Iranian Journal Of Dermatology
Volume:25 Issue: 2, Spring 2022

Acne scarring can significantly affect patients’ quality of life, particularly when it involves the face. This study aimed to compare the efficacy of microneedling with and without platelet-rich plasma (PRP) versus fractional CO2 laser therapy in treating acne scarring.

This randomized clinical study was performed on 90 patients with acne scarring. All the patients were divided into three groups (n = 30 per each): group A received microneedling, group B received microneedling plus PRP, and group C was treated by fractional CO2 laser. Each patient underwent three treatment sessions across three week intervals. The severity and depth of acne scars were graded using Goodman and Baron’s scale and Visio Face systems, respectively.

Out of 90 patients, 30 in group A, 22 in group B, and 26 in group C completed the trial. Analysis was done based on the per-protocol method on a total of 78 patients. Regarding the severity of acne scarring, significantly better results were obtained for groups A and B than for group C (P ≤ 0.001), while no meaningful difference was seen between groups A and B. Also, there was a significant difference between group B and other groups in terms of patients’ satisfaction (P = 0.04). The Visio Face systems showed that the depth of acne scars in group B had better improvement than in other groups (P = 0.02).

Microneedling plus PRP led to the most patient satisfaction and highest improvement in acne scar depth. However, considering the fewer side effects and acceptable cost-benefit profile of microneedling alone compared with fractional CO2 laser or microneedling plus PRP, isolated microneedling could be considered the first choice for treating acne scars.

Among different treatments for periorbital hyperpigmentation (POH), both semi-invasive protocols of fractional CO2 laser and platelet-rich plasma (PRP) are favored among clinicians and rarely cause complications; however, the level of patients’ satisfaction seems to differ across these methods. This randomized clinical trial was conducted on 100 patients (98 women; 2 men) between 28 to 62 years of age who complained of POH and referred to the Dermatology Clinic of Rasool Akram Medical Complex located in Tehran in 2017. The patients were randomly assigned to two groups receiving fractional CO2 laser (group C) and adding PRP treatments plus laser therapy (group CP). The outcome of both treatment protocols was followed 3 and 6 months after the last treatment by standard photography. The time for swelling after treatment in the C and CP groups was 4.58 ± 0.61 days and 2.94 ± 0.68 days, respectively, which was significantly shorter in group CP (P < 0.001). The mean time for erythema disappearance was also shorter in group CP (5.20 ± 0.76 days vs. 3.40 ± 0.76 days, P < 0.001). Regarding the trend of the change in the ΔE parameter, it fell significantly in both groups within the follow-up period (P < 0.001); however, the mean ΔE was significantly higher in the CP group when compared with the control group (P < 0.001). There were no significant or resistant side effects in either treatment group. Although both therapies are effective and safe, the concurrent use of CO2 laser and PRP can more effectively reduce the severity of POH with a shorter duration of post-treatment swelling and erythema. Hence, this combination is a superior modality for the treatment of POH as compared to laser therapy alone.

Androgenetic alopecia is defined as patterned hair loss caused by androgens in genetically susceptible individuals. Metabolic syndrome is a cluster of interrelated risk factors that increase the risk of coronary artery disease. Androgenetic alopecia is associated with metabolic syndrome components including insulin resistance, dyslipidemia, and obesity. This study aimed to compare the prevalence of metabolic syndrome in androgenetic alopecia patients with controls.

The study groups consisted of 50 androgenetic alopecia patients and 50 controls who agreed to participate. Following recruitment into the study, history taking, clinical examination, and laboratory investigations were carried out, and details of each individual were recorded into a pre-structured case record sheet.

The groups were not statistically different in terms of age or sex distribution, height and weight, glucose levels, thyroid hormone level, blood counts, and lipid levels. We found that 26% of patients in the case group and 6% in the control group satisfied the definition of metabolic syndrome; this difference was significant (P = 0.007). We observed a statistically significant difference in LDL and HDL levels between the cases and controls (P = 0.0027 and 0.0091, respectively).

