Introduction: Scientific research suggest that the more severe psoriasis symptoms are the poorer quality of life. Reviews show that appropriate health practices can reduce severity of symptoms of some diseases on the one hand and influence subjective assessment of quality of life on the other hand. The authors tried to assess the frequency of health behaviors in patients with psoriasis compared to the control group, as well as to analyze the relationship between health behavior and the quality of life. Materials and Methods: The study was conducted on 61 patients with psoriasis and 60 respondents as a control group. Two tools were used in the study: Behavioral Health Inventory and author’s questionnaire with questions concerning quality of life, satisfaction with health condition, number of medicines used and severity of psoriasis. Statistical analyzes were performed using Statistica SPPS 18. Results: Patients with psoriasis assessed as worse their quality of life compared to the control group. In case of intensity of healthy eating habits the similar differences were revealed. Inverse relation was observed in case of prevention behaviors. There were no differences between the groups in terms of positive mental attitude and health practices. Quality of life in patients with psoriasis correlated with a positive mental attitude. Conclusions: Our results suggest the need for comprehensive education in three areas: medical, nutritional and psychosocial.

Introduction: Previous studies from India concluded that the incidence of cutaneous tuberculosis has fallen from 2% to 0.15%, whereas more recent reports suggest that cutaneous tuberculosis is again becoming more prevalent. Aims: To study the patterns of clinical presentation of cutaneous tuberculosis, to correlate them with histopathology, Mantoux reactivity and BCG vaccination status in the north-west region of Punjab. Methods: Analysis of the records of patients with cutaneous tuberculosis who attended the hospital between Jan 2009 to Dec 2012. Results: A total of 36 (0.02%) of dermatology patients had cutaneous tuberculosis. The type of cutaneous tuberculosis in decreasing order of incidence was lupus vulgaris 16 (44.44%) followed by tuberculosis verrucosa cutis 10 (27.77%), scrofuloderma 7 (19.44%) and tuberculids 3 (8.33%). There were no cases of erythema nodosum or miliary tuberculosis. Multiple sites were involved in 17 (47.22%) patients. Face and neck were the most common sites affectedMost of the patients (52.77%) presented with single lesion. Active tuberculosis in other organs were observed in 8 (22.22%) patients. Mantoux test was positive in 23 (63.88%). BCG scar was present in 23 (63.8%) patients. 29 cases (80.55%) showed characteristic histopathological changes of cutaneous tuberculosis. Conclusions: The incidence of cutaneous tuberculosis in the present study was found to be 0.02% which is far lower as compared to previous reports. Reason for this observation could be the effective implementation of the National Program for tuberculosis at primary and secondary level leading to early diagnosis and treatment, hence lesser number of cases reaching to a tertiary center. This study also depicts the histopathological correlation evident in 80.55% of the histopathological specimens which is highly significant.

Although it is a “disease of antiquity”, nicely described by Kaur T et al, tuberculosis is still a challenge in the modern medicine. The authors highlighted the role of HIV coinfection, but we don’t have to forget about the role of anti-TNF therapies (widely prescribed nowadays) in reactivating tuberculosis infection, especially in endemic regions [1]. Another important point that we could observe here is the important number of cases with a negative Mantoux test (approximately 36%).

Introduction: The treatment of patients with plantar warts continues to be a frustrating matter for both primary care physicians and dermatologists. There are new trends towards the use of immunotherapy in treatment of warts, as the immune system seems to play an important role in the control of warts infection. Aim: Assessing the efficacy of intralesional injection of MMR vaccine (measles, mumps, rubella) in the treatment of plantar warts. Patients: One hundred patients complaining of plantar warts were included in this study. Methods: The patients were divided into two groups: Group 1: This group included 50 patients subjected to intralesional injection of measles, mumps, rubella vaccine (MMR). Group 2: This group included 50 patients as a control group and subjected to intralesional injection of 0.3 ml saline. Only single wart was injected. Injections were done at 3-weeks interval until complete clearance or for a maximum of 3 treatments. Follow up of patients was done every month for six months for clinical assessment of results and to show any recurrence. Results: Regarding the response of the target wart, MMR- treated group showed significantly higher rate of complete clearance compared with the control group (82% versus 0% respectively). The rate of partial response was 6% versus 30%, and the rate of no response was 12% versus 70%, respectively. Regarding the response of untreated distant warts, MMR-treated group showed 86.9% complete and 13.1% partial clearance of the warts whereas the control group showed 100% no response. This strongly indicates the development of a widespread HPV-targeted immunity as a response of antigen injection and represents a major advantage of the intra lesional immunotherapy. Conclusions: We found that treatment of plantar warts by MMR vaccine is effective, with good cure rates and excellent safety profile.

Objective: To study the genetic polymorphism of 5-α reductase type II enzyme in relation to oxidative stress in cases of androgenetic alopecia (AGA) in a sample of Egyptian population. Materials and Methods: This study was conducted on 45 patients with different grades of AGA,and 45 healthy subjects as control group. Laboratory tests included DNA extraction from blood, amplification of the 5-α reductase type II by PCR and V89L mutation analysis by restriction endonuclease enzyme Rsa?, and estimation of the levels of plasma catalase and erythrocyte lysate superoxide dismutase (SOD) enzymes by colorimetric methods. Results: The studied subjects carrying the homozygote( LL) and the heterozygote (VL) genotypes were of no risk of developing AGA.(OR=0). Regarding the leucine allele, the studied subjects carrying the (L) allele were at about 3.7 higher risk of AGA .(OR=3.692), and the results were statistically significant (p<0.001). There was significant increase in the level of SOD and catalase in patients than in control group(p=0.005),and (p<0.001) respectively,plasma catalase is significantly higher in patients with LLvariant than inVL variant (p=0.020). Asignificant relations was found between the severity of the disease and age and family history (p=0.037), and (0.036) respectively, there was no significant correlation between the level of catalase enzyme and SOD in one hand and the severity of the disease among patients. Conclusions: There is a possible association between AGA and V89L genetic polymorphism of 5-alpha reductase type II enzyme, patients carrying the mutant leucine (L) allele have a risk for developing AGA. Also there is possible association between AGA with oxidative stress.

