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Background: Mycosis fungoides (MF) in solid-organ transplant recipients (SOTRs) is rare, with limited data on disease characteristics., Objective: The aim was to study the characteristics of MF in SOTRs with an emphasis on the immunosuppressive therapy., Methods: A retrospective cohort of patients diagnosed with MF, who were also SOTRs, were followed at 3 cutaneous lymphoma outpatient clinics, between January 2010 and February 2022., Results: Ten patients were included (7 male; median ages at transplantation and at diagnosis of MF were 33 and 48 years, respectively; 40% were diagnosed before the age of 18 years). Median time from transplantation to diagnosis of MF was 8 years (range 0.5-22). Transplanted organs and immunosuppressive treatments included: liver (n = 5; 4 treated with tacrolimus, 1 with tacrolimus and prednisone), kidney (n = 3), liver and kidney (n = 1), and heart (n = 1), all treated with mycophenolic acid, tacrolimus, and prednisone. Nine had early-stage MF (IA - 4, IB - 5; 40% with early folliculotropic MF), treated with skin-directed therapies, in 2 combined with acitretin, achieving partial/complete response. One patient had advanced-stage MF (IIIA) with folliculotropic erythroderma, treated with ultraviolet A and narrow-band ultraviolet B with acitretin, achieving partial response. Immunosuppression was modified in 3. At last follow-up (median 4 years, range 1-8), no stage progression was observed; 5 had no evidence of disease, 5 had active disease (IA/IB - 4, III - 1)., Conclusions: MF in SOTRs is usually diagnosed at an early stage, with overrepresentation of folliculotropic MF, and of children. Immunosuppressive therapy alterations, not conducted in most patients, should be balanced against the risk of organ compromise/rejection. Disease course was similar to MF in immunocompetent patients, during the limited time of follow-up., (© 2023 S. Karger AG, Basel.)

Background: Data on Demodex in the immunosuppressed state is limited, focusing mainly on patients with human immunodeficiency virus and hematological malignancies. The aim of this study was to describe the manifestations of facial demodicosis in diverse immunosuppressive states., Methods: The medical records of all patients followed at a Demodex outpatient clinic of a tertiary medical center from January 2008 to November 2020 were retrospectively reviewed. Data on patients who were immunosuppressed while with demodicosis were retrieved., Results: The cohort included 28 patients (17 women and 11 men; median age, 58 years). Types of immunosuppression included treatments with hydroxyurea for polycythemia vera/essential thrombocytosis, mycophenolic acid, tacrolimus, and prednisone for liver and/or kidney transplantation, prednisone with cyclosporine/methotrexate/azathioprine/rituximab mainly for autoimmune diseases, mercaptopurine with/without anti-tumor necrosis factor alpha (TNF-α) for Crohn's disease, chemotherapy for neoplasms, anti-TNF-α for psoriasis, and Cushing's syndrome. The clinical types of demodicosis included: papulopustular, erythematotelangiectatic and fulminant rosacea, hyperpigmented, pityriasis folliculorum, pustular folliculitis, and dermatitis. The diverse clinical presentations led to various differential diagnoses. Topical treatment with ivermectin (monotherapy/combination with other treatments) was effective., Conclusion: Clinicians treating immunosuppressed patients should be familiar with the different forms of demodicosis and include them in the differential diagnosis of facial eruptions., (© 2022 the International Society of Dermatology.)

Immunosuppressive agents are essential for graft survival in solid-organ transplant recipients (SOTRs), but they have substantial durable side effects, including a higher incidence of aggressive nonmelanoma skin cancers (NMSCs). Hitherto, only one class of immunosuppressants, mammalian target of rapamycin inhibitors (mTORi), may inhibit skin tumor formation, however their durable effectiveness is controversial. To evaluate the sustained effectiveness of mTORi in reducing NMSCs' incidence in SOTRs, a retrospective study was conducted in a specialized dermatology clinic for SOTRs of a tertiary university-affiliated medical center. SOTRs with a history of at least one histologically proven NMSC were followed for 6 years: 3 years after transplantation, before initiation of mTORi, and 3 years under mTORi treatment. The cohort consisted of 44 SOTRs. Treatment with mTORi was initiated on average 6.27 (3.34-6.34) years following transplantation. In the 3 years before mTORi treatment initiation, the mean number of new NMSCs per patient was 2.11 (1-14). This value decreased to 1.2 (0-19) in the 3 years under mTORi treatment (p = 0.0007). Analysis by NMSC type yielded a significant decrease in both SCCs and BCCs. This study found that mTORi are effective for prolonged secondary prevention of NMSCs in SOTRs., (© 2022 Wiley Periodicals LLC.)

