked whether dermal fibroblasts from atopic patients differ from fibroblasts of healthy individuals in their ability to express CCL11. We compared IL-4-induced CCL11 mRNA expression using reverse transcription-polymerase chain reaction from cultured dermal fibroblasts derived from biopsies of chronic lesional and acute lesional atopic skin as well as from skin biopsies derived from normal skin of healthy donors. Considerable variability in IL-4-induced relative CCL11 mRNA expression was detected in fibroblasts derived from biopsies of different individuals. The lowest median IL-4 concentration inducing half maximal CCL11 mRNA expression (EC(50)) was found in fibroblasts derived from acute inflamed atopic lesions. Inducibility of CCL11 in dermal fibroblasts upon stimulation with Th2 cytokines explains the tissue eosinophilia observed in the presence of Th2 cytokines and the localization of eosinophils to the dermis. Decreased EC(50) values of IL-4-induced CCL11 expression in fibroblasts from acute inflamed atopic skin lesions indicates increased IL-4 responsiveness in these lesions and further substantiates the special role for IL-4-induced dermal fibroblast CCL11 expression in acute lesions. Variable CCL11 expression in fibroblasts from different patients with atopic dermatitis indicates heterogeneity of factors determining atopic phenotype in atopic dermatitis.

Ocular Features and Histopathologic Changes during Follow-up of Toxic Epidermal Necrolysis

To evaluate ocular surface histopathologic changes and ocular sequelae in the follow-up of patients with toxic epidermal necrolysis (TEN). Prospective, consecutive, comparative, interventional case series. Eleven patients (22 eyes) with TEN that developed after drug treatment and 33 normal subjects as the control group. Toxic epidermal necrolysis diagnosis was based on data obtained from medical records. Only patients with ocular involvement in the acute stage were included. Patients and controls underwent a complete ophthalmic assessment, including tear film evaluation and corneal and conjunctival impression cytology. These were performed at the beginning of the study (∼1 month after TEN) and 6 and 12 months later. Tear film production and stability were evaluated by break-up time, Schirmer's test with anesthesia, rose bengal, and fluorescein staining pattern. Conjunctival retraction was determined by studying the vanishing point in eye abduction of the lacunar folds. Break-up time, Schirmer's test, fluorescein and rose bengal stain, corneal and conjunctival epithelial squamous metaplasia, conjunctival retraction, and ocular sequelae. Mild or moderate ocular involvement was present in 73% of patients in the acute stage. Ocular involvement was not related to TEN severity, area of skin involvement, or drug etiology. One-year follow-up, ocular manifestations, slit-lamp findings, and epithelial cell squamous metaplasia were related to ocular involvement severity in the acute phase. We found pathologic conjunctival retraction in 86.4% of patients. Decreased levels of break-up time and Schirmer's test were found in patients with TEN. Conjunctival cytology showed a marked decrease in goblet cell density. No patients died, and there were no recurrences of TEN during the study. Ocular involvement in the acute stage was not related to TEN severity or etiology. Ocular sequelae were related to ocular involvement severity in the acute phase. Early ophthalmic assessment and frequent follow-up are helpful because ocular involvement represents the first long-term complication in patients with TEN. Impression cytology and measurement of conjunctival retraction can be useful tools in the assessment of dynamic ocular changes in patients with TEN.

Skin Colonization With Staphylococcus Aureus In Patients With Atopic Dermatitis

Objectives: To investigate the presence of S. aureus in the skin of AD patients and compare with healthy control group. Patients/Methods: Forty patients with AD were recruited in to our study. S. aureus skin colonization was determined in AD patients and controls, also skin distribution of S. aureus colonization was compared in three age groups of AD patients. Results: S. aureus was found on the skin of 42.5% and 7.5% of AD patients and control group, respectively (p=0.0003). The most common involved skin areas with S. aureus colonization were face (in ≤2 yrs old), flexor surfaces (in >2 and ≤12 yrs old) and extremities (in >12 yrs old). Conclusions: The incidence of S. aureus on the skin of AD patients was considerably higher rather than controls. Further studies are needed to investigate the clearance of S. aureus from the skin of AD patients using anti-staphylococcal treatment. The work was done at Department of Dermatology and Microbiology of Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.