I would like to thank Omar and colleagues for drawing our attention to genetics of androgenetic alopecia (AGA). Although it is one of the most common dermatological problems, current treatment strategies are limited and their effectiveness remains modest at best. In V89L polymorphism, leucin is inserted in the 5 alpha reductase enzyme type II instead of valine amino acid.

Introduction: The in situ immune response within skin biopsies from patients affected by autoimmune skin blistering diseases (ABDs) is not well characterized. Aim: Based on the fact that the ABD immune response is considered an adaptive immune response, both an innate immune response and inflammation would be expected in these diseases. Our investigation investigates the presence of cyclo-oxygenase-2 (COX-2), since this enzyme is commonly involved in innate immune responses. Methods: We utilized immunohistochemistry (IHC) to evaluate the presence of COX-2 in lesional skin biopsies of patients affected by ABDs. We tested 30 patients with endemic pemphigus foliaceus (EPF), 15 controls from the endemic area, and 15 biopsies from healthy controls from the USA. We also tested archival biopsies from patients with selected ABDs, including 20 patients with bullous pemphigoid, 20 with pemphigus vulgaris, 8 with pemphigus foliaceus and 12 with dermatitis herpetiformis. Results: Most ABD biopsies stained positive for COX-2 in the lesional blister and/or the dermal inflammatory infiltrate, accentuated in the upper neurovascular plexus. In BP and EPF, the COX-2 staining was also seen in the sweat glands. All controls were negative. Conclusions: We document that COX-2 is expressed in lesional skin of patients with ABDs.

Introduction: La pellagre est une carence en vitamine PP qui regroupe l’acide nicotinique ou niacine et le nicotinamide. Elle est encore fréquente dans notre pays. Le but de cette étude était de décrire les aspects épidémiologiques et cliniques de la pellagre dans la région Ouest du Burkina Faso. Patients et Méthodes: Il s’est agi d’une étude rétrospective, descriptive à partir des dossiers des patients ayant consulté ou ayant été hospitalisés dans les services de dermatologie-vénéréologie et de psychiatrie à Bobo-Dioulasso, de 2005 à 2012. Résultats: Durant la période, 223 cas de pellagre ont été enregistrés. L’âge moyen des patients était de 37,7+17,2 ans avec des extrêmes de 6 et 85 ans et un sex-ratio de 1/3. Ces cas ont été observés dans les zones aussi bien rurales qu’urbaines de l’Ouest du Burkina Faso. Les femmes étaient les plus atteintes (76,7%), particulièrement les femmes au foyer (47,1%). Les formes ulcéreuses représentaient 6,3% des cas, les atteintes neurologiques 62% et la diarrhée chronique (6,5%). Trois patients sont décédés (1,3%). Conclusion: La pellagre est une affection fréquente chez les femmes dans l’Ouest du Burkina Faso où le maïs constitue la céréale de base dans l’alimentation des populations. Les formes ulcéreuses pouvaient égarer le diagnostic. Une sensibilisation de la population est indispensable pour prévenir cette affection.

Neutrophilic myositis is an extremely rare condition, cases of which have been reported in association with neutrophilic dermatosis, inflammatory bowel disease and malignant hematological disease. The disorder is histologically characterized by a sterile infiltration of neutrophils throughout muscle, with necrosis of muscle fibres. We here report the case of a young male who also had associated pyoderma gangrenosum, and who presented with necrotizing fasciitis-like manifestations. In this case, although there were no other underlying disorders, compulsive exertional stress due to break-dancing was thought to be a precipitant. Debridement of the necrotic tissues combined with oral corticosteroid treatment was effective.

Introduction: Highly active antiretroviral therapy (HAART) is a standard treatment for HIV-infected patients. It has been reported that emtricitabine rarely induces skin pigmentation in the palms and soles. We herein report a Japanese case which presented a number of small pigmented patches on the acral sites. Main observation: A 58-year-old Japanese man complained about multiple brownish skin pigmentations on his both palms and soles after 2 months of HAART therapy. Dermatoscopic observation showed a homogeneous light brown pattern. In spite of continuance of HAART, these lesions spontaneously regressed within 11 months. Conclusion: We should know about the eruptive pigmented patches as an adverse effect under HAART with HIV infected patients.

The article is extremely interesting because has touched on the problem of neutrophilic dermatoses. Pyoderma gangrenosum has revealed as uncommon (ex. 1: 100000 person a year in United States), ulcerative cutaneous condition of uncertain etiology with known pathergic phenomenon. Slight female predominance is observed. The disease occurs mostly in 40-50 years of age.

“Werner’s syndrome” or premature aging syndrome is a rare autosomal recessive genetic disease. It is responsible of several complications related to age, including atherosclerosis and association with cancer. We report the case of a 36 year-old-patient, admitted to department of Internal Medicine of the military hospital of Tunis for suspicion of systemic sclerosis. The patient had all the major signs of Werner syndrome (bilateral cataract, sclerotic skin, “bird face”, baldness, small size, parental consanguinity) and 4 minor signs (type 2 diabetes, hypogonadism, squeaky voice, and flat feet). She has also a brother with the same morphotype died at the age of 32 by a myocardial infarction. The current follow-up time is 9 years.

