Feio, A

Páris, F

Serrão, V

Repositório do Centro Hospitalar de Lisboa Central, EPE

EJD, vol. 18, n° 3, May-June 2008342doi : 10.1684/ejd.2008.0402Most authors recommend a quick freeze and slow thaw method of tissue destruction. Slow cooling produces extra-cellular ice, but this is not as damaging as rapid cooling that produces intracellular ice formation. With slow thawing, an increased concentration of electrolytes and recrystalli-zation occurs, which is also damaging to cells. Thus the rate of rewarming, or thaw, should proceed slowly [1].Cryoblasting successfully achieves the quick freeze and slow thaw desired for destruction of thicker lesions. To our current knowledge, there is only one previous report related to cryoblast for verrucae [2]. Callaway et al. showed that cryoblast can achieve a deeper ice ball compared with classic cryosurgery on a gelatin model [2]. Cryoblast is a technique which has a short duration of freeze giving pain relief and no difference of complications compared with classical methods. In the present study, we showed that cryoblast is signiﬁ cantly more effective than cryo-spray. Although we expected more scarring with cryoblasting, there was no difference from the scarring resulting from cryo-spray, as in the previous study [2].Cryoblast could be an alternative method in the treatment of plantar verrucae. Controlled trials comparing cryoblast to cryospray are recommended for further conﬁ rmation. Acknowledgements. Financial support: none. Conﬂ ict of interest: None.Ministry of Health Dışkapı Yıldırım Beyazıt Training Hospital Department of Dermatologyﬁ lizcanpolat@hotmail.comFiliz CANPOLATBengü ÇEVİRGEN CEMİLFatma ESKİOĞLU1. Kuflik EG. Cryosurgery updated. J Am Acad Dermatol 1994; 31: 925-44.2. Callaway SR, Ratz JL. Surgical pearl: Cryoblast, a modified cryosurgi-cal technique for thick lesions. J Am Acad Dermatol 2004; 51: 458-9.Genital vitiligo-like depigmentation following use of imiquimod 5% creamImiquimod 5% cream is an immune response modiﬁ er, currently approved for use in external genital and perianal warts, superﬁ cial basal cell carcinoma and actinic kerato-ses. The anti-viral and anti-tumoral activity seems to be dependent on focal activation of the immune system with induction, synthesis and release of cytokines, such as inter-feron-alpha, interleukin-12 and tumor necrosis factor alpha [1]. This intense immune reaction is responsible for local side-effects, such as erythema, edema, erosions and crust-ing. Post-infl ammatory pigmentary change has already been described as a possible complication, which is usu-ally reversible. The induction of vitiligo-like depigmenta-tion has been reported very rarely, but assumes importance due to the expanding uses of this medication [2-4].We report a 26-year-old Caucasian male, with condyloma accuminata of the penis, treated initially with cryotherapy with only mild improvement. Imiquimod 5% cream (three times weekly) was used without signiﬁ cant side effects, except for moderate erythema and edema. After 12 weeks of continuous use, there was a complete resolution of lesions, without any pigmentary change. New lesions appeared and imiquimod was again used for 16 weeks, with a moderate to severe infl ammatory reaction. Areas of vitiligo-like depigmentation developed in the areas treated with imiquimod, and have remained stable for 18 months, much to the distress of the patient (fi gure 1). There was no previous history of vitiligo or other depigmentated areas elsewhere and no changes in thyroid function or autoim-munity were detected. The patient refused a biopsy in the affected area.The pathogenesis of vitiligo is still a matter of debate, with some evidence suggesting a T-cell mediated autoimmune reaction against melanocytes. The induction of vitiligo after skin trauma (Koebner effect) is not uncommon, but usually occurs in patients with a previous history of the disease. Theoretically, the ability of imiquimod to induce an immune response against infections and tumours may also be responsible for creating an environment in which the immune system would respond against melano-cytic antigens [5]. The activation of epidermal cytokines (IL-6 and IL-8) and interferon-alpha induced by imiqui-mod might have played a pathogenic role in the induction of vitiligo in our patient, through local activation of a cyto-toxic T-cell response [6].In conclusion, the depigmentation areas may represent the local induction of vitiligo, as a consequence of the immu-nological reaction triggered by imiquimod. This report has Figure 1. Vitiligo-like depigmentation after imiquimod for genital warts, stable for 18 months.jleejd00579_cor3.indd   342 4/16/2008   12:34:34 PMEJD, vol. 18, n° 3, May-June 2008 343doi : 10.1684/ejd.2008.0403a long follow-up period (18 months), suggesting that in some patients the depigmentation might be long-lasting or even permanent. Although uncommon, physicians must be aware of this potential side-effect, especially when using the product on visible areas. Acknowledgments. None of the authors has any affi liation or fi nancial involvement in any organization or entity with a direct fi nancial interest in the subject matter or