Efficacité du thalidomide dans le traitement de l'histiocytose langerhansienne multisystémique de l'adulte : à propos d'une observation

Background Adult multisystem Langerhans cell histiocytosis is an excepted disorder, which have several treatments. The purpose of this study was to test the disease-controlling effect of thalidomide in a case of adult multisystem Langerhans cell histiocytosis with cutaneomucous and hypothalamic localizations at dermatology department, of Mohammed-V military hospital, Rabat. Case report A 43-year-old women, presented multifocal chronic Langerhans cell histiocytosis confined to cutaneous, oral cavity, perianal, mastoid and hypothalamic areas, with severe disabling ulcers in intertriginous areas, diabetes insipid and amenorrhoea. We treated with thalidomide 200 mg/day after neurological examination. A rapid initial response with total diminution of the involved skin area, and diminution of diabetes insipid. She remained in remission for 1 year. No adverse effects from treatment were observed at clinical and electrophysiological examinations. Conclusion Thalidomide treatment is an adequate therapeutic measure in adult Langerhans cell histiocytosis, which is rare and difficult to treat. Our case showed the efficacy of thalidomide at cutaneomucosal and hypothalamic manifestations.

Treatment of gustatory sweating with low-dose botulinum toxin A: a case report

Frey's syndrome, gustatory sweating in the preauricular area, is an unpleasant phenomenon occurring during meals after surgery on the parotid gland. Recently, botulinum toxin A (BTX) has been shown to reduce the symptoms, but the variation in the reported doses is large. Objective. To quantify the effect of treatment with low-dose BTX in a case of Frey's syndrome over a period of 6 months. Material and methods. A 56-year-old woman was treated with 10 U Botox given as 20 single, intracutaneous injections of 0.5 U, one for each cm2, 3 years after resection of the parotid gland. Before treatment and repeatedly during the 6-month period, the sweating was rated subjectively on a 100-mm visual analog scale (VAS) and by a severity index, and objectively by assessment of the extent of the involved skin area using Minor's iodine-starch test, staining the area of sweating dark. Results. The treatment decreased the involved area from 20 to 5 cm2 and the VAS ratings from 98 to 8 mm. The index showed that treatment affected the sweating intensity, not the frequency. After the 6-month period the patient was still satisfied, but the involved skin area had increased; however, not entirely to pretreatment values. Conclusions. The effect of BTX injections for gustatory sweating obtained in this case was comparable to results reported using higher doses. Low doses of BTX can therefore be used in the treatment of Frey's syndrome, but studies to clarify the dose–response relationship, in terms of both time-course and obtained effect, are needed.

A study of mortality in dermatology

Certain dermatological conditions are life-threatening and can cause mortality. The aim of this study is to find out the dermatological diseases leading to death in our indoor patients. A record-based retrospective descriptive study of dermatology cases who died during the period of 1995 to 2001. The total number of cases analyzed was thirty-seven. There were 24 males and 13 females. The maximum number of deaths occurred in the age group 61-70. Vesiculobullous disorders were the commonest cause of death, found in 18 cases (48.6%), followed by drug reactions in 5 (13.5%), malignancies in 5 (13.5%) and collagen vascular disease in 2 cases ((5.40%). Pemphigus was the commonest fatal vesiculobullous disorder (13 cases - 35.13%), and toxic epidermal necrolysis the commonest drug reaction (3 cases - 8.10%). Area of skin involvement, electrolyte imbalance and septicemia were important factors leading to death in pemphigus and toxic epidermal necrolysis. We advocate that such patients should be managed in burns unit or ICU units.

