Persistent Erosions Research Articles

Herpes Simplex Virus I Infection Complicating Pemphigus Foliaceus

Pemphigus is a group of autoimmune blistering disease characterised by blisters affecting the skin and or mucosae. Herpes simplex virus (HSV) 1 is known to result in recalcitrant oral lesions of pemphigus. It is rarely described in association with pemphigus foliaceus. Here, we describe a middle aged man who had persistent erosions on the face despite adequate disease control in other body parts. Screening for secondary infection yielded HSV-1 by polymerase chain reaction.

Диагностика синдрома лимбальной недостаточности

Relevance. Limbal stem cell deficiency (LSCD) is a pathology that leads to substantial vision decrease, corneal neovascularization, corneal epithelial persistent erosions and have a negative impact on patient's the quality of life. It is known that the efficiency of corneal transplantation in LSCD patients is low and requires repeated interventions. One of the important problems is the lack of a clear diagnostic algorithm and a standardized set of diagnostic techniques for this condition. Purpose. Systematically analyze domestic and foreign literature on the currently existing methods for diagnosing LSCD. Material and methods. A systematic analysis of scientific publications from 1992 to 2021 was carried out. Its included domestic and foreign authors on the resources of PubMed, Medline, eLibrary, as well as dissertations and textbooks devoted to currently existing methods for diagnosing LSCD. Results. In addition to biomicroscopy, the main in vivomethods for diagnosing LSCD are staining of the ocular surface, impression cytology with the detection of specific cytokeratins, confocal microscopy, optical coherence tomography of the anterior segment (OST) and OST-angiography. Conclusion. Physician awareness and vigilance are required for the diagnosis of LSCD, especially in patients with conjunctivalization and corneal neovascularization. It is impossible to use only biomicroscopy and the patient's complaints, since LSCD is not always obvious. That is why diagnostics should include an integrated approach, including all available research methods, which are briefly described in Table No. 1 with their disadvantages and advantages. Key words: limbal stem cell deficiency, impression cytology, laser confocal scanning microscopy, goblet cells, cytokeratin, penetrating keratoplasty, cytokines

Lower Lid Entropion in a 78-year-old Female: A Case Report

Introduction: Entropion is a malposition of the eyelids in which the eyelid margin folds inward and causes irritation to the eye. It can be caused by congenital, spastic, cicatricial and involutional entropion. Involutional entropion affects 10.6% in group over the age of 60, especially in Asian races as compared to Caucasian races.1 It can have adverse effect on the eye such as trichiasis in which the eyelashes protrudes inwards towards the eyeball, leading to persistent erosions of punctate epithelium, pannus formation or ulcers. Definitive treatment for entropion is surgical intervention when feasible, such as the Jones procedure. The prognosis of corrective surgical intervention is highly correlated to the successfulness of the surgery and wound healing process of the patient, thus needing highly accurate and cautious procedure.2 Methods: This case report was taken from the Eye Clinic of Rumah Sakit Umum Siloam, in February 2022. Results: A 78 years-old female presented with complaints of discomfort, foreign body sensation, irritation, itching, and glare in both eyes since 1 year ago. She had a history of cataract surgery 3 years ago. Conclusions: Anamnesis and ophthalmological examinations results lead to suspected glaucoma, involution entropion ODS and pseudophakia ODS. Blepharoplasty was performed on the patient with appropriate surgical and therapeutic techniques. The post-operative examination showed results indicating a good prognosis in this patient.

Pain Management in Patients with Severe Pemphigus Vulgaris

To describe the pain management and clinical course of patients with severe Pemphigus Vulgaris (PV) admitted to a third-level Intensive Care Unit (ICU). This was a retrospective cohort study conducted in the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán over the period 2013–2020. Study population comprised patients with severe PV admitted to the ICU. Eleven patients with severe PV were included. Mean age of presentation was 43.6 years. Percentage of the total body surface area affected ranged from 70 to 85% (mean: 80%). Visual Analogue Scale was used for pain assessment upon admission. Nine patients (72%) reported a 10/10 pain. The median Morphine Equivalent Daily Dose was 200 mg (range: 90–518 mg). Mortality was 27% during the ICU stay. One patient (9%) continued to experience severe pain and consume opioids after discharge. PV is a life-threatening disease characterized by painful, persistent erosions and ulcers. Integrated and multidisciplinary approach is often required. Opioids remain the mainstay for acute pain control in patients with severe PV. Biological, psychological, and social factors influence patients’ daily opioid requirements and dose escalation. Successful pain management contributes to improving the quality of life, and the suppression and remission of PV.

