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Diala M Alshiyab,1 Firas A Al-qarqaz,1 Enas Alhaje,1 Jihane A Mayou,1 Saja Jaradat,1 Ansam Asaad,1 Jihan M Muhaidat,1 Yousef Khader,2 Safa’ M Alsheyab,3 Ashraf O Oweis,4 Basheer Y Khassawneh,4 Suleiman M Momany,4 Shaher M Samrah,4 Musa Al-Ali4 1Department of Dermatology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan; 2Department of Public Health, Community Medicine, Jordan University of Science and Technology, Irbid, Jordan; 3Department of Mathematics and Statistics, Jordan University of Science and Technology, Irbid, Jordan; 4Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, JordanCorrespondence: Diala M Alshiyab, Department of Dermatology, Faculty of Medicine, Jordan University of Science and Technology, P.O.BOX 3030, Irbid, 22110, Jordan, Tel +962798608037, Email dmalshiyab@just.edu.joBackground: COVID-19 pandemic hit the entire world with severe health and economic consequences. Although the infection primarily affected the respiratory system, it was soon recognized that COVID-19 has a multi-systemic component with various manifestations including cutaneous involvement.Objective: The main objective of this study is to assess the incidence and patterns of cutaneous manifestations among moderate-to-severe COVID-19 patients who required hospitalization and whether there was a prognostic indication for cutaneous involvement and the outcome in terms of recovery or death.Methods: This is a cross-sectional observational study that included inpatients who were diagnosed with a moderate or severe COVID-19 infection. The demographic and clinical data of patients were assessed including age, sex, smoking, and comorbidities. All patients were examined clinically for the presence of skin manifestations. Patients were followed for the outcome of COVID-19 infection.Results: A total of 821 patients (356 females and 465 males) aged 4– 95 years were included. More than half of patients (54.6%) aged > 60 years. A total of 678 patients (82.6%) had at least one comorbid condition, mostly hypertension and diabetes mellitus. Sixty-two patients (7.55%) developed rashes; 5.24% cutaneous and 2.31% oral. The rashes were then grouped into five major types: group A, Exanthema: morbilliform, papulovesicular, varicella-like. Group B, Vascular: Chilblain-like lesions, purpuric/petechial, livedoid lesions. Group C, Reactive erythemas: Urticaria, Erythema multiforme. Group D, other skin rashes including flare-up of pre-existing disease, and O for oral involvement. Most patients (70%) developed rash after admission. The most frequent skin rashes were reactive erythema (23.3%), followed by vascular (20.9%), exanthema (16.3%), and other rashes with flare-ups of pre-existing diseases (39.5%). Smoking and loss of taste were associated with the appearance of various skin rashes. However, no prognostic implications were found between cutaneous manifestations and outcome.Conclusion: COVID-19 infection may present with various skin manifestations including worsening of pre-existing skin diseases.Keywords: COVID-19, cutaneous manifestations, vitiligo-like hypopigmentation, pigmented purpuric dermatosis

Jihan M Muhaidat,1 Firas Al-Qarqaz,1 Yousef Khader,2 Diala M Alshiyab,1 Hadeel Alkofahi,1 Mohanad Almalekh1 1Department of Dermatology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan; 2Department of Public Health, Community Medicine, Jordan University of Science and Technology, Irbid, JordanCorrespondence: Jihan M MuhaidatDepartment of Dermatology, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, JordanTel +96227200600Fax +96227200624Email jmmuhaidat@just.edu.joBackground: Alopecia areata (AA) usually manifests as patches of non-scarring hair loss due to immune dysregulation. Intradermal injection of steroids is considered a first-line treatment of patchy AA.Purpose: To compare the efficacy and safety of two commonly used concentrations of intralesional triamcinolone acetonide (ILT) (5 mg/mL vs 10 mg/mL) in the treatment of patchy AA on the scalp.Patients and Methods: A retrospective comparative study that included 85 patients diagnosed with patchy AA on the scalp, who were treated with monthly injections of ILT. Patients were divided into Group 1 that received 5 mg/mL and Group 2 that received 10 mg/mL. The response rate (defined as the percentage of patients who achieved complete hair regrowth) and the side effects were compared between the two groups after completion of three treatment sessions, and recurrence was assessed after 1− 3 years.Results: Demographic composition of the two groups was comparable. The difference in response rate and the side-effects between the two groups were not statistically significant. Complete hair regrowth was noted in 43.5% of patients in Group 1 and 53.8% of those in Group 2 (P=0.340). About 17% and 25% of patients in Group 1 and Group 2, respectively, developed minor local side-effects (P=0.354), and almost 45% of patients from both groups had recurrence after 1− 3 years. Disease duration exceeding 6 months correlated with poor treatment response.Conclusion: Intralesional injection of triamcinolone acetonide 5 mg/mL is equally effective and safe compared to 10 mg/mL in the treatment of patchy alopecia areata.Keywords: alopecia areata, intralesional steroids, triamcinolone acetonide

