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Chronic idiopathic urticaria (CIU) is one of the mysteries of dermatology. An association between spontaneous CIU and contact allergy sensitization is possible. In this study, we aimed to test the hypothesis that contact allergy might play a role in disease in CIU patients. Furthermore, we examined if patch testing should be routinely performed in patients with chronic urticaria (CU). Ultimately, we concluded that patch testing should be included among the diagnostic procedures for CU.

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/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.

Background:Little is known about the prevalence and practice of complementary and alternative medicine (CAM) among dermatology patients in the Arab world. The aim of this study was to determine knowledge and attitudes about CAM, prevalence of its use, reasons for its use, and types of CAM used in dermatology patients in Saudi Arabia.Methods:This was a national survey of various regions of Saudi Arabia. In this cross-sectional study, dermatology outpatients were interviewed using a questionnaire. Sociodemographic characteristics, acceptability, utilization pattern, and reasons for CAM use were elicited. Dermatology life quality index (DLQI) was obtained.Results:Overall, 1901 patients returned complete questionnaires out of 2500 distributed (76% response rate). Of these, 808 (40%) were CAM users, and the majority were woman (55.1%), with a mean age of 31.6 ± 12 years. Most were literate (71.2%) and just over half were married (51.9%). Patients with acute skin diseases were found to be more likely to use CAM ( P = .027). The mean DLQI score was higher (worse quality of life) among CAM users than among nonusers ( P = .002). The results showed that 315 of 801 (40%) and 250 of 601 (30%) CAM users agreed that CAM methods are safer and more effective than modern medicine, respectively, and 83% will continue to use CAM in future. The most commonly used CAM modalities were vitamins, prayers, natural products, and herbs. Responses indicated that 379 of 803 (47.2%) CAM users did not consult their doctor before using CAM, and 219 of 743 (30%) did not obtain sufficient answers regarding CAM use from their dermatologists.Conclusions:There is a significant use of CAM among dermatology outpatients in Saudi Arabia. In view of the common belief that CAM has fewer side effects than conventional medicine, dermatologists need to increase their awareness of CAM.

Although the exact pathogenesis of vitiligo is not fully understood, it appears to be an autoimmune disease. It is hypothesized that tumor necrosis factor alpha (TNF-?) plays an important role in vitiligo. TNF-? can destroy melanocytes through the induction of various apoptotic pathways. In addition, TNF-? can inhibit melanocyte stem cell differentiation.To evaluate the efficacy and safety of treating vitiligo patients with anti-TNF-? agents.A total of 6 patients were recruited. All patients had widespread non-segmental vitiligo. Biologics, including infliximab, etanercept, and adalimumab, were given according to treatment regimens used for psoriasis. Photographs were taken at the initial visit, every two months during the therapy and then six months after therapy completion.All patients completed the treatment; two patients were treated with infliximab, two with etanercept, and two with adalimumab. All of the biologics were well tolerated throughout the treatment period, and none of the patients reported any significant adverse events. Digital images were compared before, during and after treatment. Repigmentation of the vitiliginous areas was not observed in any of the patients. Vitiligo worsened in one patient who was treated with infliximab and developed a psoriasiform rash. However, the remaining patients did not develop any new depigmented patches during treatment or at the six-month follow-up; vitiligo was considered stable in these five patients.Although the anti-TNF-? agents were well tolerated in all six vitiligo patients, efficacy was not observed. Further evaluation with larger studies may be required.

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.

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.