Il neonato con gli occhi socchiusi. La displasia ectodermica legata al gene TP63

An Italian female newborn presented with cleft palate, erythroderma, desquamations, skin erosions, ankyloblepharon filiforme adnatum, broad nasal root, short philtrum, thin vermillion border, maxillary hypoplasia, microstomia, microglossia, cupped ears, hypoplasia of the distal phalange of left index, widely spaced nipples and polythelia. The hallmarks of ankyloblepharon-ectodermal dysplasia-clefting syndrome (or Hay-Wells syndrome) as well as persistent scalp erosions led to exclude more frequent skin disorders like congenital ichthyosiform erythroderma or epidermolysis bullosa and to diagnose Hay-Wells syndrome by genetic analysis. Target sequencing of the tumour protein p63 (TP63) gene revealed a novel heterozygous missense mutation I576T in exon 13 (c. 1727T>C) in the sterile alpha motive domain. The paper reports the clinical features, differential diagnoses and prognosis in TP63-related ectodermal dysplasia.

Improvement of epidermal covering on AEC patients with severe skin erosions by PRIMA-1MET/APR-246

P63 is a major transcription factor regulating skin development and homeostasis. It controls many genes involved in cell proliferation, adhesion, and early differentiation. P63 is mutated in several rare syndromes called p63-related ectodermal dysplasia syndromes (ED). The main forms are EEC and AEC syndromes due to p63 missense mutations on the DBD and SAM domains, respectively. ED patients display many developmental defects, including ectrodactyly, clef/lip palate, and ectodermal dysplasia, while AEC patients suffer from severe skin erosions that not always heal. We have previously showed that ED-derived iPSC display altered epidermal commitment. P63 belongs to the p53 gene family sharing similar structural domains. We found that ED-iPSC epidermal commitment can be rescued by a p53-reactivating compounds called PRIMA-1MET, also named APR-246 and currently used in anticancer clinical trials. Here, we established primary epidermal culture from two AEC children (S.F. and Y.M.) suffering from persistent skin erosions at age of 9 and 15, respectively. These patients carry missense mutations on the SAM domain (I576T and I537T). We found that primary keratinocytes (KCs) isolated from these AEC patients underwent altered epidermal differentiation that was rescued by PRIMA-1MET treatment. It prompted us to formulate the compound onto a cream that was topically applied on the right hand of one patient and on the scalp of the second patient. In both cases, the daily treatment allowed re-epithelialization of the eroded skin and a drastic loss of pain after few weeks, improving quality of life. Normally, mutant p63 exerts a dominant-negative effect, mainly through the formation of aggregate with WT p63 and p73. PRIMA-1MET did not reduce protein aggregation while enhancing cell differentiation, suggesting that PRIMA-1MET targets cell differentiation and not p63 activity directly. In conclusion, we propose that repurposing of the antitumoral PRIMA-1MET compound could become a general treatment of AEC skin erosions.

Патогенетические механизмы нарушения эпителизации и формирования персистирующих язв трансплантата у пациентов с деструктивными процессами роговицы после сквозной кератопластики