Xeroderma pigmentosum is a autosomal recessive genetic disorder in which cutaneous malignancies are very common. We report a rare case where four different varieties of cutaneous malignancies were seen in the same patient.

The autosomal recessive total congenital anonychia is a rare genetic disorder. In this manuscript we are reporting the occurrence of this trait in a Saudi Arabian family.

Phaeohyphomycoses are rare fungal infections, caused by dematiaceous fungi, manifested as cutaneous and subcutaneous infections, meningitis, sinusitis, keratitis, osteomyelitis and disseminated infection. This is a case report of a 45year old immuno compromised female on ART (Anti Retroviral therapy) presented with fever and generalized nodular lesions draining pus on face, hands, axilla, groin and labia majora since one month. Biopsy of the subcutaneous nodule on the lateral aspect of the thigh revealed septate fungal hyphae on 10% KOH (10% Potassium Hydroxide) mount. Fungal culture of the biopsy material on SDA (Sabouraud’s Dextrose Agar) at 250C showed cotton wooly, dark gray to olivaceous black growth with black reverse and identified as dematiaceous fungi belonging to Exserohilum species by microscopy. The patient was put on Itraconazole 200mg BD in combination with Terbinafine 250mg BD for which she responded with healing of pustular lesions in two weeks and complete remission in two months.

The trichoscopy has been incorporated as a first hand method in patients consulting for scalp problems. Magnifying glass or digital microscope that permit the direct visualization of the hair shaft and the perifolicullar skin are utilized to diagnose cicatricial and non-cicatricial alopecia. A female patient with an alopecia plaque associated with a scalp dysesthesia in which trichoscopy was very useful in its diagnosis is presented.

Topical glicocorticosteroids are the most common drugs to treat acute and chronic inflammatory skin diseases. Prolonged use of them may cause systemic adverse effects including Cushing’s syndrome and hypothalamic-pituitary-adrenal axis suppression. We present a case of four year old girl who developed iatrogenic Cushing syndrome and adrenal insufficiency after atopic dermatitis treatment through the misuse of Mometasone treatment without doctor’s prescription. We observe a reddness and a moon face, a buffalo hump, central obesity, ginecomasty, subcutaneous hypertrophy, hirsutism, buttocks muscle atrophy and growth retardation. Wrist X-Ray revealed a bone age of two year old child. Laboratory values revealed hypothalamic-pituitary-adrenal axis suppression. The discontinuation of Mometasone treatment and supplement treatment with oral Hydrocotisone three times per day proved successful in this patient. For this case, the serious side effects of topical glucocorticosteroid treatment should be explained to the family and their long-term therapy should be refrained. Iatrogenic Cushing syndrome in childchood caused by topical treatment is a rare event.

Digital ulcers (DU) are a well-known problem in patients with systemic sclerosis. It is an underestimated complication of the disease causing pain and morbidity. Essential thrombocytosis is another cause of DU. The association of theses two diseases increases the risk of ischemic complications and impairment of hand function which are frequently observed in patients with digital ulcers. This report deals with a 68-year-old patient with rare association of Essential thrombocytosis ,Systemic sclerosis and Raynaud’s phenomenon that was refractory to medical treatment of Systemic sclerosis (illoprost,calcium channel blockers) and improved with hydreaR.

Drug reactions may mimic several dermatoses, including lupus erythematosus. We present an 80 year old female patient on multiple medications, who presented with blisters on her hands and arms for two weeks, which then generalized to the rest of her body. The patient was evaluated by a dermatologist, and biopsies for hematoxylin and eosin (H&E) examination, as well as for direct immunofluorescence (DIF) and immunohistochemistry (IHC) were performed. The H&E biopsy examination revealed a mild, superficial, perivascular dermal infiltrate of lymphocytes, histiocytes and abundant eosinophils; neutrophils were rare. No vasculitis was noted. DIF revealed positive basement membrane (BMZ) staining, primarily with patchy Complement/C3c and fibrinogen; in addition, strong reactivity to dermal blood vessel was appreciated. Antibodies to cell junction-like structures were also noted in the epidermis and dermis with these two antibodies. IHC using similar immunoglobulins and complement components showed similar patterns. We observed that contrary to lupus erythematosus, neither IgG nor IgM were positive at the BMZ.

Reacción adversa a medicamentos (RAM) es definida por la OMS como cualquier respuesta a un medicamento, que sea nociva e inesperada, que ocurre a dosis normalmente utilizadas en el ser humano para profilaxis, diagnóstico, terapia de enfermedad o para modificación de la función fisiológica. Cuando RAM compromete a la piel se denomina farmacodermia, dermatosis medicamentosa o toxicodermia, la cual ocurre en el 1% de pacientes ambulatorios y 2-5 % de pacientes hospitalizados. La OMS acepta que el 2% de todas las reacciones adversas a fármacos (RAM) son severas (Farmacodermia grave=FG). Son más frecuentes en mujeres, ancianos y pacientes con SIDA. La mayoría de las farmacodermias son leves, pero éstas pueden de inicio ser reacciones severas. 1 de cada 1.000 pacientes hospitalizados sufre una FG, dentro de las cuales se incluyen al síndrome de Stevens Johnson (SSJ) y la Necrolisis Epidérmica Tóxica (NET). El Síndrome de Stevens Johnson (SSJ) y la Necrolisis Epidérmica Tóxica (NET) son reacciones cutáneas graves, con un potencial de morbilidad y mortalidad elevadas, ocurre en 0.4-2 casos por millón de habitantes por año para el SSJ y para la NET en 1.2-6.0 casos millón de habitantes por año. Se presenta en pacientes de todas las edades, razas y sexo. Estas patologías constituyen una verdadera emergencia dermatológica, donde su cuidado y manejo deben ser multidisciplinarios.

