4.2014

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I am persuaded that strong and drastic therapies to eradicate some dermal-cosmetical diseases are always better than light and expensive treatments byuseless cosmetic items, like gentle scrubs containing alpha, betha or gamma-hydroxyacids or certain miscellaneous of bio-extracts of exotic fruits or herbs, and/or revolting and redundant antioxidant agnets,  or moreover  creams or lotions containing  extremely poor dosages of benzoyl peroxide generally  suggested for the  administration  to the younger  for very long time in order only  to let the producer of cosmetics grow rich and notorious. When acne vulgaris (or ribelle) is not a mere aesthetic disturb, but enbodies  a real malady connected with severe psychological malaise, the usage of strong remedies, included antibiotics and escariotic agents, is welcome, even because it is conceivable that the syndrome will not appear again after this sort of dramatic treatment. It is undeniable, besides,  that Zinc….if combined with antibiotics will reduce antibiotic resistance and does increase antibiotic absortion into the skin, and I can assert it, by direct experience made in corpore vili.Many congratulations for the courage and determination dermatological surgeons in Iraq have demonstrated to combat Acne vulgaris.  Lorenzo Martini, M.Sc.  (Italy) 

The authors deserve appreciation for there deep insight in using this modality in the treatment of acne and acne scarring for showing efficacy and safety of 88% in lactic acid as a chemical peel.Their post operative instructions for use of potassium permanganate solution / acetic acid needs more elaboration.This treatment must be offered to the patients who don’t like the use of oral or topical treatment in long term regimens.A longer follow up of  at least six month would have given better insight about the relapse rates. In our country, pure lactic acid full strength (92%) pH 3.5 is being used with similar efficacy and safety.   Dr Rakesh Tilak Raj (India) 

The excellent results of peelings in many skin conditions is well known. In the case of acne, however, it is important to emphasize that this condition is caused by a confluence of elements that intervene to produce follicular plugging, inflammation and many times scarring. The course of acne is chronic and not just limited to certain period of time [1], therefore dermatologists should be cautious in counseling patients about the physiopathology of acne, how it behaves in time, as well as what are the evidence based, most effective resources available to treat it. More evidence is needed to assess the persistence of the reduction of the inflammatory and non-inflammatory lesions in time with 88% lactic acid peel. While 88% lactic acid peel might be safe in the treatment of acne it should not be recommended as a first line of treatment and a proper counseling and patient selection should be done.   Reference:  Thiboutot D, Gollnick H, Bettoli V, Dréno B, Kang S, Leyden JJ, et al. New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne group. J Am Acad Dermatol. 2009;60:S1-50.   Dr Manuel Valdebran (República Dominicana) 

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I am persuaded that strong and drastic therapies to eradicate some dermal-cosmetical diseases are always better than light and expensive treatments byuseless cosmetic items, like gentle scrubs containing alpha, betha or gamma-hydroxyacids or certain miscellaneous of bio-extracts of exotic fruits or herbs, and/or revolting and redundant antioxidant agnets, or moreover creams or lotions containing  extremely poor dosages of benzoyl peroxide generally suggested for the administration to the younger for very long time in order only to let the producer of cosmetics grow rich and notorious. When acne vulgaris (or ribelle) is not a mere aesthetic disturb, but enbodies a real malady connected with severe psychological malaise, the usage of strong remedies, included antibiotics and escariotic agents, is welcome, even because it is conceivable that the syndrome will not appear again after this sort of dramatic treatment. It is undeniable, besides, that Zinc….if combined with antibiotics will reduce antibiotic resistance and does increase antibiotic absortion into the skin, and I can assert it, by direct experience made in corpore vili.Many congratulations for the courage and determination dermatological surgeons in Iraq have demonstrated to combat Acne vulgaris.  Lorenzo Martini, M.Sc.  (Italy) 

