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Introduction: Colorectal cancer (CRC) constitutes one of the most aggressive malignancies worldwide and in Malaysia. Due to high recurrence rate and toxic side effects associated with radiation and chemotherapies, new agents are urgently needed. CARP-1 is a peri-nuclear phospho-protein which plays a dynamic role in regulating cell growth and apoptosis. CARP-1 functional mimetics (CFMs) are a class of compounds that stimulate CARP-1. CFM-4, a lead compound, was shown to suppress growth and metastasis of various cancers, other than CRC. We hypothesized that CFM-4 inhibits proliferation and metastasis in CRC. Materials and method: CFM-4 anti-cancer effects of on CRC cells were investigated using MTT assay, Annexin V/Propidium iodide (PI) apoptosis assay, cell cycle analysis, quantitative real-time PCR (qRT-PCR) and Western blotting. Antimetastatic activities were assessed by migration, colony formation and invasion assays. Results: CFM-4 inhibited CRC cell proliferation and was much more potent than the classical anti-CRC 5-fluorouracil. These effects were shown to be mediated at least in part by stimulating apoptosis, as indicated in our Annexin V/PI assay results. Cell cycle analysis showed that CFM-4 induced G2/M phase arrest. Molecularly, qRT-PCR results revealed that CFM-4 promoted intrinsic apoptosis by upregulating expression of caspase-8 and -9 , p53, PUMA and Noxa, and stimulated extrinsic apoptosis by enhancing expression of death receptors (DR4 and DR5). CFM-4 upregulated NF- k B signaling inhibitor A20-binding inhibitor protein and the PI3K negative regulator PTEN. Western blot analysis results revealed that CFM-4 enhanced expression of CARP1, caspase-8 and executioner caspase-3. Metastatic properties of the CRC cells were reduced by CFM-4 through blocking their capabilities to form colonies, migrate and invade through the matrix-coated membranes. Conclusion: The potent antitumor and anti-metastatic properties of CFM-4 against CRC are due to collective pro-apoptotic, anti-proliferative and anti-metastatic activities. Together our data warrants further investigations of CFM-4 as potential anti-tumor agent for CRC malignancy and metastasis.

Nano-erythrocyte coating has been developed as an interesting biomimetic platform to provide hybrid nano-carriers with innate functions to target liver cancer. This goal was achieved by coating nano-erythrocyte membranes (NEMs) onto 5-fluorouracil (5-FU)-loaded liposomes (LPs) to produce NEM-5-FU-LPs. This framework is used to promote the escape of 5-FU-LPs from degradation during systemic circulation. NEMs were obtained by hypotonic lysis of erythrocytes to produce ghost erythrocytes (GEs) followed by extrusion through polycarbonate membranes. Chimeric NEM-5-FU-LPs were fabricated via the fusion of NEMs and artificial LPs. The resultant chaperoned LPs were characterized based on particle size, morphology, entrapment efficiency (EE %), stability, protein content and phosphatidylserine exposure and their in vitro release profiles and cytotoxic efficacy were also determined. The present results revealed that 5-FU-LPs, NEM-5-FU and NEM-5-FU-LPs exhibited nanosize, spherical shapes and unimodal size distributions0.3. In addition, the vesicles presented a zeta potential with EE% of 24.6-30.7% and an appropriate stability for 3 weeks. NEM-5-FU-LPs retained the erythrocyte membrane proteins as confirmed by PAGE and displayed a sustained release profile up to 48 h when compared to NEM-5-FU and the 5-FU solution. Moreover, hybrid NEM-5-FU-LPs induced a late cytotoxic effect after 48 h compared to the other formulations. Thus, mantling of 5-FU-LPs by NEMs could enhance vesicle controllability and their targetability to liver cancer cells.

Background: The onset of vitiligo during childhood is common. Limited data exist that compare the clinical associations of prepubertal and postpubertal vitiligo in Arabs. Objective: To compare the clinical profile of pre and postpubertal onset vitiligo. Methods: A cross-sectional observational study was conducted. The Vitiligo European Task Force questionnaire was completed for each patient. Results: A total of 375 patients were included; 199 had postpubertal vitiligo (>12 years), and 176 had prepubertal onset vitiligo (

Ingrown toenail (IGTN) is a common problem that can affect walking and can preclude daily activities.To compare the safety and efficacy of lateral nail avulsion with phenolization (LNAP) versus sleeve (nail tube splinting) surgical techniques in the treatment of IGTN.Patients older than 15 years with IGTN were included. Patients were evaluated for the duration and severity of pain, drainage, complete healing periods, recurrence rate, and overall success rate. Assessment was performed at baseline and at 1, 3, and 6 months. Complications were noted.A total of 53 patients, including 46 males (87.8%), were treated. The mean age was 27.7 ± 1.3 years. Thirty patients underwent LNAP, and 23 underwent sleeve methods. The surgical success rate, defined as90% improvement, was found to be 80% to 82% for both groups. Recurrence was observed in only 1 patient of each group. None of the observed differences in healing, discharge, and recovery were statistically significant except in reporting shoe-wear discomfort, which was shorter in the sleeve group (p.05). Postoperative pain experience was also noted to be less in the sleeve group (p = .057).Both methods, LNAP and sleeve, seem to be equally effective for the treatment of IGTNs. Postoperative shoe-wearing discomfort and pain are shorter when the sleeve method was used.