Bad obstetric history (BOH) is associated with social and psychological impacts on society worldwide. The causes of BOH may be genetic, hormonal, abnormal maternal immune response, and maternal infection. In women with bad obstetric history (BOH), Toxoplasma (T) IgG high rate has been reported for Nepal (55.2%), while high (42.5%) and lowest (6.97%) active toxoplasma infections has been reported for India. In Arab countries, IgG and IgM higher and lowest seroprevalence rates were for Iraq. The higher susceptibility rates for Rubella in Arab countries excluding Iraq were reported in Morocco (83.4%), Sudan (34.7%), Qatar (25.1%), and Tunisia (20.3%). The lowest susceptibility was reported for Saudi Arabia (6.7%). In Iraq, studies indicate a high susceptibility rates in Thi Qar (98.05%), Kirkuk (91%), Baghdad (79%), and Waset (45.7%). The lowest susceptibility rates were reported for Diyala (0%) in women with previous abortion, and 3.9% in pregnant women without history of BOH.

Blistering drug eruptions and drug-induced anaphylaxis and hypersensitivity syndromes are among the most serious types of adverse drug reactions. We report a 69 old female patient who was using multiple medications and presented with a two month history of recurrent blisters, pustules and crusts. The patient was evaluated by a dermatologist, and biopsies for hematoxylin and eosin (H&E) examination, as well as for direct immunofluorescence (DIF) and immunohistochemistry (IHC) were performed. The H&E examination revealed a subepidermal blister with numerous luminal eosinophils, as well as a dermal superficial and deep, perivascular infiltrate of lymphocytes, histiocytes and eosinophils. The DIF revealed a linear positive staining on the subepidermal interior of the blister with IgG, IgA, IgM, IgD, Complement/C4, lambda light chains, fibrinogen, and albumin; staining was noted in the basement membrane zone, and also focally present around dermal blood vessels and eccrine glands. The dermal staining colocalized with anti-p0071 (Plakophilin 4). We also observed overexpression of thrombomodulin in adjacent epidermal keratinocytes, as well as in the upper dermal blood vessels; its presence may be linked to mitigation of inflammation. With the increased medications that many patients are taking orally and are using topically, overall drug reaction patterns seem to be more complex than previously described.

Bad obstetric history (BOH) is reported worldwide and is associated with social and psychological impacts. Cytomegalovirus and herpes simplex virus play an important role in the induction of adverse outcomes of pregnancy. Highest CMV IgG prevalence rate was reported for India (91.05%), while the lowest rate was reported for Iran (14.28%). Unfortunately, six studies in Iraq reported a high prevalence of CMV IgM in non-married, pregnant and women with BOH. The range of recent CMV infection in pregnant women with BOH was from 1.4% in Jordan to 60.2% in Iraq. In women with BOH, the highest HSV 2 prevalence (16.8%) was noted in India, while the lowest rate (1.69%) was reported in India also. In Arab countries, among women with BOH, HSV 2 IgG and IgM seroprevalence higher rates were reported for Iraq. This literature review highlights the high bacterial and viral maternal infection rate in the developing world. Urgent, concerted action is required to reduce the burden of these infections. In addition to raising awareness about the severity of the problem of maternal infections in the developing world, data from this review will be beneficial in guiding public health policy, research interests and donor funding towards achieving improvement in health care delivery.

P- Phenylenediamine is an oxidative chemical that is frequently used as a permanent hair-coloring agent. It is added to henna to increase the intensity and longevity of the tattoo and expedites its drying time. Henna itself is a greenish brown vegetable coloring made from the leaves of Lawsonia inermis and rarely causes allergic contact dermatitis. The addition of PPD causes the contact sensitization to black henna. Serious adverse skin reactions to permanent hair dyes and temporary black tattoos have been reported. As temporary tattoos have become fashionable among adolescents, the risk profile for p-phenylenediamine (PPD) sensitization of the population has changed simultaneously with an increasing use of hair dyes in this age group. With increased popularity of body art such as body piercing and tattooing, an increase in temporary henna tattoos has also occurred. Although the appeal of non-permanence exists for henna tattoos, dermatologists have begun to see numerous cases of allergic contact dermatitis linked with a certain type of henna. We selected 50 patients using hair dye and henna for our study. Patch testing was done in all the patients using Indian standard series of antigens. Regarding to the side effects to hair dye and henna and itching was the commonest symptom seen in 16% patients, erythematous scaly plaques were seen in 10% patients, vesicular reactions were seen in 6% patients, angioneurotic oedema and contact urticaria was seen in 4% patients each and anaphylaxis and keloidal reaction was seen in 2% patients each.

Nails can has different color it may be called ungual dyschromia or chromonychia that means abnormalities in color of the substance. The transparency of the nail it’s important for dyschromia, the pigment may accumulate due to overproduction such as melanin, storage as copper, haemosiderin, drugs, or by surface deposition [1].

Pediculosis capitis is an infection of the hair and skin caused by the Pediculus humanus capitis [1]. Head-lice infestation is widely endemic, especially in children, are generally spread through direct head-to-head contact with an infected person [2]. Females get head lice twice more often than males and infestation in persons of Afro-Caribbean or other black descent is rare because of hair consistency [3].

Male patient, 80 years old hospitalized due to tumor on his left neck to diagnosis, his nails were seen by chance when he was waiting for his lung X ray examination.

In this manuscript, We shall look to some eponyms in the medical literature from the vaccination window. The impact of vaccination on the health of the world’s peoples is hard to exaggerate. With the exception of safe water, no other modality, not even antibiotics, has had such a major effect on mortality reduction and population growth [1].