More information have been given regarding the role of bacteria, in the pathogenesis of acne. Other pathogenic factors such as inflammation pathways have been more clearly understood, giving us a perspective of acne as a more inflammatory process rather than an infectious process [1]. It is very important to coordinate an appropriate therapeutical approach to patients with acne, when using antibiotics clinicians should remember not to use them as a monotherapy but in combination with topical retinoids and in conjunction with benzoyl peroxide [2]. Recent studies have suggested superior efficacy of benzoyl peroxide and clindamycin combination over erythromycin and zinc; data from Langer and coworkers suggests that benzoyl peroxide inhibits the rise in resistant bacteria that can occur with topical antibacterial treatment unlike with the zinc combination. Antibiotics are not the mainstay treatment in acne and they should not be use as a monotherapy. Concerning issues have arisen select resistance in coagulase-negative staphylococci after 12 weeks of treatment with topical erythromycin [3].   References:   1. Dreno B, Thiboutot D, Gollnick H, Bettoli V, Kang S, Leyden JJ, et al. Global Alliance to Improve Outcomes in Acne. Antibiotic stewardship in dermatology: limiting antibiotic use in acne. Eur J Dermatol. 2014;24:330-4.   2. Thiboutot D, Gollnick H, Bettoli V, Dréno B, Kang S, Leyden JJ, et al. New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne group. J Am Acad Dermatol. 2009;60:S1-50.   3. Langner A, Sheehan-Dare R, Layton A. A randomized, single-blind comparison of topical clindamycin + benzoyl peroxide (Duac) and erythromycin + zinc acetate (Zineryt) in the treatment of mild to moderate facial acne vulgaris. J Eur Acad Dermatol Venereol. 2007;21:311-9.   Dr Manuel Valdebran (República Dominicana) 

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1. The author is appreciated for highlighting the importance of ultrasonography along with biopsy to bring out undetectable lymph nodes. ( intramammary).  2. This presentation gives an advice to all dermatologist to revise the diagnosis periodically if the response to the treatment is not upto the expectation.  3. In fact, Kikuchi – Fujimo disease is the rarest of the rare in dermatology.  Prof. Sunderamoorthy Srinivasan  (India) 

Congratulations to the authors. It’s an interesting report, Thank you for the review and case report presentation. Overall the presentation is informative and educating. Kikuchi-Fujimoto disease (KFD) is a benign and self-limited disorder, characterized by regional cervical lymphadenopathy with tenderness, usually accompanied with mild fever and night sweats. Less frequent symptoms include weight loss, nausea, vomiting, sore throat. Kikuchi-Fujimoto disease is an extremely rare disease known to have a worldwide distribution with higher prevalence among Japanese and other Asiatic individuals. The role of infectious agents in the pathogenesis and evolution of Kikuchi-Fujimoto disease is a matter of debate. The onset of Kikuchi-Fujimoto disease is acute or subacute, evolving over a period of two to four weeks. Clinically, the most common presentation is unilaterally lymphadenopathy with tenderness: cervical lymph nodes are the principle site of disease in 70-90% of patients; other lymph nodes, such as the axillary and abdominal ones, may be less frequently involved. Generalized adenopathy is uncommon. KFD is generally diagnosed on the basis of an excisional biopsy of affected lymph nodes. Its recognition is crucial especially because this disease can be mistaken for systemic lupus erythematosus, malignant lymphoma or even, though rarely, for adenocarcinoma. Clinicians’ and pathologists’ awareness of this disorder may help prevent misdiagnsois and inappropriate treatment.   Dr. Yugandar Inaks (India) 

The case presented by the authors highlights the importance of including Kikuchi-Fujimoto disease as a differential diagnosis for lymphadenopathy and draw attention to clinicians that Kikuchi-Fujimoto disease can be mistaken for tuberculosis and lymphoma. Having in mind the differential diagnosis and a valuable histopathological report, unnecessary administration of certain drugs (used to treat tuberculosis) can be avoided and specific follow-up of the patient would be recommended. The article is well documented, up-to date, concise, wonderfully written and reaches the task of making us aware of this rare disease.   Prof Anca Chiriac and Prof Caius Solovan (Romania) 

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 The article is relevant and timely. This condition described is now becoming more frequent in developing countries after the introduction of triple combination regimens in day to day practice.The dermoscopy has reduced the need for biopsy in diagnosing this condition although in refractory cases, biopsy still remains the gold standard.Since this condition is refractory to treatment in most cases the authors’ observations that the indiscriminate use of hydroquinone containing compounds without medical prescription must be restricted, is the need of the hour. This article will help the dermatologists in observing this phenomenon frequently in their patients on hydroquinone.   Dr Rakesh Tilak Raj (India)