Iranian Journal Of Dermatology
Volume:24 Issue: 2, Spring 2021

The 12-Item Pruritus Severity Scale (12-PSS) is a multidimensional tool that evaluates pruritus intensity and duration along with an assessment of psychometric properties such as the patient´s mood, daily activities, and sleep pattern. Given its chronicity, uremic pruritus has a substantial impact on quality of life, so it is worth having a valid Persian questionnaire for assessing the various aspects of pruritus. This study was designed to evaluate the validity and reliability of the translated 12-PSS in hemodialysis patients with chronic uremic pruritus.
Participants in this cross-sectional study were hemodialysis patients with uremic pruritus who were referredto the dialysis departments of three hospitals in Tehran, Iran. Following forward-backward translation of the 12-PSS to and from Persian, we assessed its content validity index (CVI) and reliability. Finally, we asked patients to respond to questions using both the Visual Analog Scale (VAS) and the 12-PSS.
Overall, 195 eligible patients participated in this study. The average age was 55.08 ± 12.34 years. The internalconsistency (Cronbach’s alpha) of the 12-PSS was found to be 0.88, indicating strong consistency. The mean VAS and 12-PSS scores were 6.40 ± 2.63 and 11.52 ± 3.91, respectively, and the correlation between VAS and the total raw points of the pruritus intensity domain of the 12-PSS (questions 9 and 10) was strong(P-value < 0.05, r = 0. 90).
This study showed that the translated form of the 12-PSS questionnaire has acceptable validity and reliability and has a strong correlation with the VAS in assessing pruritus intensity.

Alopecia areata (AA) is non-scarring hair loss. Its etiopathology is not fully known, most evidence considered AA an immunologically mediated disease. To compare serum levels of total immunoglobulin E (IgE) between AA patients and healthy subjects, and to assess whether AA is associated with atopy.
50 AA patients and 50 healthy subjects were included in this study. Presence of atopy was elicited by detailed family and/ or personal history of atopy. Clinically patients were divided into 2 groups: patients with single patch of AA (alopecia unilocularis, AU), or with multiple patches (alopecia multilocularis, AM). Serum levels of IgE were measured in both groups.
Serum levels of total IgE were significantly higher in patients than in controls (178 ± 154 ku/l vs. 118 ± 57 ku/l; P < 0.05). Evidence of atopy was present in 48% of AA patients compare to 18% of control subjects (P < 0.05). Patients with disease duration more than one year had significantly higher serum IgE levels (P < 0.05), and patients with AM had significantly higher serum IgE levels than patients with AU (267 ± 189 ku/l vs. 102 ± 32.3 ku/l; P < 0.05). Mean value of serum IgE did not vary significantly with patient’s age at onset, gender, history of atopy or family history of AA. Atopy was significantly associated with AM.
Total serum IgE is elevated in AA patients with significant association with severe and chronic disease irrespective of the presence of atopy. Atopic diseases were more frequent in AA patients with severe clinical presentation.

Basal cell carcinoma (BCC) is the most common type of skin tumor. Surgical removal has remained the gold standard of treatment for BCC, but incomplete removal is an important clinical challenge. The goal of our study was to evaluate the incomplete excision of BCC and the factors affecting it.
In this retrospective study, 361 histological samples of BCC excisions referred to the Pathology Department of Imam Reza Hospital, Mashhad, Iran, from 2004 to 2018 were reviewed. Data including age, gender, tumor site, size, histopathologic subtype, surgical margin involvement, and the surgeon’s specialty were recorded.
The incomplete removal rate was 20%. Ten percent of the lesions had deep margin involvement, 5.8% had lateral margin involvement, and both margins were involved in 4.2% of cases. Incomplete excision had a significant relationship with the following variables: nodular, mixed, and sclerosing types; the 60-70 years age group; lesions larger than 2 cm, location in nose and canthi; and excision by an otorhinolaryngologist, ophthalmologist, or dermatologist.
In this study, the frequency of incomplete excision was relatively high compared with other studies. Therefore, it is suggested to perform a diagnostic biopsy before the complete excision of BCC. Excision with a wider margin or using Mohs surgery is recommended for midface lesions, older individuals, nodular, mixed, or sclerosing lesions, and for tumors larger than 2 cm.