Background: Keratinocyte carcinomas, particularly squamous cell carcinoma (SCC), occur more frequently and aggressively in solid-organ transplant recipients (SOTRs) than in the general population. Systemic retinoids are effective in secondary prevention of keratinocyte carcinomas in this population, but their use is limited by adverse effects including a rebound effect in cases of treatment discontinuation., Objective: Our aim was to determine whether low-dose acitretin is efficient in the secondary prevention of keratinocyte carcinomas in SOTRs., Methods: This retrospective case-crossover study was conducted at a specialized dermatology clinic for SOTRs in a large transplantation center in 2010-2017. Patients with at least 1 previous keratinocyte carcinoma who were treated with acitretin 10 mg/day for 2 years were included. The main outcome was the difference in the number of new keratinocyte carcinomas diagnosed during treatment compared to during the 2-year pretreatment period., Results: The cohort included 34 SOTRs. A significant reduction in the mean number of new keratinocyte carcinomas during treatment relative to the pretreatment period was observed (1.7 vs. 3.6, -53% p = 0.002). Similar results were noted on analysis by tumor type, for both SCC and basal cell carcinoma., Conclusion: This study of SOTRs demonstrated positive results for low-dose acitretin as a chemoprevention of keratinocyte carcinomas in this population., (© 2021 S. Karger AG, Basel.)

Background: The incidence of epidermal growth factor receptor inhibitor (EGFRI)-induced papulopustular rash is 60-85%., Objective: To investigate prophylactic topical treatment for EGFRI-induced rash., Methods: A single-center, randomized, double-blind, placebo-controlled trial. Adult cancer patients initiating treatment with EGFRIs were randomized to receive facial topical treatment with chloramphenicol 3% + prednisolone 0.5% (CHL-PRED) ointment, chloramphenicol 3% (CHL) ointment, or aqua cream (AQUA). The primary end points were the incidence of ≥grade 3 rash using the Common Terminology Criteria for Adverse Events (CTCAE), on days 14 and 30. A subanalysis was conducted for incidence of a protocol-specified significant rash, defined as ≥10 facial papulopustular lesions., Results: The per-protocol analysis on day 14 included 69 patients, who received CHL-PRED (21), CHL (23), or AQUA (25). The incidence of CTCAE ≥grade 3 rash was not statistically significant between arms; however, the incidence of the protocol-specified significant rash was: CHL-PRED 14%, CHL 39%, and AQUA 48% (p = 0.03, CHL-PRED vs. AQUA). At 30 days, the CTCAE ≥grade 3 incidence was similar, but the incidences of protocol-specified significant rash were 6%, 16%, and 43% (p = 0.03, CHL-PRED vs. AQUA). No significant differences were found between CHL and CHL-PRED and between CHL and AQUA., Conclusions: Prophylactic topical CHL-PRED was efficacious when compared to AQUA, in the treatment of EGFRI-induced facial papulopustular rash., (© 2020 S. Karger AG, Basel.)