Background: A permanent, unpleasant atrophic leishmaniasis scar is a potentially disfiguring condition that causes social stigma with limited treatment choices. Fractionated carbon dioxide (CO2) laser resurfacing is expected to be a safe and effective treatment for leishmaniasis scars. Objective: To assess the safety and efficacy of ablative fractional resurfacing (AFR) with a CO2 laser for facial leishmaniasis atrophic scars. Methods: Eleven patients (five males, age 18–47 years) underwent the fractional CO2 laser procedure. The mean duration for scars was 18.3 years. Three to five treatment sessions with the fractional laser eCO2 (10,600 nm, Lutronic Corporation, Gyeonggi-do, Korea) were performed for each patient, at 2-month intervals, under topical anesthesia. Two passes (with tip type 120, density 150 spots/cm2 in static mode, and peak power of 30 watts) were performed on each leishmaniasis scar. Pulse energies ranged between 100 and 140 mJ. Posttreatment improvements in texture, atrophy, and overall satisfaction with appearance were graded on a quartile scale 1 month after the second session and 3 months after the final session. Scar improvement was graded using a 4-point score with a maximum score of 20. Results: At the 3-month posttreatment follow-up, all subjects were rated as having at least 50% improvement in texture, atrophy, borders, and overall appearance of scars. The median score of improvement was 18 of 20 (range 11–19). Mild postinflammatory hyperpigmentation was the only adverse effect, observed in 18% (2 of 11) of subjects. After the procedure, moderate to severe erythema and edema typically resolved within 24 to 48 hours. No additional adverse effects were observed. Conclusion: Fractional CO2 resurfacing represents a safe, effective, and well-tolerated potential treatment for atrophic facial leishmaniasis scars in ethnic skin.

BACKGROUND:: Varicose veins and the complications of venous disease are common disorders in humans. OBJECTIVE:: To study the effects of bleomycin as a potential new sclerosing agent and its adverse events in treating varicose veins. METHODS:: Bleomycin-loaded liposomes 0.1ml was injected in the dorsal ear veins of white New Zealand rabbits. Sodium tetradecyl sulfate was used as a positive control. Normal saline was used as negative control. The blood vessels of the treated ears were photographed before and at one hour and two, eight and 45 days after treatment. Biopsies from the treated areas were obtained for histological examination. Blood samples were collected to determine any possible toxicity. RESULTS:: Bleomycin by itself was ineffective; therefore, liposomes were used as a vector to deliver bleomycin to the vein lumen. Subsequently, bleomycin started showing its sclerosing effects. Toxicity monitoring showed no apparent hematologic, pulmonary, hepatic or renal toxicities. This study revealed that bleomycin induced vasculitis, which led to vascular occlusion, which was observed on day 1 and day 8. No bleomycin-related injury was noted by histopathological examination of lung sections. The calculation of the lung/body weight coefficient indicated that edema was present in the experimental groups compared with the negative and positive controls. STUDY LIMITATIONS:: Relatively small number of experimental animals used. CONCLUSIONS:: This study showed that bleomycin-loaded liposomes were able to induce vasculitis and vascular occlusion without any toxicity or complications. It might be useful, hence, to treat patients suffering from Varicose veins and other ectatic vascular diseases with this agent.

Background: Previous studies have discussed attitudes of vitiligo patients toward their disease. However, no studies have addressed this issue from the public's point of view. Objective: To explore the perceptions, attitudes, and misconceptions of the public toward vitiligo. Methods: A self-administered questionnaire was distributed to attendees of primary health care centers in Riyadh, Saudi Arabia, between January and August 2010. Results: Overall, 924 of the 1,000 distributed questionnaires were returned, and 429 were males (46.8%). Moreover, 33.1% (303 of 916) believed that vitiligo is contagious or did not know that it is not. The cause of vitiligo was thought to be infectious by 20.4% of respondents (182 of 894), inherited by 40.5% (365 of 902), autoimmune by 41.2% (370 of 899), and due to a lack of hygiene by 22.5% (199 of 883). Unmarried individuals and those with less education were more likely to state that vitiligo is caused by an infection ( p = .02, p = .03, respectively). Younger individuals and those with less education were more likely to think that vitiligo is caused by a lack of hygiene ( p = .01, p = .001, respectively). More than half of the participants (56.1%, 504 of 898) would be unwilling to marry a vitiligo patient. Younger individuals and males were less likely to marry a vitiligo patient ( p = .01, p = .05, respectively), whereas those of lower income were more likely to accept it ( p = .002). Conclusions: Various misconceptions and negative attitudes about vitiligo among the public are prevalent. Educating the public about vitiligo could ultimately lead to better psychosocial well-being of vitiligo patients. Contexte: Des études ont déjà porté sur la perception des personnes atteintes de vitiligo à l'égard de leur propre maladie, mais aucune étude n'a porté sur la perception du public à l'égard de cette maladie. Objectif: L'étude visait à analyser les perceptions, les attitudes, et les idées fausses du public à l'égard du vitiligo. Méthodes: Un questionnaire autoadministré a été remis à des personnes présentes dans des centres de soins primaires à Riyad, en Arabie saoudite, entre janvier et août 2010. Résultats: En tout, 924 questionnaires sur 1,000 ont été remis. Sur ce nombre, 429 avaient été remplis par des hommes (46.8%). De plus, 33.1% (303 sur 916) des répondants croyaient que le vitiligo était contagieux ou ne savaient pas qu'il ne l'était pas. Quant à la cause du vitiligo, 20.4% des participants (182 sur 894) croyaient que c'était une maladie contagieuse; 40.5% (365 sur 902), que c'était une maladie héréditaire; 41.2% (370 sur 899), que c'était une maladie auto-immune; et 22.5% (199 sur 883), que c'était une maladie due à un manque d'hygiène. Les personnes célibataires et celles moins instruites étaient plus portées à croire que le vitiligo était causé par une infection ( p = .02 et p = .03, respectivement). Les jeunes et les personnes moins instruites étaient plus susceptibles de croire que le vitiligo était causé par un manque d'hygiène ( p = .01 et p = .001, respectivement). Plus de la moitié des participants (56.1%, 504 sur 898) ne voulaient pas se marier avec une personne atteinte de vitiligo. Les jeunes et les hommes étaient moins disposés à se marier avec une personne atteinte de vitiligo ( p = .01 et p = .05, respectivement), tandis que ceux à faible revenu étaient plus susceptibles d'accepter le fait ( p = .002). Conclusions: Il existe plusieurs idées fausses sur le vitiligo au sein de la population, et la maladie suscite des réactions négatives. L'éducation du public sur le vitiligo pourrait peut-être améliorer le bien-être psychosocial des personnes atteintes de vitiligo.