Staining is an auxiliary technique used in microscopy to enhance contrast in the microscopic image. Stains and dyes are frequently used in biology and medicine to highlight structures in biological tissues for viewing, often with the aid of different microscopes [1]. Hematoxylin and eosin stain (H&E stain or HE stain), is the routine staining for skin biopsies.

A 40-year-old man presented painless red lesions under his fingernails that appeared after ciprofloxacin treatment . He was complaining about fever, abdominal pain and urgency with urination. Urine sample obtained and bacteriologic examination performed. According to urinalysis and culture results, patient evaluated as urinary tract infection and oral ciprofloxacin was initiated. He had a history of kidney stone.

The word “sign” refers to important physical finding or observation made by the physician when examining the patient. Dermatologic diagnosis relies on the careful observation and documentation of signs, which can be highly pathognomonic for a certain conditions. Most of the signs appear either de novo or have to be elicited by the physician [1].

In dermatology practice, it is very common to hear about „Bodies’’, which refer to a pthological structure with a particular features. Most of them are large and can be seen by light microscopy, but there are few very tiny bodies which can only be seen by electron microscopy. Examples for the latter are comma-shaped body, and the worm-shaped body, seen in histiocytoses like benign cephalic histiocytosis (however; they are not specific), and zebra body, seen in mucopolysaccharidoses.

I write to honor our memory of Ernst H. Beutner, Ph.D., a distinguished leader in dermatology and immunology; a mentor, gentleman, husband and father, an outstanding supervisor and true light in this world for many years. I do not write to characterize his outstanding scientific achievements; these are well known. For those desiring to learn more about his scientific legacy, please refer to the links provided below.

Palmoplantar keratodermas (PPKs) represent a diverse group of hereditary and acquired disorders characterized by hyperkeratosis of the skin on the palms and soles [1]. The three major patterns of involvement are diffuse, focal and punctate. There are clinical distinguishing features for each disease in this group, for example, transmigration to areas beyond the palmoplantar skin.

Introduction: In patients with autoimmune skin blistering diseases (ABDs), the diagnostic gold standard has classically been direct and indirect immunofluorescence (DIF and IIF), despite inherent technical problems of autofluorescence. Aim: We sought to overcome autofluorescence issues and compare the reliability of immunofluorescence versus immunohistochemistry (IHC) staining in the diagnoses of these diseases. Methods: We tested via IHC for anti-human IgG, IgM, IgA, IgD, IgE, Kappa light chains, Lambda light chains, Complement/C3c, Complement/C1q, Complement/C3d, albumin and fibrinogen in 30 patients affected by a new variant of endemic pemphigus foliaceus in El Bagre, Colombia (El Bagre-EPF), and 30 control biopsies from the endemic area. We also tested archival biopsies from patients with ABDs whose diagnoses were made clinically, histopathologically and by DIF/IIF studies from 2 independent dermatopathology laboratories in the USA. Specifically, we tested 34 patients with bullous pemphigoid (BP), 18 with pemphigus vulgaris (PV), 8 with pemphigus foliaceus (PF), 14 with dermatitis herpetiformis (DH) and 30 control skin samples from plastic esthetic surgery reduction surgeries. Results: The diagnostic correlation between IHC and DIF-IIF was almost 98% in most cases. IHC revealed evidence of autofluorescence around dermal blood vessels, dermal eccrine glands and neurovascular packages feeding skin appendices in ABDs; this autofluorescence may represent a non-specific immune response. Strong patterns of positivity were seen also in endothelial-mesenchymal cell junction-like structures, as well as between dermal fibrohistiocytic cells. In PV, we noted strong reactivity to neurovascular packages supplying sebaceous glands, as well as apocrine glands with edematous changes. Conclusions: We suggest that IHC is as reliable as DIF or IIF for the diagnosis of ABDs; our findings further suggest that what has previously been considered DIF/IIF autofluorescence background may be of relevance in ABDs. Our discovery of reactivity against edematous dermal apocrine glands may be related to the fact that PV has a vegetant form, with lesions present in anatomic areas where these glands exist.

Introduction: Pemphigus foliaceus (PF) is endemic in some South American countries, especially in Colombia and Brazil; in Brazil, it is also known as fogo selvagem (FS). We aimed to study the presence of mast cells and the expression of the mast/stem cell growth factor receptor (c-kit/CD117) in PF skin biopsies, as well as the role of IgE in the disease pathogenesis. Methods: Forty-four skin biopsies from patients affected by endemic PF (EPF) (30 patients from El Bagre, Colombia, and 14 from the northeastern region of São Paulo State, Brazil), 48 control biopsies from Colombian and Brazilian endemic areas, and additional control biopsies from none endemic areas in Colombia and the USA non were studied. Immunohistochemistry (IHC) was performed to evaluate skin biopsies with anti-mast cell tryptase (MCT), anti-c-kit and anti-IgE antibodies. We also searched for serum IgE in 30 EPF and 30 non-atopic controls from the El Bagre region via ELISA. In our El Bagre patients and controls, we also searched for IgE in skin samples by direct immunofluorescence. Results: In 100% of the EPF biopsies, MCT, c-kit and IgE were identified with stronger expression relative to control biopsies, especially in the inflammatory infiltrates around upper dermal blood vessels and dermal eccrine glands. IgE staining was positive along the BMZ in some EPF skin samples. The DIF results confirmed a linear deposition of IgE at the BMZ. Increased IgE serum levels were also noted in PF patients relative to controls.. Conclusions: In patients with EPF, the observed increased expression of MCT, c-kit and IgE in lesional skin, associated with higher serum IgE levels may indicate possible IgE participation in the antigenic response.