The gold-standard method for dermatophyte identification involves direct microscopy and culture, which have inherent shortcomings. Only few molecular methods have been standardised for routine clinical work. This study aimed to develop and test a platform for identifying the most common dermatophytes in Israel using multiplex real-time polymerase chain reaction (RT-PCR). Specific primers were designed for the multiplex system (LightCycler 480) according to known cultures and validated by reference isolates. The dermatophyte detection rate was compared to smear and culture in 223 clinical samples obtained from a tertiary medical centre. Inconsistencies between methods were evaluated by sequencing. The RT-PCR was further evaluated in 200 community-based samples obtained from a health maintenance organisation and 103 military-personnel-based samples analysed at a central laboratory. In hospital-based clinical samples, complete concordance between methods was observed in 190 samples (85%; Kappa = 0.69). In most cases of non-concordance, sequencing was consistent with RT-PCR results. RT-PCR correctly identified all smear- and culture-positive cases in community and military-personnel samples. The results were available within 4 hours. The multiplex RT-PCR platform is a rapid and efficient method for identifying dermatophyte species in clinical samples and may serve as a first step in the diagnostic algorithm of superficial fungal infections., (© 2017 Blackwell Verlag GmbH.)

Background: Tinea pedis is a common chronic skin disease; the role of contaminated clothes as a possible source of infection or re-infection has not been fully understood. The ability of ultraviolet light to inactivate microorganisms has long been known and UV is used in many applications., Objectives: To evaluate the effectivity of sun exposure in reducing fungal contamination in used clothes., Methods: Fifty-two contaminated socks proven by fungal culture from patients with tinea pedis were studied. The samples were divided into two groups: group A underwent sun exposure for 3 consecutive days and group B remained indoors. At the end of each day fungal cultures of the samples were performed., Results: Overall, there was an increase in the percentage of negative cultures with time. The change was significantly higher in socks that were left in the sun (chi-square for linear trend = 37.449, P < 0.0001)., Conclusions: Sun exposure of contaminated clothes was effective in lowering the contamination rate. This finding enhances the current trends of energy saving and environmental protection, which recommend low temperature laundry.

Background: The literature on mycosis fungoides (MF) in children/adolescents is sparse., Objective: We sought to evaluate the characteristics of juvenile MF in a large cohort., Methods: Data were collected on all patients with MF, aged 18 years or younger at the time of clinicopathologic diagnosis, who attended the Rabin Medical Center Dermatology Department, Petach Tikva, Israel, between 1994 and 2012 and were followed up prospectively., Results: There were 50 patients (30 male; mean age 11.4 years at diagnosis); 18 (36%) had Fitzpatrick skin type IV or higher. All were given a diagnosis of early-stage disease (IA-IIA) except 1 (tumor stage, IIB). Eight had classic MF lesions only and 42 had other variants, alone or in combination; these were mainly hypopigmented MF (n = 29) and cases with subtle but clear clinicopathologic features of folliculotropic MF (FMF) (n = 18). Among the various skin-targeted therapies, psoralen plus ultraviolet A (systemic/bath) proved beneficial for FMF. During a follow-up period of 0.25 to 15 years (mean 4.5), 2 patients progressed from stage IA to IB or IIA., Limitations: Relatively short follow-up is a limitation., Conclusions: This case series shows that FMF is not uncommon in children and adolescents. It is characterized by more superficial clinical features and less heavy perifollicular lymphocytic infiltrates than adult FMF, and responds well to psoralen plus ultraviolet A. The prognosis of childhood FMF remains unclear., (Copyright © 2014 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Tinea pedis is a common chronic skin disease. The role of contaminated clothes as a possible source of reinfection is not fully understood. This study was conducted to evaluate the efficacy of domestic laundering at different temperatures in the eradication of fungal pathogens from contaminated socks. Samples from 81 socks worn by patients suffering from tinea pedis underwent domestic laundering at either 40 °C or 60 °C. The socks were dried at room temperature; fungal cultures were taken from two samples from, respectively, the toe and heel areas of the socks. Samples from socks washed at 40 °C revealed 29 (36%) positive fungal cultures, of which 14 came from the toe and 15 from the heel areas of socks. Trichophyton rubrum was isolated in four specimens, and Aspergillus spp. were found in 20 (70%) specimens. Samples from the same socks washed at 60 °C revealed five (6%) positive fungal cultures, of which three came from the toe and two from the heel areas of socks. Only Aspergillus spp. were detected. Yeasts were eradicated at 40 °C. Contravening current trends for energy saving and environmental protection, laundering at low temperatures is not effective in eradicating fungal pathogens, which requires high-temperature laundering at 60 °C., (© 2013 The International Society of Dermatology.)