Striae is a common condition that is relatively difficult to treat. Recently, carboxytherapy was proposed as a treatment modality. This study aimed to evaluate the therapeutic effect of carboxytherapy in patients with striae.
This was a pilot clinical study. Patients were treated with 10 sessions of carboxytherapy every week. The patients were photographed at the onset of the treatment course, before each treatment session, and three months after the last ones. Two dermatologists compared the images of each patient before and three months after treatment and evaluated the treatment response based on the following scores: I, no improvement (0%);II, poor (1% to 25%); III, fair (26% to 50%); IV, good (51% to 75%); and V, excellent improvement (76% to 100%). Furthermore, patients’ satisfaction with therapy outcome was recorded on a scale of 0 to 10.
15 patients were enrolled in this study; 2 (13.4%) were male and 13 (86.6%) were female. Three patients (20%) showed good response, one (6.7%) had a relatively good response, two showed (13.3%) poor response, and seven (46.6%) had no response to treatment. Analysis of the association of carboxytherapy outcomewith different patients’ characteristics showed no statistically significant correlation (P > 0.05).
Although carboxytherapy therapy did not result in a significant response in the majority of our patients, it is somehow capable of improving the striae in some patients. Further studies with bigger sample sizes may be required to ensure the efficacy of this modality in the treatment of striae.

Alopecia areata (AA) is an autoimmune disease involving the inflammation of hair follicles. In many autoimmune diseases, inadequate levels of vitamin D have been reported. We aimed to determine the association between vitamin D levels and AA.
In this case-control study, 50 AA patients and 50 controls were assessed regarding serum levels of 25-hydroxy vitamin D [25-(OH)-D3]. The levels of 25-(OH)-D3 were classified as deficient ( < 20 ng/ml), insufficient (20 to 30 ng/ml), and sufficient ( > 30 ng/dl). The severity of the disease was scored according to the Severity of Alopecia Tool (SALT).
The serum level of 25-(OH)-D3 was significantly lower in AA cases compared with the control group. Patients with the totalis or universalis pattern of hair loss had lower levels of 25-(OH)-D3 relative to patients with the patchy or ophiasis type of AA. Moreover, severe cases showed significantly lower levels of vitamin D relative to mild and moderate cases. We found a significant inverse association between 25-(OH)-D3 level and age. We found no association between serum levels of 25-(OH)-D3 and gender, disease duration, disease recurrence, nail involvement, or positive family history of AA.
AA patients had lower serum levels of vitamin D, though this did not contribute to the severity or duration of disease or pattern of hair loss. More studies are required to evaluate the role of vitamin D supplementation in the pathophysiology of AA.

Bleomycin is used for the treatment of warts. However, only its injected form can be used due to systemic use side effects, and plantar warts have a high recurrence rate following administration of bleomycin tattooing alone. To find an effective alternative with fewer side effects, we decided to investigate the effectiveness of bleomycin tattooing combined with trichloroacetic acid (TCA) and shaving in the management of treatment-resistant plantar warts.
The patients with treatment-resistant plantar warts entered the present quasi-experimental study. the wart site was shaved ahead of bleomycin tattooing and TCA peeling. This treatment was provided at one-month intervals and was repeated a maximum of four times. Patients were followed for six months after completion of the therapy. Finally, the patients’ data were completed according to photographs (monthly photos taken of lesions) and careful examinations.
The present study involved 56 patients with a mean age of 25.75 ± 12.22 years. Twelve patients (21.4%) recovered after the first treatment; 14 (25%) needed the second treatment, 12 (21.4%) needed the third, 10 (17.9%) the fourth, and eight (14.3%) did not recover after the fourth treatment. The recovery rate was 21.4% with one, 45.4% with two, 66.8% with three, and 85.7% with four treatment sessions.
The combination treatment of bleomycin plus TCA and shaving led to a remarkable recovery from treatment-resistant plantar warts (21.4% recovery with the first treatment session and up to 85.7% recovery after four sessions). The treatment included tattooing and local injections, leaving few side effects.