Patients with androgenetic alopecia have an increased likelihood of having metabolic syndrome and must be routinely screened for hypertension, diabetes mellitus, and dyslipidemia. They should be made conscious of the more serious implications of the apparently cosmetic disorder.

Diabetes mellitus is a non-communicable disease that affects all the body’s organ systems, including the dermatologic system. Skin lesions can cause discomfort, harm one’s quality of life (QOL), and increase treatment costs. The objective of conducting this study was to compare the proportion of dermatologic comorbidities, the direct cost of treatment, and the QOL between cases and controls. The study was conducted in a medical college hospital in the hilly region of Uttarakhand using a case-control design. Cases were recruited from the Outpatient Department (OPD) and controls from the hospital. Comparisons were made for the presence of skin diseases between 195 patients with diabetes andan equal number of age and gender-matched non-diabetics. The independent t-test was used to compare QOL and treatment cost between the two groups. The risk of skin diseases was 5.3 times higher in cases than in controls. The proportion of skin diseases in cases was 36.4% versus 9.7% in controls. Limitations: There is a probability that the QOL scores could be lower and the treatment cost higher than that observed. The proportion of skin disorders and the mean direct cost of treatment was reported to be significantly higher among cases.

Androgenetic alopecia (AGA) is a non-scarring form of patterned hair loss characterized by the miniaturization of terminal hair into vellus hair. The scalp biopsy was once considered an ideal tool for diagnosing the disease, though dermatoscopy has emerged as a reliable technique that can aid in the diagnosis and monitor the disease severity. A total of 68 patients (38 males and 30 females) in the age group of 21-70 years attending the dermatology outpatient department in 1 year were included in the study. A detailed history was taken, followed by a scalp examination. The type of hair loss in each patient was documented. Then, a dermatoscopic examination was done using a Dermlite DL4 dermoscope. Hair thickness heterogeneity was the most common dermatoscopic feature seen in all the patients of male and female pattern hair loss. There was a positive correlation between some dermatoscopic variables such as yellow dots and perifollicular pigmentation with the disease severity. Yellow dots were seen in the late stages of AGA (P < 0.01), while perifollicular pigmentation was observed in the early stages of AGA (P < 0.01). Trichoscopy is a simple and non-invasive office tool that aids in diagnosing AGA. It allows the various sections of hair to be examined simultaneously and obviates the need for a scalp biopsy. Besides this, it helps assess the disease severity and the photographic documentation at each visit helps monitor the response to treatment.

The increased prevalence of metabolic syndrome has been established in chronic inflammatory skin diseases. Patients with metabolic syndrome have a higher mortality rate due to cardiovascular disease and malignancy. In this study, the prevalence of metabolic syndrome was evaluated in lichen planus patients compared with a control group in Kerman, southeast Iran. This was a cross-sectional study on 90 patients with lichen planus and 90 healthy participants from the Dermatology Clinic of Afzalipour Hospital, Kerman, Iran. Demographic features of the patients and clinical features of the lesions were recorded. Then, parameters of metabolic syndrome were evaluated in both groups. The independent t-test and chi-squared test were used to compare quantitative and qualitative variables, respectively. There was no significant difference in demographic features of the participants between the two groups. Metabolic syndrome was significantly more prevalent in the lichen planus group (62.6%) than in the control group (14.4%) (P = 0.001). Metabolic syndrome parameter values (except waist circumference) were significantly higher in the lichen planus group than in the control group. Lichen planus patients with metabolic syndrome had a significantly higher percentage of mucosal involvement (66.1%) than lichen planus patients without metabolic syndrome (44.1%). Lichen planus patients with metabolic syndrome were significantly older than those without metabolic syndrome. This study observed a higher prevalence of metabolic syndrome in lichen planus patients relative to controls. Furthermore, lichen planus patients with metabolic syndrome had significantly higher age, mucosal involvement, and body mass index than lichen planus patients without metabolic syndrome.