Background: Plantar warts are common and often painful. Treatment of plantar warts is difficult and requires multiple treatments. Several clinical trials have proven the efficacy of bleomycin, but relatively high concentrations have been required and considerable side effects have been experienced. Objective: To evaluate the efficacy and safety of low-concentration (0.1 U/mL) bleomycin using a translesional injection technique for the treatment of plantar warts. Methods: The study included 23 patients with single or multiple plantar warts. Very low-concentration bleomycin was injected into a single wart or the largest plantar wart in the case of multiple lesions. Injections were performed at 4-week intervals until resolution of the warts or development of side effects. The translesional multipuncture technique was used. Results: Thirteen patients were male (56.5%), and the mean age was 27.7 years. The results revealed complete clearance of warts in 17 of 23 (74%) patients, partial response in 1 (4.3%) patient, and no response in 3 (13%) patients. Recurrence was observed in 2 patients at 3 months of follow-up. Among those two, one patient showed complete clearance after the second injection at 6 months of follow-up. All patients were followed for 6 months after the initial treatment. No significant long-term adverse effects were noted. Only three patients (13%) had localized moderate pain for 2 to 3 days after the injection. Conclusion: Translesional injection by very low-concentration (0.1 U/mL) bleomycin appears to be a simple, effective, and safe treatment modality for plantar warts.

BACKGROUND AND OBJECTIVES: Mycosis fungoides (MF) is a rare disease; and to our knowledge, there are no reports on its profile in Arabs. The objective of this study was to preliminarily analyze the clinical characteristics of MF patients seen in our institution. DESIGN AND SETTING: Retrospective review of 140 patients with pathologic or clinical diagnosis or differential diagnosis of MF for the period 2000-2006. PATIENTS AND METHODS: Pathology reports with diagnosis or differential diagnosis of MF were retrieved and suspected cases were identified and reviewed. For pathologically confirmed cases, sociodemographic, clinical, laboratory, and radiological details were collected. Details of staging, treatment modalities, and disease status at the last follow-up were retrieved. RESULTS: A total of 43 pathologically confirmed MF patients (skin phototypes IV and V) with a mean age at diagnosis of 33.5 years were reviewed. This comprised 29 males (M:F ratio, 2:1), and the majority (86%) of patients had early-stage (I and II) MF. Twenty-one (48.8%) patients had classic MF; 18 (41.8%), hypopigmented MF; and 4 (9.3%), other variants. The male-to-female ratio was higher in the hypopigmented (3.5:1) than in the classic variant (1.6:1). The mean age at diagnosis was lower in the hypopigmented compared to the classic variant (25 versus 38.8 years, P=.019). The mean duration of follow-up was 27.6 months (range, 1-98 months). At the final assessment, 4 (9.5%) patients recovered; whereas 35 (83.3%) had MF skin disease; 1 had (2.4%) extracutaneous disease; and 2 (4.8%) died of MF. CONCLUSIONS: MF tends to affect younger Saudi patients. The hypopigmented variant constitutes a significant proportion of MF cases, especially in younger patients.

Summary Background Until now, segmental vitiligo has been considered as a stable entity and mixed vitiligo, the association of segmental and nonsegmental vitiligo, has been reported rarely. Objectives The aim of this study was to search for factors associated with the generalization of vitiligo in patients with segmental vitiligo. Patients and methods This was a prospective observational study conducted in the vitiligo clinic of the Department of Dermatology of Bordeaux, France. The Vitiligo European Task Force questionnaire was completed for each patient attending the clinic with a confirmed diagnosis of segmental vitiligo after exclusion of other forms of vitiligo (focal, mucosal, not classifiable.) Thyroid function and antithyroid antibodies were screened if not obtained in the previous year. Results One hundred and twenty-seven patients were recruited: 101 had segmental vitiligo and 26 had segmental vitiligo that evolved into mixed vitiligo; 56 were male and 71 were female. Most patients had onset of segmental vitiligo before the age of 18. When conducting multivariate analysis, we found the following to be independent factors associated with the evolution of patients’ disease from segmental vitiligo to mixed vitiligo: initial percentage of body surface involvement of the segment > 1% [odds ratio (OR) 15·14, P = 0·002], the presence of halo naevi (OR 24·82, P = 0·0001) and leukotrichia (OR 25·73, P = 0·0009). Conclusions Halo naevi association and leukotrichia at first consultation in segmental vitiligo are risk factors for the progression of segmental vitiligo to mixed vitiligo. In addition, this progression of segmental vitiligo to mixed vitiligo carries a stronger link if initial segmental involvement is situated on the trunk.