Introduction: Pemphigus are autoimmune blistering diseases that affect the skin and mucous membranes. The blisters characteristics of pemphigus tend to break, causing painful erosions that easily bleed. This study aimed to identify the experiences involved in the triggering of pemphigus and how patients face the illness and treatment. Material and Methods: The study included 31 patients diagnosed with pemphigus foliaceus and vulgaris, under a standardized pulsetherapy treatment. Data collection was through semi-structured interviews, which were audio-recorded, transcribed and analyzed using a qualitative approach. Results: During the journey in search of the phenomenon, were defined two thematic categories, subdivided into eleven subcategories. Months before the triggering of the illness, patients experienced feelings of losses, familiar conflicts and concerns; also showed an experience permeated by heartache and disappointments. After the first signs of pemphigus, patients experienced a long journey until the correct diagnose; worsening of the lesions after the communication of the diagnosis; feelings of isolation, shame and prejudgment; interruptions of the future plans; lack of information about the disease and treatment; difficult adherence to the pulsetherapy and the appearance of new lesions or worse by stressful events. Discussion: It might be observed that the disease is not just a biological deviation, but also a social deviance, which explicit the need to adapt to the new reality of the disease and face the isolation, prejudgment and shame of living with a stigmatizing disease.

Introduction: The in situ immune response in skin biopsies from patients affected by autoimmune skin blistering diseases (ABD) is not well characterized. Aim: Our investigation attempts to immunophenotype cells in lesional skin in several ABD, utilizing immunohistochemistry (ICH). Methods: We tested by IHC for CD4, CD8, CD19, CD20, CD45, CD56/NCAM, PAX-5, granzyme B, myeloperoxidase, neutrophil elastase, LAT and ZAP-70 in patients affected by ABD. We tested 30 patients with endemic pemphigus foliaceus (EPF), 15 controls from the EPF endemic area, and 15 biopsies from healthy controls from the USA. We also tested archival biopsies from patients with selected ABD, including 30 patients with bullous pemphigoid, 20 with pemphigus vulgaris, 8 with pemphigus foliaceus and 14 with dermatitis herpetiformis. Results: We found a predominantly CD8 positive/CD45 positive T cell infiltrate in all ABD. Our skin biopsies demonstrated consistently positive staining for myeloperoxidase, but negative staining for neutrophil elastase. Most ABD biopsies displayed negative staining for CD4 and B cell markers; natural killer cell markers were also rarely seen. ZAP-70 and LAT were frequently detected. In El Bagre-EPF, a significant fragmentation of T cells in lesional skin was noted, as well as autoreactivity to lymph nodes. Conclusions: The documented T cell and myeloperoxidase staining are indicative of the role of T lymphocytes and neutrophils in lesional biopsies in patients with ABD, in addition to previously documented deposition of B cells, immunoglobulins and complement in situ. In El Bagre-EPF, T cells could also target lymph nodes; however, further studies are needed to confirm this possibility.

Introduction: Autoimmune bullous skin diseases (ABDs) represent a heterogeneous group of disorders of the skin and mucosa; these disorders are commonly associated with deposits of immunoglobulins, complement, and fibrinogen, usually directed against distinct adhesion molecules. Methods: We utilized hematoxylin and eosin (H & E) stained tissues sections to evaluate for the presence of rouleaux in lesional skin biopsies of patients affected by ABDs including patients with endemic and nonendemic pemphigus foliaceus, bullous pemphigoid (BP), pemphigus vulgaris (PV), dermatitis herpetiformis (DH), and a group of controls taken from routine biopsies seen in our practice. Results: Most autoimmune bullous skin diseases biopsies showed rouleaux formation within and around post-capillary venules in the superficial vascular plexus in association with a pinkish brush-like material that resembles fibrin or other amorphous eosinophilic material. Discussion: We document that rouleaux and the pinkish aggregates are present in within biopsies taken from lesional skin in the majority of patients with ABDs and speculate that this maybe as result of the exocytosis of inflammatory cells, antibodies that form when exposed to the extracellular matrix which is already edematous in most ABDs. In addition red blood cells in the presence of plasma proteins or other macromolecules may form aggregates. Further studies are needed.

Linear IgA bullous dermatosis (LABD) is occasionally induced by certain drugs, of which vancomycin is the most common. We herein describe a case of vancomycin-induced LABD on the trunk and extremities. Our case was unique in which tense bulla was induced on the old operation scars. A 92-year-old man developed diffuse erythema and bullas on his trunk and extremities. Also, blister formation was observed on the operation scar on the abdomen. A biopsy specimen showed subepidermal split with neutrophilic and lymphocytic infiltration in the upper dermis. Direct immunofluorescence showed a linear IgA deposition at the basement membrane zone. His skin conditions were improved by stoppage of vancomycin and topical corticosteroids. We should know about the occurrence of LABD in patients under vancomycin treatment.

Introduction: Psychological stress has been associated with the course of several autoimmune skin diseases and reported a possible factor in triggering and aggravating for pemphigus in predisposed patients. Aim: The aim of this study is to present an upgrade of the scientific literature on the relation between pemphigus and psychological stress. Methods: To assure a comprehensive investigation, we have performed searches on LILACS, MedLine, PEPSIC, PubMed, SCOPUS and Web of Science databases. The terms used were pemphigus, psychological stress and psychological distress. We have selected works published on journals indexed in different online databases, without distinction as to language and date of the studies. Results and Discussion: Initially, 22 works had fulfilled the selection criteria. After discarding publications which deviated from the subject, 9 works were selected for analysis. Among the selected articles, one was a theoretical review, five case studies, two case-control studies and one documental analysis. Publications discuss the importance of recognizing the influence of exogenous factors, such as psychological stress, on the development and evolution of pemphigus, since the health condition of the patients can be improved through the recognition, validation and treatment of their psychological issues, associating psychological assistance to the immunosuppressive treatment. Conclusion: The report of stressor events by patients at the Dermatology Clinical is frequently observed, however, the relation between psychological stress and the development or aggravation of pemphigus is a recent subject among researchers of the field.