Objective: To compare the efficacy and safety of fluconazole and griseofulvin in the treatment of tinea capitis., Patients and Methods: Patients with tinea capitis (n = 113) with positive fungal cultures entered the study. The patients were divided into four groups with different treatment regimes. Two groups received griseofulvin 15 or 25 mg/kg/day and two groups received fluconazole 4 or 6 mg/kg/day, all for up to 12 weeks., Results: Griseofulvin was found to be slightly better than fluconazole. The lower doses for both griseofulvin and fluconazole required significantly longer treatment duration until mycological cure than the higher doses, independent of the fungus type., Conclusions: Since no significant difference was found between the drugs, it is suggested that the choice should be based on tolerability, availability and cost of the drugs., (© The Authors • Journal compilation © Blackwell Verlag GmbH, Berlin.)

The purpose of this study was to evaluate the severity-of-illness score called SCORTEN with respect to its predictive ability and by using data obtained in the RegiSCAR study, the most comprehensive European registry of patients with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). For advanced comparisons, an auxiliary score (AS) was defined using data obtained in a previous study. Three hundred sixty-nine patients with SJS/TEN were included in RegiSCAR between 2003 and 2005. The data needed for calculation of SCORTEN were available for 45% of patients. The score revealed a moderate predictive ability with a slight underestimation of the total number of in-hospital deaths by 11%, an area under the receiver operating characteristic curve of 0.75, and a Brier score of 0.14. Problems could be seen by analyzing subgroups such as patients with TEN. The AS was better calibrated but discriminated worse (area under the receiver operating characteristic curve: 0.72; Brier score: 0.14). With the help of a refined score derived from SCORTEN and AS, potential for a possible improvement could be demonstrated. The authors were able to show that the predictive ability of SCORTEN is acceptable. Although improvement might be possible, SCORTEN remains the tool of choice, whereas AS might be an alternative in retrospective settings with missing laboratory data.

A 76-year-old man developed a maculopapular purpuric eruption confined to the intertriginous areas (i.e. the inguinal, gluteal, and axillary folds). Two days before the eruption appeared, he had received a second course of chemotherapy consisting of cisplatinum 40 mg and gemcitabine (Gemzar) 1700 mg for the treatment of squamous cell carcinoma of the lung stage III B. The histologic picture was of either lymphomatoid drug eruption or lymphomatoid papulosis. The antineoplastic therapy was changed to once-weekly intravenous vinorelbine (Navelbine) 50 mg, a Vinca alkaloid, and the eruption resolved completely within two weeks without any further therapy. These circumstantial evidences support the diagnosis of intertriginous drug eruption. Our case is interesting and unusual in that it demonstrated a rare clinical presentation of drug eruption, namely, intertriginous drug eruption or baboon syndrome, with a histologic picture of a lymphomatoid drug eruption that can mimic lymphoma. We are unaware of any earlier reported case of baboon syndrome with a histologic picture of lymphomatoid drug eruption. The pathomechanisms of both types of drug eruption, i.e. baboon syndrome and lymphomatoid drug eruption, are not fully understood., (© 2009 The International Society of Dermatology.)

Unlike many other skin diseases, success or failure of therapy of ectoparasitic infestation depends much more on how to use the topical preparation and whom we treat than on which scabicide or pediculicides to use. The diagnosis of scabies should no longer rely on the rather uncommon and unpractical sign of finding a burrow or the number of parasites per infected patient. Most infested individuals have been shown to have several-fold more acari than the oft-quoted average of 12 adult acari per infected patient that appears in most of our textbooks (stemming from Mellanby's work). Contrary to what Mellanby taught us, we know that indirect transmission (ie, without personal contact) does occur. As to which agent to use, the winner remains undeclared at present. Although indirect contact transmission of hair lice has been clarified after thousands of years of infestation, there are still numerous questions, uncertainties, disagreements, and controversies on the subject; for example, we know that lice survive immersion in water but are probably not transmitted in swimming pools. There is no consensus on the best or most correct way to diagnose lice, nor is the problem of resistance resolved. We do not recommend a "no-nit" policy., (Copyright 2010 Elsevier Inc. All rights reserved.)