Background: The details of phototherapy practices for vitiligo have been rarely studied. Objective: To explore the details of phototherapy practices for vitiligo among dermatologists. Methods: A self-administered questionnaire about the details of phototherapy practices for vitiligo was distributed to all dermatologists attending a national general dermatology conference in Riyadh, Saudi Arabia, in 2008. Results: Questionnaires were returned by 121 of 140 participants (response rate = 86.4%). The mean age of the respondents was 39.34 ΁ 9.7 years, and 65% were males. One hundred eight of 110 (98.2%) respondents provided phototherapy to their vitiligo patients. The mean number of vitiligo patients who underwent phototherapy each week per dermatologist's office was 18 ΁ 2.26. Narrowband ultraviolet B (NB-UVB) was the most common modality chosen to treat generalized vitiligo (84%). Excimer laser was the most common modality used to treat focal and segmental vitiligo (53% and 39%, respectively). Sixty-eight percent of dermatologists administered a fixed starting dose of NB-UVB to all patients, whereas 31% used the minimal erythema dose as a guide. Fifty percent reported that NB-UVB resulted in better color matching with the surrounding skin. Thirty-seven percent favored NB-UVB over psoralen + ultraviolet A for a faster response, and 31% preferred NB-UVB for a pigmentation that is more durable. Forty-seven percent (50/106) of the respondents limited the number of phototherapy sessions to reduce the risks of skin cancer. However, no respondent reported any skin cancer incidence in phototherapy-treated vitiligo patients. Conclusion: There is a need for phototherapy guidelines for the treatment of vitiligo in patients with skin of color.

Background Potent teratogenicity limits the use of isotretinoin among females of childbearing potential (FCBP). Objective To explore the current practice of dermatologists for pregnancy prevention when prescribing isotretinoin for FCBP. Materials and methods A self-administered questionnaire was distributed to 160 dermatologists attending a national conference in Riyadh, Saudi Arabia, in 2008. The survey was designed to capture the details of precautions taken by dermatologists to prevent pregnancy among isotretinoin users. Results Ultimately, 134 dermatologists completed the questionnaire (84% response rate). Their mean age was 39 ± 9.5 years. A total of 82 were female (65%). The median number of FCBP for whom isotretinoin was prescribed by each dermatologist during the previous 12 months was two (range from 0 to 30). Of the 792 total FCBP, seven were reported to have become pregnant (incidence rate of 8.8/1000) while on isotretinoin. Out of those seven, three women terminated the pregnancy (elective abortions: 42.7%). The majority of the dermatologists (79%) always obtained written consent and discussed teratogenic risks (98%); 44% provided written information about potential isotretinoin teratogenicity, and 30% offered printed information on contraception. Survey results also revealed that 62% recommended double contraception for FCBP, 60% always recommended pregnancy testing prior to therapy, but only 16% requested monthly pregnancy tests. In general, 62.4% avoided isotretinoin prescription to FCBP, which was independent of dermatologists’ gender, years of experience, or having a previous incident of isotretinoin-exposed pregnancy. Conclusion Some dermatologists still do not follow the recommendations for isotretinoin prescription to FCBP. This needs to be corrected, especially in countries with restrictions on abortion.

Background Patients’ beliefs about their illness can result in positive and/or negative implications for the management of their disease. To examine the beliefs held by vitiligo patients about their condition and to explore the potential factors that might influence such beliefs. Methods The illness perception questionnaire (IPQ) was translated into the particular regional language (Arabic) and administered to adult vitiligo patients visiting our Dermatology Department, from 2006 to 2008. Demographic and illness details were obtained. Results We recruited 164 vitiligo patients (91 male subjects). The mean age was 27 years (SD = 13, range 15–57 years). It was believed that stress, altered immunity, and heredity were the cause of vitiligo by 33%, 26%, and 24% of the respondents respectively. Eighty-four percent and 28% believed in fate and evil eye as a cause of their illness respectively. Fortytwo percent believed that their illness had a major effect on their lives and 44% believed that vitiligo had strongly affected the way others see them. For both beliefs, this was independent of the gender. Thirty-seven percent reported that they do not understand their illness. Six percent believed that their disease was contagious while 12% were not sure. Fifty-four and 57% reported feeling depressed and anxious respectively, because of their disease. This was more common in female patients (P = 0.019 and 0.031 respectively). Conclusion Misconceptions and negative attitudes are widespread among vitiligo patients. The lack of disease-related understanding and the existence of anxiety and depression require targeted health education and psychosocial support.

Background Although the practice of bleaching is common worldwide, there are few studies that discuss knowledge, attitudes and practices towards bleaching. Objective The aim of this study was to explore the knowledge, attitudes and practices towards the usage of topical bleaching agents among women. Methods A self-administered questionnaire on the use of bleaching creams was distributed randomly to women attending the outpatient clinics at a university hospital in Saudi Arabia during 2008. Results Five hundred and nine of 620 women responded (82% response rate). All the participants had dark skin (skin type 4–5). The mean age was 29.22 ± 9 years. Of the participants, 38.9% (197 ⁄506) were current users of bleaching agents. Only 26.7% (106 ⁄397) of the respondents used bleaching agents for medical purposes to treat localized abnormal skin hyper-pigmentation; 20.8% (101 ⁄485) were ready to use any bleaching cream that gives fast results, even if the components were unknown. Of the respondents, 30% (152 ⁄509) used more than 100 g of bleaching creams monthly. These products were applied to the whole body in 7.3% of the cases. While 10.3% (28 ⁄271) continued applying the bleaching products during pregnancy, 20.8% (54 ⁄260) did so during lactation. No associations could be found between the various sociodemographic variables and differences in the attitude towards and practice of using bleaching creams. Conclusion A major proportion of our sample respondents have overused and ⁄or misused bleaching agents. This was regardless of age, income, education or marital status. There is a need to educate women about the possible risks.