Introduction: Bullous pemphigoid (BP) is one of the most prevalent autoimmune blistering diseases, and believed to be mediated by autoantibodies and complement. The disorder is categorized by the development of urticarial plaques surmounted by subepidermal blisters, and the deposition of immunoglobulins and complement at the basement membrane zone (BMZ) of the skin. Case Report: A 70-year-old male Caucasian patient was evaluated for a four day history of multiple itchy, erythematous blisters on his abdomen. Biopsies for hematoxylin and eosin (H&E) examination, immunohistochemistry (IHC) and direct immunofluorescence (DIF) analyses were performed. Results: The H&E biopsy demonstrated a subepidermal blister, with partial re-epithelialization of the blister floor. Within the blister lumen numerous neutrophils and eosinophils, and occasional lymphocytes were observed. Within the dermis, dilated superficial blood vessels with a mild, perivascular infiltrate of lymphocytes, histiocytes and eosinophils were seen; mild perivascular leukocytoclastic debris was also noted. A periodic acid Schiff (PAS) special stain demonstrated positive staining along the BMZ, and around selected dermal blood vessels and sweat glands. DIF revealed linear deposits of IgG, Complement/C3 and fibrinogen at the BMZ, and around selected dermal blood vessels and sweat glands. By IHC, positive staining for CD8 and CD45, and occasional CD4 positivity was seen on dermal lymphocytes. These lymphocytes were present surrounding selected dermal blood vessels and eccrine sweat glands. Conclusions: The patient displayed immunoreactivity to the BMZ, and also to dermal blood vessels and eccrine glands in his immune response. Similar immune responses would be of interest in immunologic studies of BP patients.

Autoimmune bullous disease is sometimes seen in patients with rheumatoid arthritis (RA). In addition, pemphigus can be induced by certain disease modifying anti-rheumatic drugs (DMARDs) for RA, such as thiol compounds. Antibodies against desmogleins are occasionally detected in the sera of drug-induced pemphigus patients. We herein describe a case which showed ulceration following herpes zoster in the oral cavity of a patient with RA under treatment with bucillamine. The patient was misdiagnosed with pemphigus in another clinic, because of mucous membrane lesions and positive circulating levels of anti-desmoglein-1 IgG. Clinicians should know that circulating antibodies against desmogleins can be detected, although at low titers, in the sera of patients under therapies with certain drugs.

Introduction: Dermatitis herpetiformis (DH) is an autoimmune, clinically pleomorphic, papulovesicular disorder sometimes associated with celiac disease and gluten sensitivity. DH is categorized by subepidermal vesicles and bullae on hematoxylin and eosin (H&E) staining, and with immunoglobulin A deposits present along the dermal papillary tips on direct immunofluorescence (DIF). Case Report: We describe a 50 year old female that presented with sudden onset pruritus and clinical blisters, predominantly on extensor areas of the extremities. Biopsies for H&E examination, as well as immunohistochemistry (IHC) and DIF analysis were performed. Results: H&E examination demonstrated subepidermal blistering; within the blister lumen, numerous neutrophils were present, with occasional eosinophils and lymphocytes also seen. DIF examination revealed linear deposits of IgA along the epidermal basement membrane zone, associated with other immunoglobulins and complement. IHC examination showed similar patterns of reactivity to IgA, and also to other immunoreactants. Cells positive for CD1a were present within the blisters, correlating with S-100 staining. Cells staining positive for CD8, CD45 and occasionally CD4 and Granzyme B were seen not only in the blister lumens, but also around neurovascular packages under the blisters. Finally, CD2 positive cells were found around the upper dermal blood vessels. Discussion: Focal DIF linear IgA deposition is the classic hallmark diagnostic finding in DH. However, it is possible that genetic susceptibility and environmental triggers also play a crucial role in the pathogenesis, often acting via cellular pathways exhibiting disease-associated polymorphisms. In tolerance breakthrough, the initiating antigen presenting cells likely lead to immune system cell differentiation, and activation of adaptive immunity.