Penser à une histiocytose devant une lyse vertébrale

Les histiocytoses langerhansiennes multiviscérales de l’adulte sont exceptionnelles, ce qui explique que leur traitement n’est pas bien codifié.Une femme de 43 ans présentant une histiocytose langerhansienne multisystémique avec diabète insipide a été améliorée par le thalidomide 200 mg/j.Le thalidomide a montré son efficacité de façon ponctuelle dans l’histiocytose langerhansienne avec atteinte cutanéomuqueuse mais aussi sur les lésions hypothalamiques.Adult multisystem Langerhans cell histiocytosis is an excepted disorder, which have several treatments. The purpose of this study was to test the disease-controlling effect of thalidomide in a case of adult multisystem Langerhans cell histiocytosis with cutaneomucous and hypothalamic localizations at dermatology department, of Mohammed-V military hospital, Rabat.A 43-year-old women, presented multifocal chronic Langerhans cell histiocytosis confined to cutaneous, oral cavity, perianal, mastoid and hypothalamic areas, with severe disabling ulcers in intertriginous areas, diabetes insipid and amenorrhoea. We treated with thalidomide 200 mg/day after neurological examination. A rapid initial response with total diminution of the involved skin area, and diminution of diabetes insipid. She remained in remission for 1 year. No adverse effects from treatment were observed at clinical and electrophysiological examinations.Thalidomide treatment is an adequate therapeutic measure in adult Langerhans cell histiocytosis, which is rare and difficult to treat. Our case showed the efficacy of thalidomide at cutaneomucosal and hypothalamic manifestations.

Incidence of cutaneous tuberculosis in patients with organ tuberculosis.

Tuberculosis continues to be a health problem in some countries. The development of resistance to antituberculitic drugs and the increase in diseases and conditions associated with immunodeficiency such as AIDS and chemotherapy have caused tuberculosis to increase recently. As a result, the incidence of cutaneous tuberculosis has been increasing as well. To detect cutaneous tuberculosis in patients with organ tuberculosis and to establish some characteristics of the relation between organ and cutaneous TB. A total of 370 patients (145 females and 225 males), aged 2-76 years (mean age 27.5), enrolled for this screening study. These patients were hospitalized patients who already had pulmonary or extrapulmonary tuberculosis diagnosed before admission. All patients underwent a general skin examination, and, if needed, cutaneous biopsies were taken from involved skin areas. Three hundred and forty-seven (93.78%) out of 370 patients had pulmonary tuberculosis only or in association with one of other organ tuberculoses. Twenty-three patients had extrapulmonary TB: nine were TB adenitis, six were TB peritonitis, three were bone tuberculosis, and five were TB meningitides. Of 370 patients, only 13 (3.51%) had cutaneous TB: seven scrofuloderma (SCD; 2.16%), four lupus vulgaris (LV; 1.35%), one LV and SCD, and one Bacille Calmette-Guerin (BCG) adenitis (0.027%). Cutaneous tuberculosis was observed in seven out of 260 patients with parenchymal tuberculosis (2.96%). Four out of nine patients with TB adenitis (44.4%), one out of 12 pulmopleuretic (8.3%), and one out of 67 pleuresic patients (1.40%) had cutaneous TB as well. Mean age of the 13 patients was 32.46 years: mean age of SCD and LV was 24.8 and 48 years, respectively. The one patient with BCG adenitis was 7 months old. Five (62.5%) out of eight patients with SCD, and only one (20%) out of five patients with LV were new cases. Four patients with SCD had a positive family history, while LV patients did not. Organ tuberculosis is rarely associated with cutaneous tuberculosis. Scrofuloderma and LV are the most frequent forms of skin TB associated with organ TB in this population. Tuberculosis adenitis is the organ TB that causes cutaneous TB most often among other organ tuberculoses. More than one form of cutaneous TB affected only one patient with pulmonary TB; therefore, it is very rare. Tuberculids were not observed in any of the patients.

Botulinum toxin A in the treatment of patients with Frey syndrome.