Background/Aim: There is scarce literature connecting vitiligo and primary open angle glaucoma (POAG). Most literature reports that secondary complications are a direct consequence of corticosteroid treatment of vitiligo. In this study, we aimed to investigate the prevalence of ocular problems in patients with vitiligo and to determine its association with periorbital topical corticosteroid use. Method: A cross-sectional study was carried out on 90 patients with vitiligo. The Vitiligo European Task Force questionnaire was completed for each patient. A control group comprising 90 healthy individuals who did not have vitiligo and who were matched on age and gender was used for comparison. A complete ophthalmologic examination was performed. A family history of glaucoma and the use of topical steroids were recorded. Results: Two (2/90, 2.2%) of the patients with vitiligo had glaucoma compared with none of the individuals in the control group ( P = .25). Nineteen of the 90 patients with vitiligo used periorbital steroids, and of these patients, 10.5% (2/19) developed glaucoma. The duration of periorbital corticosteroid use was 4.50 ± 2.1 years. Eighty-nine percent (17/19) of the vitiligo patients who applied the potent topical corticosteroid (class I) clobetasol propionate to the periorbital area did not develop glaucoma. In contrast, glaucoma was not observed in 79% (71/90) of the vitiligo patients who did not use steroids. Cataract, uveitis, or fundus problems were not observed in either group. Conclusion: The study suggests that patients who have vitiligo and use topical steroids periorbitally do not have an increased risk of glaucoma or cataracts. Future studies that have a larger sample size and use a detailed steroid use protocol are needed.

Background: Low vitamin D levels have been associated with several autoimmune diseases. Vitiligo could be associated with low vitamin D levels. Objective: To determine the level of serum vitamin D in vitiligo patients compared to controls and reveal the possible association of vitamin levels with the pathogenesis of vitiligo. Patients and Methods: A case-controlled study was conducted. After excluding factors that may affect serum vitamin D levels, blood samples were taken from vitiligo patients and controls. The association between vitamin D levels and various vitiligo subgroups (duration of vitiligo, site of onset, age, etc) was measured and correlated. Results: A total of 150 vitiligo patients, 90 (60%) males with a mean age of 30.6 ± 11.4 years, were recruited. The study also had 150 age- and gender-matched vitiligo-free control subjects. There was no significant difference in median serum vitamin D levels between the cases and the controls ( P = .25). The serum levels of vitamin D of the vitiligo patients were found to be lower in males ( P = .01), the younger age group ( P = .01), and patients not treated with ultraviolet (UV) treatment ( P = .01). Conclusion: There is no difference between the vitamin D levels of the vitiligo patients and the control subjects. However, deficiency of 25(OH)D levels within the vitiligo subgroups may be linked to younger age, male gender, short duration of vitiligo, and non-use of phototherapy.

Summary Lymphangioma circumscriptum is a rare lymphatic malformation that involves the skin and may extend to subcutaneous tissue and muscle. It usually presents as grouped micro- to macroscopic vesicles filled with lymph. Surgical excision has been the standard treatment, but it is associated with scarring, infection, injury to the surrounding structures, and a high recurrence rate. Herein, we report a 24-year-old male patient with a lymphangioma circumscriptum on the nape of the neck that was treated with two sessions of an intralesional injection of 1% sodium tetradecyl sulfate sclerotherapy with a very good result. After this treatment, there was no more discharge and a reduction in the lesion’s size by 70%. Sclerotherapy using sodium tetradecyl sulfate can be considered a successful minimally invasive treatment option for lymphangioma circumscriptum.

The aim of this study was to investigate the effects of different low-level laser therapies (LLLTs) of various wavelengths and energies on normal cultured human melanocytes. Various studies have shown the effects of LLLs on various types of cultured cells. Presently, little is known about the biological effects of LLLTs on melanocytes. Melanocytes were exposed to LLLT at 0.5, 1.0, 1.5, 2.0, 2.5, 3.0, 3.5, 4.0, 4.5, or 5.0 J/cm(2) using a blue (457 nm), red (635 nm), or ultraviolet (UV) (355 nm) laser. Melanocyte viability, proliferation, and migration were monitored at 72 h after irradiation. The blue (P 0.001) and red (P 0.001 and P 0.01) lasers significantly enhanced viability at 0.5 to 2.0 J/cm(2), whereas the UV laser (P 0.001) could significantly enhance viability only at 0.5 and 1.0 J/cm(2) compared with controls. The blue and red lasers also significantly enhanced the proliferation of the melanocytes at 0.5 to 2.0 J/cm(2) (P 0.001), and the UV laser significantly enhanced proliferation at 0.5 to 1.5 J/cm(2) (P 0.001 and P 0.01) compared with controls. The blue laser significantly enhanced melanocyte migration at 0.5 to 4.0 J/cm(2) (P 0.001 to P 0.05), but the red (P 0.001 and P 0.01) and UV (P 0.001 to P 0.05) lasers could significantly enhance such migration at 0.5 to 1.0 J/cm(2) and 0.5 to 2.0 J/cm(2), respectively, compared with controls. LLLT at low energy densities is able to significantly increase melanocyte viability, proliferation, and migration in vitro, and at higher energy densities, it gives non-stimulatory results. Additionally, the blue laser was the best among the three lasers. These findings might have potential application in vitiligo treatment in future.

Lauren V. Ackerman coined the name verrucous carcinoma (VC) for an uncommon low-grade squamous cell carcinoma of the oral cavity. It is characterized by a slowly enlarging warty tumor with a locally destructive behavior and minimal if any metastasis. Through the years similar tumors have been described in other locations. According to the anatomic localization, four types are now recognized: (1) VC of the oral cavity known as Ackerman’s tumor or oral florid papillomatosis; (2) VC of the anogenital area also known as giant condyloma of Buschke and Lowenstein or warty squamous cell carcinoma; (3) VC of the soles also known as epithelioma cuniculatum (EC); and (4) VC at other sites.