Functional dyspepsia (FD) is a common disorder of the upper gastrointestinal tract. Several documents in conventional medicine claim an association between FD, sleep disturbance, and some dermatological conditions, but there is still debate about these relationships. This study aimed to measure the association between FD and some skin problems and sleep indices based on the attitudes of traditional Persian medicine.
This study was carried out on patients with the diagnosis of FD and healthy people. The study populationconsisted of patients who referred to the gastroenterology clinic of Shiraz University of Medical Sciences (Shiraz, Iran) from July to December 2019. To diagnose dyspepsia, we used Rome III criteria. Skin problems and sleep indices were evaluated using a validated researcher-made questionnaire. P-values of ≤0.05 were considered significant.
Overall, 160 patients (46 men and 116 women) with FD and 155 healthy individuals (36 men and 119 women) were enrolled in the study. There were significant differences between patients and healthy individuals in terms of dryness of skin (P = 0.001), oily hair, deep sleep, long sleep, insomnia, difficulty sleeping, and nightmares (p≤0.001). On the other hand, there were no significant differences between the groups in intermittent sleeping (P = 0.116) and periorbital edema after sleeping (P = 0.195).
According to the results of this study, it seems that there is a positive relationship between FD and some dermatological and sleeping indices based on traditional Persian medicine resources.

Anogenital warts are the most prevalent sexually transmitted disease worldwide and are caused by human papillomavirus (HPV). There are more than 100 different types of HPV, of which certain types make the patient more susceptible to malignant neoplasms. This study aimed to determine the frequencies of specific types of HPV in anogenital warts.
This study included 157 patients diagnosed with anogenital warts that underwent HPV DNA detection using polymerase chain reaction (PCR) with INNO-LiPA genotyping assay.
Of 157 patients with anogenital warts, 122 samples (77.7%) were positive for HPV, with some patients showing mixed HPV subtypes. HPV 6 (n = 99; 68.3%) and HPV 11 (n = 13; 8.9%) were the most prevalent types. 101 patients were male (64.3%). The mean age was 32.02 ± 10.06 years (range: 2 to 72 years). Most patients were infected with the low-risk types (80%); the high-risk HPV type 16 was significantly more common among women (P = 0.0001).
This study showed the higher relative frequency of HPV6 and HPV11 in anogenital warts in Guilan, northern Iran. The frequency of genital HPV infection appears to be higher among men, but the frequency of high-risk types seems to be higher among women.

Basal cell carcinoma (BCC) is the most common type of skin malignancy. Hyperthermia is used as adjuvant therapy together with radiotherapy and chemotherapy in the treatment of some cancers. This study aimed to evaluate the efficacy and safety of thermotherapy in the treatment of BCCs.
This pilot trial was carried out on five patients with nodular or superficial BCCs on the scalp and face.Thermotherapy was done at 50° C for a duration of 30 seconds with a radiofrequency device (Thermomed 1.8 thermosurgery technologies). Thermotherapy treatment was applied only in one session. The first follow-up was one week after the procedure and then every month for six months. The last follow-up was one year after the procedure.
All patients showed clearance of the tumors. Blisters, ulcers, crusts, and necrosis were the side effects, which healed with acceptable degrees of scarring. No recurrence was observed at the end of the study.
Thermotherapy was safe and efficacious for the treatment of BCCs on the scalp and face. It should be considered especially for the low-risk subtypes of this cancer.

Hand hygiene is one of the most crucial measures against coronavirus disease 2019 (COVID-19) transmission; however, frequent handwashing may lead to contact dermatitis causing many problems. Occupational hand dermatitis is a relatively common but challenging issue that imposes a negative effect on the quality of life, work performance, and adherence to hygiene principles. We performed a cross-sectional study to assess the psychosocial impacts of hand dermatitis on healthcare workers (HCWs) using an online Persian version of the Nordic Occupational Skin Questionnaire (NOSQ-2002). Sixty-three from a total of 390 HCWs (21%) reported that hand eczema had adverse effects on their occupation, such as a necessity to use gloves (17.3%) and decreased adherence to hand hygiene (14%). HCWs reported a higher exacerbation of hand dermatitis in winter (40.3%) and fall (24.7%). Hand dermatitis exerted a significant impact on sporting activities, sleep, social life, mood, and sex in 17.7%, 43.3%, 44.3%, 66%, and 11.7% of HCWs, respectively. It seems that hand dermatitis-related impairment of the mentioned activities has increased in HCWs during the COVID-19 pandemic.