This was a prospective study of the treatment of Frey syndrome, also known as gustatory sweating, with botulinum toxin A. Thirteen patients with a mean involved skin area of 53 (range 36-80) cm2, as assessed with the Minor starch-iodine test, were treated with 0.1 ml toxin (75 units/ml) injected intracutaneously into every 4 cm2 of involved skin. The mean total dose was 100 (range 67.5-150) units. Treatment results were assessed every 3 months with the Minor test. The Frey Questionnaire Card (FQC) was used for subjective assessment. The mean follow-up after primary treatment was 20 (range 9-24) months. Treatment was repeated if the symptoms recurred. After 3 months 11 of the 13 patients showed a decrease of gustatory sweating of more than 90 per cent. All but one patient with a follow-up of 2 years suffered recurrent gustatory sweating. The mean recurrence-free period after primary treatment was 11 months and that after secondary treatment was 15 months. FQC score and objective assessment correlated well. Treatments were well tolerated, although two patients developed a temporary perioral muscle paresis. Botulinum toxin A produces good results in the treatment of Frey syndrome. Repeated treatment improves on the results of primary treatment.

Expression of RANTES in biopsies of skin and upper gastrointestinal tract from patients with systemic sclerosis

Inflammatory infiltrates and upregulated collagen production are hallmarks of systemic sclerosis (SSc). There are indications that chemokines are involved in accumulation of inflammatory and matrix-synthesizing cells in SSc skin lesions. Therefore, we searched for the expression and localization of the chemokine RANTES ("regulated upon activation and normal T cells expressed and secreted") in skin and esophageal biopsies from patients with SSc. Using immunohistochemistry and in situ hybridization, skin biopsies derived from clinically involved and noninvolved skin of 18 patients with early and long-term SSc were examined for RANTES expression and compared with nondiseased skin sections of seven patients without SSc. In addition, esophageal snap biopsies were taken in a subgroup of six SSc patients. Strong expression of RANTES could be detected in the epidermis in keratinocytes of patients with short-term and long-term disease, both on the mRNA and protein level. The percentage of RANTES-expressing cells were significantly higher in clinically noninvolved skin sections than in involved skin areas. In contrast, no RANTES expression was found in esophageal biopsies or in the control group. The results indicate that RANTES is present in human sclerodermatous skin. RANTES may be involved in early pathogenesis of SSc as well as in fibrosis pathways, either by chemoattraction of immunocompetent cells and/or by modulation of collagen production.

Fibroblast expression of collagen integrin receptors alpha1beta1 and alpha2beta1 is not changed in systemic scleroderma.

The skin of patients with systemic scleroderma (SSc) is characterized by excessive extracellular matrix deposition in the dermis. As collagens represent the major structural component, we used fluorescence-activated cell sorter analysis to study the levels of collagen receptors expressed at the surface of fibroblasts derived from involved skin areas. In contrast to previous reports, no differences in the expression of alpha1, alpha2 or beta1 integrin subunits, which constitute the major collagen receptors on fibroblasts, were detected on SSc fibroblasts as compared with normal control fibroblasts. Variation of cell culture conditions, e. g. passage number (from 2 to 10), seeding density, cell cycle or serum concentration, did not change this result. These observations indicate that any abnormal response of SSc fibroblasts to their matrix environment is not controlled at the level of receptor expression.

Application of machine vision to assess involved surface in patients with psoriasis

An objective method is still lacking in the quantitative assessment of psoriasis severity. The purpose of this study was to examine whether computer image analysis (CIA) by a new colour segmentation method can be used as an objective method of estimating involved surface area in patients with psoriasis. Involved surface area in psoriasis was assessed from colour photographs covering the same areas as the psoriasis area and severity index (PASI) scores of 26 patients by human observers from different medical professional groups and by CIA. The reliability of CIA was tested with reference analysis by colouring manually the involved areas in the images with the aid of projected slides. The surface area estimates by the different methods were compared with each other and the resulting effects on the PASI score were assessed. The agreement between the reference analysis and the image analysis was high, especially on trunk areas, but the cylindrical shape of the limbs resulted in some difficulties in assessing involved skin area. The human eye estimates differed from the image analysis ones in almost one-third of the cases and mostly when psoriasis affected under 30% of the skin surface area. Both over- and underestimates emerged, but overestimates were more common. Error estimates had a significant effect on the PASI score. The CIA method seems to be reliable and practicable in estimating the actual surface of psoriasis. The method has the disadvantage of being time-consuming (photographing, processing of pictures) and technically demanding. Further development of this method should make it faster in the future.