Vitiligo is a common pigmentary disorder caused by the destruction of functional melanocytes. Vitamin D is an essential hormone synthesized in the skin and is responsible for skin pigmentation. Low levels of vitamin D have been observed in vitiligo patients and in patients with other autoimmune diseases. Therefore, the relationship between vitamin D and vitiligo needs to be investigated more thoroughly. We reviewed the literature to date regarding the role of vitamin D in skin pigmentation. Our review revealed that vitamin D deficiency has been identified in many conditions, including premature and dysmature birth, pigmented skin, obesity, advanced age, and malabsorption. Vitamin D increases melanogenesis and the tyrosinase content of cultured human melanocytes by its antiapoptotic effect. However, a few growth-inhibitory effects on melanocytes were also reported. Vitamin D regulates calcium and bone metabolism, controls cell proliferation and differentiation, and exerts immunoregulatory activities. Vitamin D exerts its effect via a nuclear hormone receptor for vitamin D. The topical application of vitamin D increased the number of L-3,4-dihydroxyphenylalanine-positive melanocytes. The topical application of vitamin D yields significant results when used in combination with phototherapy and ultraviolet exposure to treat vitiligo in humans. Vitamin D decreases the expression of various cytokines that cause vitiligo. In conclusion, application of vitamin D might help in preventing destruction of melanocytes thus causing vitiligo and other autoimmune disorders. The association between low vitamin D levels and the occurrence of vitiligo and other forms of autoimmunity is to be further evaluated.

To compare factors associated with halo nevi with nonsegmental vitiligo (NSV) vs NSV alone.Prospective observational study in 553 patients with a confirmed diagnosis of NSV attending a vitiligo clinic between January 1, 2006, and July 1, 2010.Vitiligo Clinic at the Department of Dermatology, University Hospital Center of Bordeaux, Bordeaux, France.The Vitiligo European Task Force questionnaire was informed for each patient attending the clinic with a confirmed diagnosis of NSV after the exclusion of other forms of vitiligo (focal, mucosal, and not classifiable). Thyroid function and antithyroid antibodies were screened if not obtained in the previous year.Extent of disease and markers of autoimmunity or autoinflammation.Of the 553 patients, 130 had halo nevi-NSV and 423 had NSV. Family history of premature hair graying (odds ratio, 1.74; P.01) was positively associated with halo nevi-NSV by univariate analysis. Using multivariate analysis, age at onset younger than 18 years, phototype, total body area, localization on the trunk, involvement of hands and feet, and total staging were found to be independent factors. Age at onset younger than 18 years; phototypes I, II, and III; trunk involvement; and staging were positively associated with halo nevi-NSV, whereas this association was negative for total affected area and involvement of hands and feet.Halo nevi association in NSV affects age at onset and depigmentation pattern and has a stronger link with familial premature hair graying, suggesting that premature hair graying may involve, at least partly, an autoimmune pathway.

There is no standardized method for assessing vitiligo. In this article, we review the literature from 1981 to 2011 on different vitiligo assessment methods. We aim to classify the techniques available for vitiligo assessment as subjective, semi-objective or objective; microscopic or macroscopic; and as based on morphometry or colorimetry. Macroscopic morphological measurements include visual assessment, photography in natural or ultraviolet light, photography with computerized image analysis and tristimulus colorimetry or spectrophotometry. Non-invasive micromorphological methods include confocal laser microscopy (CLM). Subjective methods include clinical evaluation by a dermatologist and a vitiligo disease activity score. Semi-objective methods include the Vitiligo Area Scoring Index (VASI) and point-counting methods. Objective methods include software-based image analysis, tristimulus colorimetry, spectrophotometry and CLM. Morphometry is the measurement of the vitiliginous surface area, whereas colorimetry quantitatively analyses skin colour changes caused by erythema or pigment. Most methods involve morphometry, except for the chromameter method, which assesses colorimetry. Some image analysis software programs can assess both morphometry and colorimetry. The details of these programs (Corel Draw, Image Pro Plus, AutoCad and Photoshop) are discussed in the review. Reflectance confocal microscopy provides real-time images and has great potential for the non-invasive assessment of pigmentary lesions. In conclusion, there is no single best method for assessing vitiligo. This review revealed that VASI, the rule of nine and Wood’s lamp are likely to be the best techniques available for assessing the degree of pigmentary lesions and measuring the extent and progression of vitiligo in the clinic and in clinical trials.

Background The use of lasers is very common in dermatology; however, many patients fear it and have various misconceptions about it. A literature search failed to show any studies on this topic. Objective To explore the various misconceptions of patients about lasers in dermatology. Methods A self-administered questionnaire containing 21 questions about laser use in dermatology was distributed randomly to patients attending the dermatology clinic at King Khalid University Hospital in Riyadh, Saudi Arabia, from February to April 2009. Results The response rate was 79.3%, with 714 of the 900 distributed questionnaires being returned; the individuals sampled included 348 men (48.73%). When asked about the nature of laser, 40% (279 of 698) reported that they did not know. About 36% (251 of 698) knew it was radiation of stimulated light amplification, while 10.2% (71 of 698) reported it to be nuclear radiation. Among study participants, 51.5% (364 of 707) believed that laser was harmful to children, while 51.1% (357 of 699) believed it was unsafe during pregnancy, and 21.4% (146 of 683) thought it could cause skin cancer. Laser was believed to treat most skin diseases by 47.7% (330 of 692) of those interviewed, among whom 24.1% said that they would not accept laser treatment if it was suggested to them by a dermatologist. A stance against laser (16.3%) was most common among men (P < 0.001), the illiterate (P = 0.006), and those with lower education (P = 0.001). Conclusion Various misconceptions about laser treatment among patients are prevalent, especially among less educated individuals. Educating the community about laser could solve this problem.