Keratoplasty in patients with recurrent destructive processes in the cornea nowadays remains one of the most serious problems in ophthalmic surgery. Purpose. The analysis of results of penetrating keratoplasty (PK) in patients with destructive processes of the cornea or the corneal graft depending on the initial level of GDNF and the activity of the MAP kinase cascade of the signaling pathways. Material and methods. The analysis of the results of PK was performed in 23 patients (34 eyes) with acute destructive processes of cornea or the corneal graft in different etiologies. The follow-up period was from 6 months to 2 years. The analysis of the results of treatment was carried out depending on the condition of the corneal graft at various times after PK. The immunohistochemical examination of the biological material (corneal disks of the recipient) was performed using antibodies to GDNF, phospho-ERK1 / 2, phospho-JNK1 / 2, Ki67, GAP43, Bcl2 and Bax. Results. The time of epithelialization of the graft after PK in destructive processes of the cornea was increased in 79% of cases. When the epithelialization of the corneal graft was completed more than 6 and 10 days after PK in the postoperative period persistent erosions of the graft (PEG) with ulceration were formed in 22% and 89% of cases, respectively. The intensity of immunohistochemical reactions with antibodies to GDNF, phospho-ERK1 / 2, phospho-JNK1 / 2 in corneal disks at the epithelialization time of up to 5, 10 days and more eythan 10 days after PK was reduced from moderately positive to weakly positive and negative, respectively. When the time of epithelialization was completed in 6-10 days and there was not PECG, the intensity of reactions with antibodies to GDNF remains moderately positive, phospho-ERK1 / 2, phospho-JNK1 / 2 was lightly positive; when there was PEG the intensity of all reactions was weakly positive. Conclusion. The severity of the destructive pathological process in the cornea and postoperative complications after PK in patients with destructive corneal processes depend on the degree of GDNF deficiency, the decrease in the activity of the MAP kinase cascade of signaling pathways; the density of nerve plexuses in the own corneal tissue or corneal graft, and the activity of apoptosis processes.

English

Gastric ulcer generally results from persistent erosions and damage of the stomach wall which become perforated and develops into peritonitis and massive haemorrhage as a result of inhibition of the synthesis of mucus, bicarbonate and prostaglandins. The commercially available antiulcer drugs usually have various side effects. Due to these side effects, there is a need to find new antiulcerogenic compound(s) with potentially less or no side effects and medicinal plants have always been the main source of new drugs for the treatment of gastric ulcer. Several hundred plant genera are used medicinally mainly in the form of herbal preparation in indigenous system of medicine in different countries for the treatment of ulcers. In this review, we have given a detailed description of ulcer and its causative factors along with medicinal plants with antiulcer potency.   Key words: Helicobacter pylori, Meckel’s Diverticulum ulcer, gastroesophageal reflux disease, peptic ulcer disease.

Mucosal Healing in Patients Receiving Certolizumab Pegol for Crohnʼs Disease (CHARTER Study)

Purpose: The introduction of biological agents has been popularized by research showing statistically significant responses and remission rates. Only a few studies have commented on mucosal healing. This paper presents the preliminary results of an ongoing study. Methods: Prospective analyses of patients beginning certolizumab pegol within the last 12 months were eligible to participate in the study. 24 patients with known mucosal lesions received certolizumab pegol per standard protocol that included induction followed by maintenance of 400mg every 4 weeks. All patients had active erosions or ulcerations prior to treatment. A Harvey-Bradshaw Index (HBI) was used to correlate symptoms with endoscopic appearance. Results: Of the 24 patients, 10 had follow-up colonoscopies following initiation of therapy. The average time to colonoscopy was 6 months post-induction. The range was 4-9 months. 7 patients had complete colonic mucosal healing; 2 had resolution of their ulcers or erosions but had friability and erythema; and the tenth patient, though improved endoscopically, had persistent erosions. 6 of these patients also had Ileal disease. 2 had no change in their endoscopic appearance; 2 showed moderate improvement; and 2 had complete mucosal healing. 8 patients were in clinical remission by the HBI and 2 showed response. Conclusion: 1. Colonic healing can be expected early in the course of therapy. 2. Ileal healing occurs, but at a slower rate than does the colon. 3. Mucosal healing lags behind clinical remission and response. 4. Continuing investigation will allow a better understanding of time required to see healing and what percent of patients we expect to have mucosal healing. Disclosure: Dr Randall - Consultant: UCB, Speakers Bureau.