Skin cancer is the out-of-control growth of skin cells that can be divided into keratinocyte carcinoma (non-melanoma) and malignant melanoma. Basal cell carcinoma (BCC) and squamous cell carcinomas (SCC) are the most common forms of keratinocyte carcinoma that may grow to involve other parts of the body. These cancers are caused by exposure to ultraviolet (UV) light, toxic substances, and a family history of skin problems. Different signaling pathways are likely to be involved in skin cancer. The TP53 gene (the gene coding for cellular tumor protein p53) is among the most diverse and complex molecules involved in cellular functions. The p53 pathway can initiate DNA replication, modulate cell cycle events, and interact with tumor suppressor genes (TSGs). Mutations in TP53 can occur in numerous human cancers, leading to cellular immortalization, inappropriate proliferation, and genomic instability. TP53 plays a big role in both melanoma and non-melanoma skin cancers. Despite the intensive investigation to clarify the impact of TP53 mutations in the induction of skin cancer, much remains to be elucidated. In this mini-review, we will discuss the protective role of p53 as a bona fide tumor suppressor gene in human skin cancers.

Bedsores are caused by decreased tissue perfusion due to prolonged pressure on the skin and represent one of the problems of immobilized patients, including hospitalized ones. This study reports the successful treatment of a patient with bedsore wounds using the larvae of the fly Lucilia sericata. The study focused on a 64-year-old man residing in Qom (a city in central Iran), who was hospitalized for 45 days at Qom Shahid Beheshti Hospital in November 2019 because of cardiovascular disease and chronic obstructive pulmonary disease (COPD). He had a pressure ulcer of about 9.5 cm in diameter on the skin overlying the sacrum. After showing resistance to honey dressing and conventionalantibiotic treatments, maggot therapy was recommended. This procedure was done by releasing the larvae of L. sericata 12 times every three days. The removal of necrotic tissues and the appearance of the granulated tissues were recorded using a ruler as an indicator of healing. After 12 sessions of larval treatment, the wound surface considerably reduced and was finally healed. Thus, it can be argued that maggot debridement therapy (MDT) is an effective treatment for bedsores and can be recommended to physicians as an adjuvant treatment for complex and resistant ulcers.

Basal cell carcinoma (BCC) is the most common form of nonmelanoma skin cancer. A review of the literature revealed only a few reports of BCC on the auricle or conchal bowl, usually occurring in elderly patients. Herein, we report an exceptional case of BCC in a young man with an unusual anatomical location of the tumor as a solitary erythematous to black-colored plaque located in the conchal bowl of his right ear. By thoroughly reviewing the literature, there was no other documented case of BCC located in the conchal bowl of the ear of a young adult. Dermatologists should be aware that skin tumors may also occur in uncommon anatomical locations and with unusual presentations in the young population, even if they have no known predisposing factor. Unusual presentations make clinical suspicion of skin tumors very difficult, so these lesions can easily be missed. Early diagnosis can prevent further growth, extensive destruction, and severe consequence of invasive treatments.

Trichilemmal carcinoma is a rare tumor of the outer sheath cells of hair follicles. These tumors occur on the sun-exposed skin of the elderly in the majority of cases. The gross tumor demonstrates exophytic, polypoid, ulcerative, or nodular lesions with or without bleeding. Histopathologically, it is characterized by an anastomosing trabecular, diffuse, or lobular growth pattern with clear keratinization. A critical differential diagnosis is squamous cell carcinoma (SCC), where the prognosis of trichilemmal carcinoma is far better than SCC. Surgery is a significant and effective treatment for trichilemmal carcinoma cases, and recurrence after complete surgical resection with a negative margin is uncommon. Trichilemmal carcinoma is considered a low-grade tumor with low metastatic potential. This paper reports a 48-year-old Iranian male with trichilemmal carcinoma of the scalp treated with surgery, having no recurrence after three years of follow-up. The role of other treatment modalities like radiation, local therapy, and systemic therapy are also discussed.