Basal cell carcinoma is the most common skin cancer, constituting nearly 80% of non-melanoma skin cancers. In this study, for the first time in Kerman, the clinicopathological features of basal cell carcinoma in patients referred to Afzalipour Hospital were evaluated. This is a retrospective, cross-sectional study on 145 skin biopsy samples with a diagnosis of basal cell carcinoma in Afzalipour Hospital, Kerman. Demographic features of patients and clinical and pathologic types of basal cell carcinoma were recorded. Then, the correlation between clinical or histological types with demographic features was evaluated using the chi-squared test. Ninety-four (64.8%) of the cases were male, and the mean age of the patients was 68.12 ± 14.54 (min = 15, max = 101) years. The most and the least common sites of involvement were the nose (35.9%) and trunk (0.7%), respectively. The most common clinical (76.5%) and pathological subtypes (71.03%) were nodular. The least common clinical (6.3%) and pathological types (2.1%) were morpheaform. There was no significant correlation between histopathological or clinical types with demographic features including age and sex. Furthermore, there was no significant correlation between sex and the site of the involvement or age of the patients. In this study, most patients were between 60-79 years of age, and the male-to-female ratio was 1.8 to 1. Nodular and morpheaform types were the most and the least common pathological and clinical types, respectively.

Acne vulgaris is a common skin disease. Choosing an appropriate treatment modality is important. We compared benzoyl peroxide 5% gel vs. new topical dapsone 5% gel in combination with doxycycline to improve acne. In a clinical trial, 60 cases with acne vulgaris aged 18-25 years were divided randomly into two groups, DD (dapsone 5% gel plus oral 100 mg doxycycline) and BD (benzoyl peroxide 5% gel plus oral 100 mg doxycycline). Topical dapsone 5% gel was made for the first time at Guilan University of Medical Sciences. The lesion counts, side effects, and acne severity (GAAS) were examined at baseline, 2, 4, 8, and 12 weeks. Satisfaction and improvement were assessed after 12 weeks. The Mann-Whitney, chi-squared, Wilcoxon, and Friedman tests were used for statistical analysis in SPSS v. 21. Inflammatory and non-inflammatory lesions were similar between the groups. Lesions were reduced within groups (P > 0.05). GAAS scores were similar between groups but decreased in both groups after 12 weeks (P = 0.003). Side effects (especially skin dryness) were less in the BD group after 12 weeks (P = 0.017), though erythema and skin irritation were less in the DD group (P > 0.05). Both groups reported a similar improvement rate (85%). However, satisfaction was more in the DD group (78%). The new dapsone 5% gel seems to be as effective as benzoyl peroxide 5% in combination with doxycycline. Considering its good tolerability, safety, and acceptability, it is suggested as an appropriate treatment for moderate acne vulgaris. (Clinical trial number: IRCT2017072035195N1)

Keloid is a benign fibroproliferative skin disorder. Surgery has a high recurrence rate as the treatment of choice to instantly eliminate the lesion, so adjuvant radiotherapy may be useful. This article aims to discuss case reports and present a systematic review of external beam radiation therapy (EBRT) as an adjuvant in postoperative keloid management.

Case reports were obtained from patients in our institution. Informed consent was obtained for each patient. Articles found on literature search from Pubmed and Scopus were processed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Centre of Evidence-Based Medicine University of Oxford guidelines. The risk of bias was rated using the Cochrane risk of bias tool.

We reported the cases of two Asian women aged 18 and 23 years old with a history of injury to the earlobe before keloid formation. Postoperative radiotherapy was administered within 7 hours, with an 8-months follow-up showing no recurrence and grade 1 toxicity. Five articles appraised in this review suggested a lower recurrence rate for postoperative radiotherapy compared to steroid injection and conventional surgery (11.5 vs. 26.67 vs. 33%). Brachytherapy had a lower recurrence rate than external radiation but was limited by the need for a special applicator. The side effects of all treatment modalities in this study were well-tolerated.