Pemphigus Pain

Pemphigus vulgaris is an autoimmune disease that commonly presents with painful persistent erosions and ulcers. The current literature has focused on managing and maintaining remittance of this life-threatening disease. However, remission is not instantaneous and chronic pain is common. In this manuscript, we review the current peer reviewed works that elaborate specifically on pain management in pemphigus patients. A medline search was preformed and included any case report, review, clinical trial, or other publication that covered the subject matter. From the review of literature, it is clear that pain is an important and underemphasized part of the literature on pemphigus. The majority of pain management in these patients is based on clinical experience rather than randomized blinded clinical studies. Large scale blinded randomized studies are lacking in this field, and would be of great benefit to academia and the patient population. Current large-scale studies of pemphigus would also be strongly enhanced by inclusion and reporting pain scale assessments.

An Unusual Presentation of Mucous Membrane Pemphigoid

A 68-year-old woman presented with recurrent mucocutaneous blisters of 6 years' duration and progressive loss of scalp hair of 2 years' duration. The disease had started as tense blisters associated with a burning sensation over the lower part of her back, gradually followed by involvement of her chest, upper part of her back, and arms. The blisters persisted for weeks before rupturing spontaneously. Four years later, she developed tense oral blisters, resulting in painful persistent erosions. At about the same time, blisters on her scalp developed, followed by erosions and hair loss. No other mucosal sites were involved. She had no symptoms of photosensitivity, joint pain, dysphagia, weight loss, or other systemic complaints. On examination, multiple tense bullae and well-defined deep erosions were seen over the hard and soft palates (Figure 1). Cutaneous examination revealed a few tense bullae on normal-looking skin over her abdomen (Figure 2 inset) and arms and areas of scarring at the site of healed lesions on her back. Her scalp had bullae of similar morphology, crusted erosions, and cicatricial alopecia at the site of previous lesions involving a large area of scalp (Figure 2). Examination of the other mucosae did not reveal any abnormality. Histologic studies with hematoxylin and eosin stain of a skin biopsy specimen revealed deroofed subepidermal bullae with dense dermal inflammatory infiltrate predominantly composed of eosinophils (Figure 3). Direct immunofluorescence of a biopsy specimen from perilesional skin revealed linear deposits of immunoglobulins M and G and of C3 at the dermoepidermal junction which was consistent with mucous membrane pemphigoid. This patient was prescribed prednisolone 30 mg daily and dapsone 100 mg daily, following which there were no new blisters. At 3 months' follow-up, previous erosions had partially healed.

Treatment decision-making for patients with the Herlitz subtype of junctional epidermolysis bullosa

The Herlitz subtype of junctional epidermolysis bullosa (JEB-H) is a lethal genetic disorder characterized by recurrent and persistent erosions of the epithelial surfaces that heal with exuberant granulation tissue. In addition, respiratory distress, refractory anemia and failure to thrive are often seen. Mortality in the first year of life approaches 90%. JEB-H is caused by mutations in the genes that encode the protein laminin 5, a structural molecule involved in the adhesion of epidermis to dermis. There is currently no cure for JEB-H. Medical interventions treat complications but do not ultimately limit mortality. Ethical principles contend that offering comfort and company to the patient and family, not aggressive therapies, should comprise the mainstay of care for affected infants.

Abdominovaginal sacral colpoperineopexy: patientperceptions, anatomical outcomes, and graft erosions

This is a retrospective analysis of 169 consecutive patients who underwent the abdominovaginal sacral colpoperineopexy. POP-Q measurements, patient willingness to have the same surgery again, and mesh erosions were recorded during follow-up visits. Patients whose erosion responded to office excision were defined as having minor mesh erosion. Patients with persistent erosions requiring outpatient surgical excisions were defined as having major mesh erosion. For the 122 patients with 12-month follow-up, all POP-Q points improved (p<0.005) compared with preoperative measurements. The response to the question "Would you go through the same surgery again?" was "yes" 77.3% of the time and "no" 4.9% of the time. Minor mesh erosion rate was 5.9% (10/169). Major erosion rate was 0.6% (1/169). In conclusion, when combined with paravaginal defect repair and Burch urethropexy, the abdominovaginal sacral colpoperineopexy effectively addresses all support defects in patients with advanced prolapse. The procedure is associated with a high level of patient willingness to have the same surgery again, and it is achieved with low erosion rate.