Background: Vitiligo is a depigmentation disorder caused by melanocyte destruction that possibly results from an autoimmune mechanism. Psoriasis is an immune-mediated, chronic, inflammatory dermatosis. Although tumor necrosis factor α antagonists (anti-TNF-α), such as infliximab, are effective in treating psoriasis, many cases reported in the literature indicate that psoriasis might also be induced by treatment with infliximab. Some studies also suggest that TNF-α antagonists might be an effective treatment for vitiligo because the disorder is characterized by increased levels of TNF-α, indicating that it might play a role in the pathogenesis of this disease. Objective: We report a case of psoriasiform dermatitis with vacuolar interface reaction that occurred after infliximab therapy in a patient with vitiligo. Method: A 17-year-old male patient with vitiligo vulgaris was treated with an intravenous infusion of 5 mg/kg of infliximab at 0, 2, and 6 weeks and then once every 6 weeks over a span of 6 months. The patient was monitored both clinically and with laboratory investigations. He had no personal or family history of psoriasis. He tolerated the treatment well, without side effects. However, he developed a biopsy-proven psoriasiform lesion for the first time 4 months after he completed his sixth dose of infliximab. His vitiligo also worsened. Conclusion: This case report shows that infliximab given for vitiligo did not improve the disorder and that the vitiligo actually progressed. Moreover, psoriasiform lesions developed after this therapy. Further studies are needed to identify the effects of infliximab in patients with vitiligo.

Background: Punch instrument is a circular blade that can be used for many diagnostic and therapeutic purposes in different medical and surgical specialties. Punch surgery (or biopsy) is achieved by using this versatile punch blade under local anesthesia. Basic punch surgery is quick and easy to learn. Complications such as bleeding and infection are minimal. Diagnostic punch surgery can obtain a part of or whole skin lesion for histologic examination. In addition to the skin, nail and mucous membrane tissue can be obtained by punch biopsy. Interestingly, punch biopsy can be used as an adjunctive to fine-needle aspiration to establish the diagnosis of tumors of solid organ such as the breast. Diagnostic punch surgery can be modified to overcome certain problems. The split-punch technique helps avoid crushing the tissue punch when trying to divide it for different examinations. The double-trephine punch facilitates obtaining subcutaneous tissue without the need for full elliptical excision. The string-of-beads technique obviates the need for dissection of tissue into pieces. In other nondermatology and dermatology conditions, such as nerve pathology, arteriosclerosis, melanoma mapping, and eyelid tumors, the diagnosis can be enhanced with the use of punch surgery. Therapeutic punch surgery can be used for excision of unwanted lesions such as nevi, as well as pathologic bone and cartilage tissues. Punch grafting is used in vitiligo surgery and hair transplantion. Punch evacuative surgery can help in the evacuation of unwanted tissue or materials such as lipoma, subungual hematoma, scrotal calcinosis, pseudocyst of the auricle, pilar cyst, and others. Reconstructive punch surgery includes correction of ear lobe defects and acne scars. Enhancement of wound healing can be achieved by use of the punch; therefore, it can help nonhealing ulcers.

Background: Cutaneous leishmaniasis can lead to unsightly atrophic scars, which have limited treatment options. There is a scarcity of literature on its treatment modalities. Fractional lasers have been successfully used in treating a variety of skin conditions with minimal downtime and side effects. Methods: We report a successful treatment of a 25-year-old female patient with an atrophic scar from cutaneous leishmaniasis on the nose with a fractional laser (Fraxel Re:store SR 1500). Ten treatment sessions were performed at a pulse energy of 45 to 70 mJ. The treatment response was assessed by comparing pre- and posttreatment clinical photographs. Results: After three sessions, the patient observed 40% improvement. More than 90% improvement was noticed after the tenth session. No significant adverse effects were noted. The improvement was persistent at the 3-month follow-up. Conclusion: The excellent improvement in this patient should encourage further studies to achieve more efficacy and optimize the treatment parameters.

Background There are concerns that there is no uniform approach towards the management of vitiligo. Objectives To explore attitudes and strategies for the management of vitiligo among dermatologists. Methods A self-administered questionnaire containing 22 questions was distributed to 160 dermatologists attending a national dermatology conference in 2007. Results One hundred and twelve dermatologists responded to the questionnaire (70% response rate). We had 105 completed questionnaires (seven were excluded due to incompleteness). Active treatment of vitiligo was recommended by 96% in more than half of patients, while 79% recommended treatment at non-visible sites. Repigmentation was regarded as main treatment goal by 54%. Mid-potent topical steroids were widely prescribed for focal vitiligo (72% in children and 65% in adults). Use of tacrolimus and pimecrolimus was limited. The most common used phototherapy was ‘narrowband ultraviolet B’ (NBUVB; 36% and 40% for generaliased vitiligo in children and adults, respectively). The use of oral psoralen plus UVA (PUVA) was limited (8% for generalized vitiligo in adults). Few respondents (1–8% for different types of vitiligo) prescribed outdoor topical PUVA. Vitiligo surgery was advised mainly for segmental type (18% in adults and 5% in children). Depigmentation was the first option for universal vitiligo by 50% and 30% in adults and children, respectively. Conclusions Most dermatologists are enthusiastic about active treatment of vitiligo even in hidden sites. Overall, the most two common treatment modalities were topical steroids and NBUVB. Vitiligo surgery is underutilized. Development of national practice guidelines is needed.

In 1974, Shulman et al. reported two patients with scleroderma-like skin changes, peripheral eosinophilia and hypergammaglobulinemia.1 This disorder was initially distinguished from progressive sys...