Postoperative EBRT is a promising modality to minimize the risk of recurrence with low toxicity for keloid lesions. More randomized control trials are needed to better understand the role of EBRT in keloid management.

Multiple endocrine neoplasia type 1 (MEN1) is a rare, autosomal dominant hereditary syndrome caused by mutations of the MEN1 tumor suppressor gene. We describe a patient with a prior confirmed diagnosis of pemphigus vulgaris (PV), who presented with new cutaneous manifestations that led to the diagnosis of MEN1. A man in his early forties with a history of PV from 11 years ago presented with some cutaneous lesions six months ago, diagnosed as angiofibroma and collagenoma. Moreover, he suffered from recurrent renal stones and gout for several years. Laboratory analysis showed hypercalcemia, which led us to confirm the diagnosis of a parathyroid adenoma by sestamibi scintigraphy. Contrast-enhanced computed tomography (CT) of the abdomen revealed hyper-enhancing pancreatic lesions while the patient had no related symptoms. Thus, the clinical diagnosis of MEN1 syndrome was settled, and the patient underwent surgical and medical management. A hitherto unreported cooccurrence between MEN-1, as a hereditary syndrome, and PV, as an autoimmune bullous cutaneous dermatosis, opens a hazy challenging issue: whether MEN-1 has any association with autoimmune bullous cutaneous diseases like PV or increases the incidence of such conditions.

An ectopic nail is an extremely infrequent disorder, also known as onychoheterotopia. Onychoheterotopia can present congenitally as well as in acquired form, although the acquired form is a rare occurrence. Ohya et al. first described the congenital ectopic nail in 1931. The growth of tissue resembling nails at sites different from the nail bed is characteristic of this condition. Acquired type or post-traumatic ectopic nail has been postulated to be due to acute or repeated trauma to the nail unit followed by transfer and inoculation of the nail matrix at another site. A posttraumatic ectopic nail is rare and unusual, making its diagnosis and management important. Histopathological correlation is necessary to confirm the diagnosis and differentiate it from other nail conditions. Here, a classic case of a post-traumatic ectopic nail in the left little finger in a male laborer following a cut injury is reported. The ectopic nail had horizontal growth and was approximately 5 × 3 mm in size and 1 cm away from the normal nail. After surgical resection and biopsy of the resected part, it was successfully diagnosed as a nail of ectopic origin. This is a rare case of a post-traumatic ectopic nail on the little finger with horizontal growth away from the normal nail.

Primary angioplasmacellular hyperplasia is a scarce clinical dermatologic condition presenting different skin lesions diagnosed through biopsies indicating vascular proliferation with perivascular plasma cell infiltrations. In the current case presentation, a 40-yearold healthy male was referred to our outpatient dermatologic clinic with concurrent limbs and trunk erythematous vascular lesions for five years. The chief complaint of the patient was intermittent pruritus and relative irritation for years. Multiple biopsies were derived from the lesions, and vascular proliferation of capillaries with intensive perivascular infiltration of plasma cells was detected in the pathological specimen that finally led us to the final diagnosis of primary angioplasmocellular hyperplasia. Treatment with isotretinoin was initiated, and the patient responded to the treatment protocol dramatically. Given the rarity of reported cases, this report is considered the first case of primary angioplasmacellular hyperplasia with numerous lesions scattered and the first experience of successful treatment with isotretinoin.