There are two opposing approaches in the treatment of genital warts: (1) the traditional approach advocates complete elimination of all lesions, and (2) a second approach regards condyloma as merely a cosmetic nuisance. After a long journey through many arguments and scientific papers, we have concluded that many unknowns, uncertainties, and controversies concerning the value of treatment of genital warts in terms of clearing and curing the disease (ie, eradicating the viruses, preventing cancer, and reducing infectivity). There is no consensus at present of whether treatment of men with evidence of genital human papillomavirus infection influences the natural history of their female sex partner's cervical disease., (Copyright 2010 Elsevier Inc. All rights reserved.)

Nail changes in patients with psoriasis have been reported with varying prevalence. Onychomycosis has been reported in up to 47% of the psoriasis patients. The purpose of this study was to determine the prevalence of nail abnormalities, onychomycosis in psoriasis and response to itraconazole treatment. We evaluated 312 patients suffering from psoriasis for nail changes and onychomycosis. Patients having laboratory confirmation of onychomycosis were treated with three courses of itraconazole (400 mg day(-1) for 1 week). Of 312 patients with psoriasis, 67 (21.5%) patients had nail changes, 23 (34%) of them suffered from onychomycosis. Complete cure (clinical and mycological) was achieved in 30% of the patients with onychomycosis. The response to treatment of onychomycosis with itraconazole in psoriasis patients was found to be lower than in the general population. Considering the low response to onychomycosis systemic therapy in psoriatic patients and the potential side-effects of the treatment, the rationality of this treatment is questionable.

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are uncommon but extremely serious and often life-threatening mucocutaneous reactions characterized by extensive epithelial sloughing and systemic symptoms. There is no effective evidence-based treatment for severe cutaneous adverse reactions (SCAR) to drugs and no consensus on how to treat these patients. This contribution presents some of the controversies concerning the treatment of SCAR patients, including where and by whom, as well as the issue of the value of treatment with corticosteroids and intravenous immunoglobulin. Investigators agree that more studies are needed and that there are insufficient data to draw definite conclusions. The spectrum of disagreement is wide and the debate is ongoing. At the end, the important question is should we wait with our decisions until all these controversies are settled and we have more or full evidence. This question, as well as all others, is open for debate, evidently a "toxic" debate on toxic epidermal necrolysis., (Copyright 2010 Elsevier Inc. All rights reserved.)

Psoriasis vulgaris is a multifactorial heritable disease characterized by severe inflammation resulting in poorly differentiated, hyperproliferative keratinocytes. Recent advances in genetic analyses have implicated components regulating the interleukin (IL)-23 and nuclear factor-kappaB pathways as risk factors for psoriasis. These inflammatory pathways exhibit increased activity in skin lesions, and promote secretion of various cytokines, such as IL-17 and IL-22. Unrestrained, the activated inflammatory cytokine network in psoriasis may trigger a vicious cycle of inflammation and cellular proliferation that ultimately results in lesion formation. These advances in genetic analyses, together with the progress made in targeted biological therapy, pave the path to tailor treatment on the basis of an individual's genetic and immunologic profile.

Onychomycosis is a common problem. Obtaining accurate laboratory test results before treatment is important in clinical practice. The purpose of this study was to compare results of curettage and drilling techniques of nail sampling in the diagnosis of onychomycosis, and to establish the best technique and location of sampling. We evaluated 60 patients suffering from distal and lateral subungual onychomycosis and lateral subungual onychomycosis using curettage and vertical and horizontal drilling sampling techniques from three different sites of the infected nail. KOH examination and fungal culture were used for detection and identification of fungal infection. At each sample site, the horizontal drilling technique has a better culture sensitivity than curettage. Trichophyton rubrum was by far the most common pathogen detected by both techniques from all sampling sites. The drilling technique was found to be statistically better than curettage at each site of sampling, furthermore vertical drilling from the proximal part of the affected nail was found to be the best procedure for nail sampling. With each technique we found that the culture sensitivity improved as the location of the sample was more proximal. More types of pathogens were detected in samples taken by both methods from proximal parts of the affected nails.