Autoimmune bullous skin diseases (ABDs) are uncommon, potentially fatal diseases of skin and mucous membranes which are associated with deposits of autoantibodies and complement against distinct molecules of the epidermis and dermal/epidermal basement membrane zone (BMZ). These autoantibodies lead to a loss in skin molecular integrity, which manifests clinically as formation of blisters or erosions. In pemphigus vulgaris, loss of adhesion occurs within the epidermis. The pioneering work of Ernst H. Beutner, Ph.D. and Robert E. Jordon, M.D. confirmed the autoimmune nature of these diseases. Walter F. Lever, M.D. contributed significantly to our understanding of the histopathologic features of these diseases. Walter Lever, M.D. and Ken Hashimoto, M.D. contributed electron microscopic studies of these diseases, especially in pemphigus vulgaris and bullous pemphigoid. In bullous pemphigoid (BP), linear IgA bullous dermatosis, epidermolysis bullosa acquisita (EBA) and dermatitis herpetiformis (DH), loss of adhesion takes place within or underneath the BMZ. Classic EBA demonstrates extensive skin fragility; DH is commonly associated with gluten-sensitive enteropathy, and manifests clinically with pruritic papulovesicles on the extensor surfaces of the extremities and the lumbosacral area. The clinical spectrum of bullous pemphigoid includes tense blisters, urticarial plaques, and prurigo-like eczematous lesions. Pemphigoid gestationis mostly occurs during the last trimester of pregnancy, and mucous membrane pemphigoid primarily involves the oral mucosa and conjunctivae and leads to scarring. Linear IgA bullous dermatosis manifests with tense blisters in a „cluster of jewels”-like pattern in childhood (chronic bullous disease of childhood) and is more clinically heterogeneous in adulthood. Many of the autoantigens in these disorders are known and have been well characterized. ABDs may be influenced by both genetic and exogenous factors. The diagnoses of ABDs is based on histology of lesional skin and direct immunofluorescence (DIF) of perilesional skin, as well as by serologic confirmation of autoantibodies by indirect immunofluorescence (IIF) and recombinant autoantigens. The titers of the autoantibodies may correlate with the disease severity, and can be measured by indirect immunofluorescence and by ELISA testing. Therapeutically, systemic treatment with glucocorticoids is combined with immunosuppressive adjuvants which allow for fast reduction of systemic steroids. A prospective clinical trial in pemphigus showed that adjuvant treatment with azathioprine, mycophenolate mofetil and cyclophosphamide led to a significant reduction of the cumulative dose of systemic steroids until complete clinical remission was achieved. In bullous pemphigoid, topical treatment with clobetasol can help to accomplish a clinical remission without the major side effects seen with systemic steroids. Also, therapeutic depletion of B lymphocytes by rituximab has considerably improved the overall prognosis of pemphigus. Nurses and other paramedical personal caring for patients with these disorders play a critical role in improving the quality of life of the patients and their families. The patients need to be continuously evaluated to avoid secondary infections, especially if they have long term immuosupressive treatment.

Autoimmune mucocutaneous blistering diseases (ABDs) represent a group of conditions that manifest with blisters on the skin and/or mucous membranes. Bullous pemphigoid (BP) is the most common autoimmune mucocutaneous blistering disease. In BP, the location of the blisters is subepidermal and the oral involvement is rare. Variants of BP have been described, including pemphigoid vegetans; however, this disease is not completely characterized. The majority of ABDs have blisters and/or vesicles, that are often pruritic, and manifest autoantibodies to diverse proteins. These proteins include 1) hemidesmosomal plaque proteins(ie, BP230, plectins), 2) transmembrane proteins such as BP180 and α6β4-integrin, which are connected via laminin 332 to type VII collagen and 3) currently uncharacterized 105 kDa and 200 kDa molecules. Other ABDs include drug-induced linear IgA disease, bullous systemic lupus erythematosus (BSLE), dermatitis herpetiformis (DH), cicatricial pemphigoid (CP; also termed mucous membrane pemphigoid), lichen planus pemphigoides (LPP), pemphigoid gestationis (PG), herpes gestationis(HG), chronic bullous dermatosis of childhood (CBDC) and the localized forms of CP, such as Brunsting-Perry pemphigoid. The diagnosis of ABDs requires clinical data; skin biopsies (in 10% buffered formalin) for hematoxylin and eosin (H&E) examination and skin biopsies(in Michel’s transport medium) for direct immunofluorescence (DIF). In many ABDs, the histopathologic findings demonstrate a subepidermal vesicle or bulla with a luminal inflammatory infiltrate of neutrophils, eosinophils and/or lymphocytes. In many ABDs, an extensive perivascular and interstitial inflammatory infiltrate is also noted subjacent to the blister in the upper dermis. Normal skin adjacent to an ABD plaque is often excellent for DIF results. Many ABD biopsies reveal autoantibody deposition at the lesional basement membrane zone (BMZ); IgG, IgM, IgA, other immunoglobulins, complement components and fibrinogen may be detected. Indirect immunofluorescence (IIF) yields antibody titer data; the titers usually correlate with disease activity and with ELISA. Linear epitopes are commonly studied by using an immunoblotting (IB) assay. Topical and systemic corticosteroids remain as mainstays of therapy in ABDs; however, multiple other immunosupressors and/or “steroid sparing agents” such as azathioprine have been demonstrated to be of therapeutic value. In the IgA mediated dermatoses, dapsone is often helpful; in addition, liver and blood testing (including G6PD levels) is indicated. The prognosis depends on each case; rapid diagnosis avoids complications and assists in maintaining a good quality of life for each patient.

These group of disorders are chronic blistering auto immune disorders characterized histologically by intra epidermal/sub epidermal blister formation. They have circulatory auto antibodies against distinct adhesion molecules of epidermis and BMZ. They are potentially life threatening, characterized by widespread blisters and erosions of skin and mucosa.

Introduction: Topical corticosteroids (TCS) are widely misused. Uncontrolled use of steroids can cause undesirable adverse effects especially on face. Aim: The aim of this study was to assess the skin manifestations of TCS misuse over the face in the patients attending dermatology outpatient and to analyze various factors contributing to such misuse. Material and Methods: A total of 200 patients with facial dermatoses using topical steroids over face for minimum period of 1 month, reported between June 2010 and May 2011 were enrolled in the study. Details about the usage of topical corticosteroids and their side effects were recorded. The patients were educated about the misuse. Results: Majority of the patients were females (71%). The most common reason for misuse was acne (61%) followed by use as a fairness cream (23%). The average duration of usage was 6 months to 1 year, longest being 8 years. The drug most commonly misused was Betamethaone Valerate (71%). The commonest side effect noted was acne form eruptions (52%) followed by steroid dependent face (SDF) (36%). There were no cases of allergic contact dermatitis or perioral dermatitis. The exacerbation of the lesions on stoppage of steroid cream (90%) fairness effect (10%) were the reasons for continued use. (100%) were unaware of side effects of topical steroids. Conclusions: Steroids have been misused by patients on their own or by doctors for various reasons. Hence the awareness about their correct usage is essential.