Pruritus vulvae

Women with vulval pruritus commonly attend gynaecology clinics for diagnosis and management. A successful outcome relies on a detailed history and clinical examination. Vulval biopsies are useful where the diagnosis is in doubt or when there is induration or persistent erosions on the vulval skin. This review focuses on patient assessment and the general management of patients with vulval complaints. Specific causes will be covered including candidiasis, lichen sclerosus, contact dermatitis, tinea infections, vulval intraepithelial neoplasia, lichen simplex chronicus and psoriasis.

Do we need antivirals for genital herpes simplex virus and human papillomavirus infection?

Genital herpes simplex virus (HSV) and human papillomavirus (HPV) infections are two widespread infections that are hardly recognized by the public as sexually transmitted diseases (STD). According to a survey of the American Social Health Association only 17% of adults recognize genital herpes as a STD and only 3% are aware of genital warts being sexually transmitted [1]. About 500 000 cases of genital herpes are estimated each year in the USA [2] and more than 20 000 cases are reported from STD clinics in the UK [3]. Data taken from ten developed countries show that 107 million people are herpes simplex virus type 2 (HSV 2) seropositive [4]. HSV 2 infection, which is mainly responsible for genital herpes, has increased worldwide [5]. A recently published report by Fleming et al. showed that every fifth person in the USA older than 12 years is carrying HSV 2 [6]. The HSV 2 seroprevalence has increased by 30% between 1976 and 1994. This affected increase particularly white teenagers [6]. This is surprising, because at the same time intensive HIV-prevention campaigns were performed in the USA. The special features of genital HSV infection which make therapy so vital are that it is carried lifelong and patients may suffer from many recurrences. Fortunately primary disease affects only 1% of those who get infected. Primary herpes is a severe outbreak of disseminated vesicular lesions accompanied by local swelling, discharge and altogether more serious symptoms than those of recurrent disease. However, recurrences with minor symptoms continually affect people and cause distress and psychosocial problems. In addition stable partnerships may be jeopardized and quality of life reduced. The list of complications and risks of genital HSV infection make efficacious therapy highly desirable. This applies particularly to persistent genital erosions and ulcers that make transmission and acquisition of HIV a lot easier [7–9]. In the case of genital herpes during pregnancy, different modes of management are being used. It is important to consider systemic antiviral therapy for the mother and for the benefit of the unborn child, for whom HSV may be dangerous and even life-threatening [10]. It is common knowledge that current systemic antiviral therapies alleviate symptomatic genital herpes and act prophylactically when long term therapy is continued. Treatment with acyclovir is safe according to several studies of long term treatment of persons with recurrent genital herpes [11,12]. Recently, moreover, antiviral therapy of genital herpes has been considerably improved. Valaciclovir, the valylester of acyclovir if given orally, has the same antiviral activity as acyclovir, but has the potential for less frequent administration because of its superior pharmacokinetics [13,14]. Both first-episodes and recurrences are best treated by twice daily oral administration of 500 mg valaciclovir for 5 days. Suppressive therapy is one tablet daily during the first year, in cases with frequent recurrences (history of six to eight genital herpes recurrences per year). Intravenous acyclovir should be reserved for severe first-episode or primary genital herpes. Another compound developed for herpesvirus infections and also successfully used for genital herpes is famciclovir, the diacetylester of penciclovir. Famciclovir acts similarly to acyclovir and valaciclovir. Its efficacy in genital herpes is comparable. There is also better biovailability of famciclovir in comparison to acyclovir which allows a less frequent and more convenient dosing schedule. Dosing three times daily is necessary for first-episode and recurrent disease. Suppressive therapy requires two oral administrations per day [15]. A recently published observation in mice suggests that * Tel.: +49-381-4949701; fax: +49-381-4949702.