Dear Editor Vitiligo is a disorder of depigmentation resulting from the destruction of melanocytes in the epidermis. The incidence of vitiligo is 0.5–2% worldwide (Dell’anna and Picardo, 2006). Although the exact etiology of vitiligo remains unclear, autoimmunity is currently recognized as one of the most likely pathogenic mechanisms (Kemp et al., 2001). Moreover, some studies provided evidence that in vitiligo skin a significantly higher expression of TNF-α was detected, compared with perilesional, non-lesional and healthy skin (Birol et al., 2006). Thus, it seems that TNF-α is a key step in the development of vitiligo (Birol et al., 2006). Methotrexate (MTX), is an antimetabolite and antifolate drug. Methotrexate (MTX), is an antimetabolite and antifolate drug. It is used in the treatment of cancer, autoimmune diseases, ectopic pregnancy, and for the induction of medical abortions (Dell’anna and Picardo, 2006). It acts by inhibiting the metabolism of folic acid. It is used as a treatment for some autoimmune diseases including: psoriasis and psoriatic arthritis, Crohn’s disease, and rheumatoid arthritis (Dell’anna and Picardo, 2006). It has also been used for multiple sclerosis (Dell’anna and Picardo, 2006). It was shown in one study that methotrexate treatment results in a decreased number of T cells capable of TNFα production, whereas the number of T cells producing IL-10 after polyclonal activation increased (Rudwaleit et al., 2000). Methotrexate possibly suppresses TNFα-induced NF-κB activation (Majumdar and Aggarwal, 2001). There is only one case report in the literature about the effect of MTX on vitiligo. In that report, a 54-year-old female patient with a 10-year history of rheumatoid arthritis presented with a 6 month history of rapidly progressing vitiligo lesions over trunk and limbs. She was started on a once weekly dose of 7.5 mg methotrexate. At three months follow up after starting methotrexate her arthritis had improved and it was noticed that she had stopped developing new depigmented lesions, The rapid spread of depigmentation had ceased and there was considerable repigmentation of the existing vitiligo lesions (Sandra et al., 1998). Methotrexate has been reported to be useful in other auto-immune disorders like pemphigus (Lever and Goldberg, 1969). Hence in rapidly progressing unstable vitiligo short courses of methotrexate may help in stopping progress and bringing the disease process under control. Based on this, we conducted a pilot prospective study to evaluate the effects of MTX on vitiligo. All patients signed an informed consent and the study protocol was approved by the local ethics committee. Six vitiligo patients with an average age of 29 years were recruited. Full details of patients are shown in Table 1. All were having vitiligo involving more than 6% of the body surface area. Pre-treatment blood tests were normal (full blood count, biochemistry including liver function test and chest X-ray). Liver ultrasound was done to assess baseline liver status. Table 1 Summary of six vitiligo patients treated by Methotrexate. All the patients received MTX for 6 months and assessed at 0, 1, 3, 6 and 9 months. All the six patients received 25 mg dose per week with folic acid 5 mg daily except the day on which they took MTX. Clinical and photographic assessments revealed no change in their vitiligo lesions. No patient withdrew from the course and none of the patient discontinued the therapy. The Methotrexate therapy was well tolerated and no side effect was noted. Follow up laboratory investigations, chest X ray and liver ultrasound were normal. To date, we did not come across in the literature, any study done on MTX use in vitiligo patients except the case report mentioned above (Sandra et al., 1998). It is true that this is a small uncontrolled pilot study and further controlled trials are probably warranted to evaluate the use of methotrexate in vitiligo, notwithstanding the fact that no clinical improvement in vitiligo with the use of methotrexate was evident for the first time in our study.

Background: Many international studies have been conducted to assess the knowledge, attitudes and practices (KAP) of the public toward sun exposure and sun-protection measures. However, there are scarce data on these factors from the Middle East. Objectives: This study aimed to explore the KAP of the public toward sun exposure and sun-protection measures among Saudis. Methods: A cross-sectional survey using a specially designed questionnaire was conducted on a stratified random sample of the general population in the five geographical regions of Saudi Arabia (central, eastern, northern, southern, and western). Data were collected between October 2010 and March 2011. Multiple logistic regressions were applied to relate the use of sunscreen and skin cancer awareness with various socio-demographic variables. Results: The questionnaire was distributed to 2900 Saudis. A total of 2622 questionnaires were completed, returned, and included in the data analysis, corresponding to a response rate of 90.4%. The mean (SD) age of respondents was 27.8 ± 9.7 years. Fifty percent (1301/1601) of the respondents were males. Fifty-five percent (1406/2544) were aware of the association between sun exposure and skin cancer. Female, young and student respondents were more likely to be aware of the connection between sun exposure and skin cancer (p

Background Middle Eastern Respiratory Syndrome coronavirus (MERS-CoV) is a poorly understood disease with no known treatments. We describe the clinical features and treatment outcomes of patients with laboratory confirmed MERS-CoV at a regional referral center in the Kingdom of Saudi Arabia. Methods In 2014, a retrospective chart review was performed on patients with a laboratory confirmed diagnosis of MERS-CoV to determine clinical and treatment characteristics associated with death. Confounding was evaluated and a multivariate logistic regression was performed to assess the independent effect of treatments administered. Results Fifty-one patients had an overall mortality of 37 %. Most patients were male (78 %) with a mean age of 54 years. Almost a quarter of the patients were healthcare workers (23.5 %) and 41 % had a known exposure to another person with MERS-CoV. Survival was associated with male gender, working as a healthcare worker, history of hypertension, vomiting on admission, elevated respiratory rate, abnormal lung exam, elevated alanine transaminase (ALT), clearance of MERS-CoV on repeat PCR polymerase chain reaction (PCR) testing, and mycophenolate mofetil treatment. Survival was reduced in the presence of coronary artery disease, hypotension, hypoxemia, CXR (chest X-ray) abnormalities, leukocytosis, creatinine >1 · 5 mg/dL, thrombocytopenia, anemia, and renal failure. In a multivariate analysis of treatments administered, severity of illness was the greatest predictor of reduced survival. Conclusions Care for patients with MERS-CoV remains a challenge. In this retrospective cohort, interferon beta and mycophenolate mofetil treatment were predictors of increased survival in the univariate analysis. Severity of illness was the greatest predictor of reduced survival in the multivariate analysis. Larger randomized trials are needed to better evaluate the efficacy of these treatment regimens for MERS-CoV.