materials discussed in the manuscriptDermatology Department, Hospital dos Capuchos, Alameda Santo António dos Capuchos, 1150 – 314 Lisbon, Portugalvvsferreira@netcabo.ptVasco VIEIRA SERRÃOFilipa ROCHA PÁRISAna BARATA FEIO1. Schöfer H, Van Ophoven A, Henke U, Lenz T, Eul A. Randomized, comparative trial on the sustained efficacy of topical imiquimod 5% cream versus conventional ablative methods in external anogenital warts. Eur J Dermatol 2006; 16: 642-8.2. Brown T, Zirvi M, Cotsarelis G, Gelfand JM. Vitiligo-like hypopigmen-tation associated with imiquimod treatment of genital warts. J Am Acad Dermatol 2005; 52: 715-6.3. Stefanaki C, Nicolaidou E, Hadjivassiliou M, et al. Imiquimod-induced vitiligo in a patient with genital warts. J Eur Acad Dermatol Venereol 2006; 20: 755-6.4. Mendonca CO, Yates VM. Permanent facial hypopigmentation fol-lowing treatment with imiquimod cream. Clin Exp Dermatol 2006; 31: 721-2.5. Rajpar SF, Marsden JR. Imiquimod in the treatment of lentigo maligna. Br J Dermatol 2006; 155: 653-6.6. Al-Dujaili Z, Hsu S. Imiquimod-induced vitiligo. Dermatol Online J 2007; 13: 10.Investigation for the leptin 1 and LEP G2548A gene polymorphism in psoriasisSince leptin is thought to play a role in immune functions [1] and an increased risk ofobesity and operation of a Th1 type of cell mediated immune response have been docu-mented in psoriasis; we aimed to investigate serum leptin levels and the effects of G2548A leptin gene polymor-phism on serum leptin levels in patients with psoriasis.Materials and methodsSixty-ﬁ ve patients with psoriasis and 64 healthy volunteers were included in this study. Family history of psoriasis, age of onset (before and after 40 years of age), duration of the disease, type of psoriasis (plaque psoriasis versus oth-ers), psoriasis area severity index (PASI), and activity of the disease (stable and unstable) were recorded.Leptin was measured by the ELISA method and G2548A polymorphism of the LEP gene was analyzed by PCR ampliﬁ cation. Statistical analysis was performed by using SPSS 13.0 for Windows. A summary of data is presented as mean ± sd (median, minimum and maximum).ResultsThere were 36 (55.4%) males and 29 (44.6%) females in the patient group and 41 (64.1%) males and 23 (35.9%) females in the control group. The mean ages of the patient and control groups were 45.17 ± 14.1 and 44.92 ± 14.2, respectively. There was no signiﬁ cant difference between the groups in terms of gender (x2 = 0.681, p = 0.409). Leptin levels were signiﬁ cantly correlated with BMI in both groups (r = 0.585, p = 0.0001 in patient group; r = 0.417, p = 0.0001 in control group; r = 0.518, p = 0.0001 for the whole group).Leptin levels of female patients with psoriasis were signiﬁ -cantly higher than control females. However, there was no signiﬁ cant difference between the diseased and control males (table 1, fi gure 1). Leptin levels were also signiﬁ cantly dif-ferent between females and males in patient (p = 0.001) and control groups (p = 0.026). The difference was more signiﬁ -cant for the patient group. There was no signiﬁ cant differ-ence in leptin levels of patients with a positive and negative family history, age of onset (below and above 40), patients with different clinical types and activity of the  disease. Meaningful correlations were not found between leptin  levels and duration of the disease (r = – 0.041, p = 0.746), and PASI score (r = 0.115 and p = 0.361).Leptin levels were not different between patients having GG, GA and AA genotypes (p = 0.424). Male patients with psoriasis did not show a signiﬁ cant difference in leptin lev-els based on the coding alleles (p = 0.915). Although female patients with the AA genotype had lower levels of leptin, the difference was not statistically signiﬁ cant (p = 0.322).DiscussionApart from the role of leptin in weight control and immune modulation, increasing evidence suggests a role in some immunologically mediated pathophysiological conditions [1]. Although there is no study investigating serum leptin levels in psoriasis, it has been investigated in diseases in which a Th1 type of immune response plays an important role. Increased levels have been reported in active Behcet’s disease [2].Correlation of serum leptin levels and G2548A poly-morphism was investigated and subjects with an AA genotype were found to have signiﬁ cantly higher levels Table 1. Serum leptin levels and BMI according to genders in patient and control groups.Mean leptin levels (med; min; max)Signifi cance BMI (mean)(med; min; max)Signifi canceFemale patients 39.07 ± 30.88(30.5; 1.3; 111.7)P = 0.006 29.41 ± 7.28(29; 17.58; 52.48)P = 0.191Female controls 18.28 ± 18.57(10.4; 0; 61.5)27.25 ± 6.01(25.97; 18.82; 44.53)Male patients 7.19 ± 12.64(4.95; –3.6; 55.2)P = 0.417 27.08 ± 4.51(26.91; 18.67; 37.18)P = 0.931Male controls 7.42 ± 9.29(4.2; –3.9; 33.5)27.41 ± 4.31(26.57; 20.24; 41.91)jleejd00579_cor3.indd   343 4/16/2008   12:34:34 PM

Genital Vitiligo-Like Depigmentation Following Use of Imiquimod 5% Cream

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Genital Vitiligo-Like Depigmentation Following Use of Imiquimod 5% Cream

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