Therapy of persistent erosion after severe chemical eye burn with the excimer laser

The course after severe eye burns is characterized by many complications which require a longlasting and intensive therapy. The success of treatment is menaced especially by superficial problems like persistent erosiones which occur also after keratoplasty. As a cause of persistent erosions, pathological changes of Bowmans' membrane are discussed. Therefore, it was removed by PTK (phototherapeutic keratectomy) in our patient, in order to allow better adhesion of the epithelium to the deeper, less changed layers. The patient suffered from a severe burn accident of his right eye with liquid cement. After proliferations were excised twice, we had to glue on a hard contact lens as an artificial epithelium due to a persistent erosion. Later, the development of a bacterial keratitis required keratoplasty. The epithelium remained intact for eleven months, but then an erosion arose and persisted for nine months. Therefore we performed a PTK and the epithelium closed subsequently within four days. The treatment of persistent erosions has been very difficult so far, and often procedures like artificial epithelium or even keratoplasty have been necessary. The astonishing course of our patient indicates, that PTK is a promising and less invasive therapy in these cases.

Guidelines for treatment of skin diseases in children with HIV infection

Bacterial infection. Bacterial skin infections, including impetigo, ecthyma, and cellulitis, may occur in the child with HIV infection. Most skin lesions are caused by infection with staphylococci or streptococci; if there is doubt as to the cause of the skin infection, a skin biopsy specimen should be taken for both culture and histologic examination. Obvious impetigo may be treated with appropriate oral antibiotics effective against both staphylococci and streptococci; most HIV-infected children will require hospitalization and intravenous antibiotic therapy effective against staphylococci and streptococci for therapy of more involved skin infections. Candidiasis. Oral thrush and recalcitrant monilial diaper dermatitis are the most common mucocutaneous manifestations of HIV infection in children. Monilial infection also may involve intertriginal areas (axilla, neck folds) and the proximal nail folds (paronychia). In addition to topical therapy, a therapeutic regimen for these infections may include oral therapy to eradicate a gastrointestinal source of the fungus. The first line of therapy for oral thrush during infancy consists of nystatin solution (100,000 U/ml) in a dose of 1 to 2 ml four times per day. In older children clotrimazole troches may be more effective. For infants who do not respond to nystatin, these troches also may be inserted into a plastic nipple and used four times a day as a pacifier. Ketoconazole at 5 to 10 mg/kg /day or fluconazole (not licensed for use in children) at 3 to 6 mg/kg /day may be required for the treatment of oral thrush that does not respond to these measures. The development of feeding difficulty or dysphagia in the child with oral thrush may signal the presence of candidal esophagitis. Topical nystatin or an imidazole cream are effective in treating candidal infection of the skin. Dermatophyte infection. Children with HIV infection may develop severe or widespread tinea corporis or tinea capitis. The presence of fungal infection should be verified by either a potassium hydroxide preparation or a fungal culture. Tinea corporis may be treated with twice daily application of an imidazole cream. Tinea capitis will not respond to topical antifungals and requires a 4to 6-week course of oral griseofulvin 10 to 20 mg/kg/day. Viral infection Herpes simplex. Severe, chronic, or recurrent infection with herpes simplex virus is a complication of HIV infection in children. The most common presentation is the development of severe and persistent erosions of the lips and tongue. However, vesicular and ulcerative lesions of the fingers and other cutaneous surfaces sometimes are seen. Any chronic ulcer of the mouth or skin should be cultured for herpes simplex.

Effect of repeated colloidal bismuth subcitrate treatment on the response of the rat gastric mucosa to the presence of luminal ethanol.

The purpose of this study was to determine the effects of repeated colloidal bismuth subcitrate administration on the cellular populations of the fundic region of the rat stomach and to investigate the effect of such treatment, after initial ethanol damage, on the gastric response to a second challenge by ethanol. The administration of 240 mg of colloidal bismuth subcitrate per kilogram body weight, at 12 hour intervals, for 14 days, resulted in an increase in the density of the mucosal epithelial cells, but a decreased rate of epithelial cell division in the neck region. Comparison with placebo treated animals showed that the repeated administration of colloidal bismuth subcitrate after an initial ethanol challenge, decreased the degree of damage induced by a second ethanol challenge, enhanced the rate of tissue repair and prevented the establishment of persistent erosions.