We report a case of an otherwise healthy male newborn, with segmental café au lait spots on his left buttocks and left thigh down to the medial knee, in a nevoid pattern, and an aberrant Mongolian spot on the ipsilateral cheek of the buttocks in a checkerboard pattern. We propose the name phacomatosis pigmentopigmentalis in analogy to phacomatosis pigmentovascularis, and phacomatosis pigmentokeratotica.

An otherwise healthy 72-year-old man presented with a painful eruption composed of grouped hemorrhagic purulent blisters on erythematous plaques, on both palms of his hands, which appeared 12 h after he had been vaccinated against influenza. Based on the patient's history, physical examination, histopathological and laboratory findings, the diagnosis of neutrophilic dermatosis of the hands (NDH) was made. NDH is currently considered a distributional variant of Sweet's syndrome (SS). It is identical to atypical pyoderma gangrenosum (PG) and pustular vasculitis of the hands. There are only seven reported cases of SS after vaccination, none of them with lesions confined solely to the palms or soles. Our current case is the third one of SS following influenza vaccination.

Any injector can accidentally spill a few drops of BTX into the eye. It might very well be a harrowing experience to the uninformed: the good news is that the patient is at no risk of untoward sequelae. Although the BTX that diffuses into the orbit from these injections might well cause adverse effects, the same neurotoxin dropped into the eye is no more than a matter of wasting expensive material. We present herein our experience with such an accident, and support it with theoretical considerations.

Background: Fungal infection of the nail affects millions of people worldwide and has an estimated prevalence of more than 10% of the general population., Objectives: To determinate the prevalence of fungal infection in toenails, in order to decide the treatment policy for onychomycosis., Methods: We evaluated 331 patients with suspected clinical toenail onychomycosis affecting at least two toenails. Mycological examination of the affected nails was performed; both the KOH test and fungal culture were used., Results: Of 331 patients with suspected clinical toenail onychomycosis, 78.2% of the patients had at least three infected nails. The first toenail was the most affected. Trichophyton rubrum was by far the most common dermatophyte cultured from all samples., Conclusions: Most of the patients had at least three affected toenails. Topical treatment is not effective or practical, and systemic treatment should therefore be considered.

Background: Acute generalized exanthematous pustulosis is a rare pustular severe cutaneous adverse reaction characterized by a rapid clinical course and unique histological findings. It is usually attributed to drugs, although other factors have also been implicated., Objectives: To analyze demographic, clinical and laboratory data of AGEP cases in Israel, based on the RegisCAR study, a multinational European study., Methods: Patients included in the present study were actively recruited by the Israeli RegiSCAR network, which comprised 10 dermatology departments and units. The cases were validated by a multinational expert committee of dermatologists based on a standardized scoring system., Results: Overall, 11 potential cases of AGEP were collected in Israel: 9 (81.8%) definite and 2 (19.2%) possible. The adjusted annual incidence of AGEP in Israel was 0.35/million/year. The nine definite cases that entered the analyses showed a male/female ratio of 0.28 with an age range of 10-60 years. Most cases were reported during the summer months. The clinical course and laboratory findings in most of our patients were in accordance with previous reports. A drug etiology was suspected in the majority of cases and consisted of analgesics (66.7%), antibiotics (22.2%) and non-steroidal anti-inflammatory drugs (11.1%) as the main culprit drugs., Conclusions: Whereas the clinical and laboratory findings of AGEP in Israel corresponded to the reported features of AGEP in the literature, some unique findings were noted, namely, marked female predominance, seasonality and a profile of culprit drugs.

Amifostine is an organic thiophosphate prodrug used for cytoprotection against toxic effects of radiotherapy and chemotherapy. In a European prospective study of SJS/TEN, six patients were suspected to have SJS/TEN associated with amifostine. Our findings suggest that the risk of life-threatening cutaneous adverse reactions to amifostine could be significantly increased.