Background: The pathogenesis of vitiligo is complex and multifactorial, accumulating evidence of increased oxidative stress and reduction in catalase levels in vitiligo patients has been shown, hence, pseudocatalase/superoxide dismutase (PSD) gel has been used as treatment option for vitiligo., Aim: To assesses the synergic effect of PSD when combines with Tacrolimus 0.1% ointment versus Tacrolimus 0.1% alone., Method: A randomized controlled trial that included 49 children with vitiligo with limited area (10% or less). Patients were randomized into two groups: Group 1 (24 patients) were treated only with Tacrolimus 0.1% ointment whereas Group 2 (25 patients) were treated with Tacrolimus 0.1% ointment plus PSD. Degree of repigmentation compared to baseline was assessed at 3, 6, and 9 months., Results: The median age was 10.05 years (range 2-18). The percentages of pigmentation on 3, 6, and 9 months for Group 1 were 23.9%, 40.4%, and 60%, respectively and for Group 2 were 23.2%, 40.7%, and 62.4%, respectively. There was no significant difference according to repigmentation percentages between the two groups ( p  > .86, p  > .97, and p  > .78, respectively)., Conclusions: The results showed that the addition of PSD to Tacrolimus ointment in children with limited vitiligo was not associated with any therapeutic benefit.

Background: The world has changed dramatically since the COVID-19 pandemic began. Jordan was among countries which enforced early lock-down for most non-vital services. Health care was mainly directed to cope with COVID-19 cases. The pandemic posed challenges for all patients, including dermatology patients especially those on systemic treatments. This resulted in interruption of medical care and exacerbation of pre-existing skin diseases for many patients., Material and Methods: A cross-sectional, questionnaire-based study of dermatology patients on systemic treatment prior to corona pandemic. After lockdown was lifted, patients taking systemic treatments were evaluated for continuity of care during lockdown period and how that affected their skin condition. Demographic data, details of skin condition, continuity of care and impact on skin condition data were collected and analyzed., Results: 154 patients (120 males, 34 females) were included. The majority (around 80%) of patients were unable to attend to dermatology clinics or do the needed lab monitoring. Around one fifth of patients had drug interruption mostly due to no access to hospital pharmacy. Most patients were using oral isotretinoin for acne, others include methotrexate and other immune suppressive agents. Patients with acne and oral isotretinoin treatment were more likely to continue their treatment during lockdown period. Amongst those who stopped treatment, around 42% had flare up of their disease., Conclusion: COVID-19 pandemic had an important impact on various aspects of care for dermatology patients especially those on systemic therapy. This study demonstrated limited access to specialist care, inability to do lab tests and discontinuation of treatment during lockdown. Some patients (42%) had flare up of their skin condition as a result., Competing Interests: The authors declare no conflict of interest in relation to this study., (© 2020 The Authors.)

Background: Cryotherapy (freezing by liquid nitrogen) is an effective and widely used method for treatment of common warts. Patients often need multiple sessions at variable intervals. Protocols used by different dermatologists vary in terms of freezing time, the number of cycles, and the intervals between sessions., Aim: To compare the efficacy (cure rates) and safety (complications, early and late) of two cryotherapy treatment protocols for common viral warts., Method: A prospective observational study was conducted; it involved 80 patients with common warts on the hands and feet who were treated with cryotherapy done by two dermatologists who use different protocols; group 1 (45 patients) were treated by a single cycle of 10 seconds of freezing at 2 weekly intervals, and group 2 (35 patients) received a single cycle of 20 seconds of freezing at 4-weeks intervals. The two protocols were compared in terms of cure rate and complications 1-2 months after the final treatment. Recurrence rate and late complications were assessed at 9-12 months after the final treatment., Results: Group 1 patients achieved higher cure rate than group 2, 77.8% and 54.3%, respectively ( P =0.001). Early (blistering) and late complications (dyspigmentation and scarring) were comparable in both groups. Pain score associated with protocol 1 (5.2/10) was less than protocol 2 (6.4/10) ( P =0.004). Recurrence rate (17%) was comparable in both groups. Association between cure rate and duration of warts ( P =0.022) and also association between cure rate and the mean number of warts ( P =0.001) were demonstrated., Conclusions: Cryotherapy is an effective and safe treatment for common viral warts of hands and feet. The impact of shorter intervals on cure rate was more significant than increasing freezing time with longer intervals between freezing sessions. The study was approved by the local IRB committee (285-2018)., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Jihan M. Muhaidat et al.)

Background: Low vitamin D serum levels have been associated with many autoimmune disorders and several other skin diseases. Vitiligo is an autoimmune disease characterized by destruction of melanocytes by immune mechanisms. Melanocytes express vitamin D receptors, and their function can be affected by vitamin D status., Objectives: The main objective of this study is to compare vitamin D levels in patients with vitiligo vs normal population and whether vitamin D deficiency is associated with vitiligo., Methods: A case-control study was conducted. 100 vitiligo patients and 100 as controls were included in this study. Serum vitamin D level was measured for both vitiligo patients and controls, results were compared, and statistical analysis was done to compare the results., Results: The median age of vitiligo cases was 23 years (ranges, 2-80). 58% of vitiligo patients were females. The median vitamin D level was not significantly different between the two groups (vitiligo = 14.1 (IQR 9.9-20.4) vs control = 16.5 (IQR 10.3-25.3) ( P =0.28)). Most vitiligo cases and controls were found to have low levels of vitamin D (either insufficient 20-30 ng/mL or low <20 ng/mL)., Conclusions: There was no significant difference in vitamin D levels in vitiligo patients compared to controls. However, vitamin D levels were generally low in both groups., Competing Interests: The authors declare no conflicts of interest in relation to this study., (Copyright © 2019 Diala M. Alshiyab et al.)