Mycosis fungoides (MF) is the most common skin subtype of T-cell lymphoma. Its underlying cause is not yet clearly understood, and diagnosis might be difficult since MF presents itself with symptoms similar to some other dermatologic disorders. In the current case presentation, we report a 12-year-old female with concurrenthypopigmented and pigmented purpuric dermatosis-like lesions that underwent skin biopsies and immunohistochemistry study. Microscopic findings of hyperkeratosis and mild acanthosis in addition to epidermotropism of lymphocytes with perivascular and interstitial infiltration led us to the probable diagnosis of MF.Intraepidermal lymphocyte immunohistochemistry assessments were positive for CD3 and CD4 while negative for CD8 and CD7. The peripheral blood smear revealed a normal CD4 to CD8 ratio, and the number of Sézary cells detected was insufficient to diagnose Sézary syndrome. Therefore, the final diagnosis of MF was made for this young patient.

Actinomycotic mycetoma or actinomycetoma is a type of mycetoma caused by Nocardia and Actinomyces. It usually affects the trauma-prone areas or extremities of the body. It is associated with characteristic discharging granules and sinuses. Gram staining of discharged granules shows thin Gram-positive filaments. Histopathology of granules shows suppurative granulomas composed of neutrophils surrounding characteristic grains. Several antibiotics are effective, including co-trimoxazole, dapsone, streptomycin, trimethoprim (TMP), rifampicin, and amoxicillin-clavulanic acid. However, co-trimoxazole remains the gold-standard therapy. Actinomycetoma of the scalp has been rarely reported. Here, we report the case of an Asian male in his 50s presenting with swelling over the scalp. It had developed seven years ago after a road traffic accident and remained elusive to treatment. There were no discharging sinuses or granules characteristic of actinomycetoma. The Gram stain and Modified Ziehl-Neelsen stain from superficial swabs were negative for pathogens. Bacterial and fungal cultures of the biopsy sample were inconclusive. However, histopathology showed epidermis having focal acanthosis overlying granulation tissue with proliferating capillaries, edema, and infiltration by lymphocytes, plasma cells, neutrophils, and eosinophils along with scattered foreign body giant cells. Filamentous bacterial colonies with surrounding neutrophils were present. These features were suggestive of actinomycetoma. The patient was treated with oral doxycycline and co-trimoxazole and had a complete regression of swelling after three months of follow-up. This case highlights an unusual morphology and location of actinomycetoma, which should be considered when encountering subcutaneous swelling.

Methotrexate, an anti-psoriatic drug possessing immunoregulatory, antiproliferative, and anti-inflammatory properties,acts by blocking deoxyribonucleic acid and ribonucleic acid synthesis. It acts especially on rapidly dividing bone marrow cells and proliferating epithelia and mucosae. The toxicity of this double-edged sword occurs due to accidental excessive intake or daily dosing instead of weekly dosing. We report the case of a 31-year-old male with acute methotrexate toxicity presenting with ulcerations over pre-existing psoriatic plaques with foci of bleeding. Oral mucosal involvement in the form of buccal and palatal ulceration was present in the setting of sepsis, pancytopenia, and acute kidney injury. It is worth emphasizing the role of adequate prescription guidelines, patient education, stringent monitoring, early recognition of tell-tale signs of toxicity, timely leucovorin rescue, and the need for strict enforcement of regulations regarding the over-the-counter availability of such drugs, especially in developing countries.

The rate of cosmetic tattooing in Iran is increasing as in many other countries, with concomitant rises in tattoo-associated complications, including inflammatory (infectious and noninfectious) and neoplastic reactions. We reviewed clinical and pathology features of a series of 13 cases of adverse reactions to tattoo pigments. The participants included 11 women and 2 men aged between 22 and 58. The histopathologic reaction patterns were seven granulomatous (four sarcoid, with heavy tattoo pigments in the superficial dermis, and three tuberculoid, with scanty tattoo pigments in the superficial dermis), three cases of pseudoepitheliomatous hyperplasia, one cutaneous lupuserythematosus-like reaction, one pseudolymphomatous reaction, and one case of mild superficial perivascular inflammation. More than two-thirds of the reactions were to brown tattoos on the eyebrows. The lag in lesion development after tattooing varied from five days to two years.