ACTA DERMATOVENEROLOGICA ALPINA, PANNONICA ET AD Rl ATI CA Volume 24 Issue 3 Ljubljana, September 2015 ISSN 1318-4458 dH H Acta Dermatovenerologica Alpina, Pannonica et Adriatica ACTA DERMATOVENEROLOGICA ALPINA, PANNONICA ET ADRIATICA Volume 24, Issue 3, September 2015 Editor in Chief J. Miljkovic (Slovenia) Honorary Editor A. Kansky (Slovenia) Editors A. Godic (Slovenia), B. Luzar (Slovenia), M. Poljak (Slovenia) Section Editors Allergology: M. Košnik (Slovenia) Histopathology: S. Hodl (Austria), H.P. Soyer (Austria), E. Calonje (UK) Infectious Diseases: J. Tomažič (Slovenia) Dermatooncology: I. Bartenjev (Slovenia), G. Trevisan (Italy) Sexually Transmitted Infections: M. Matičič (Slovenia), M. Potočnik (Slovenia), E. Vrtačnik Bokal (Slovenia) Clinical Dermatology: M. Dolenc-Voljč (Slovenia), G. Jemec (Denmark), M.D. Pavlovic (Slovenia) Internal Medicine: S. Bevc (Slovenia) Microbiology: M. Poljak (Slovenia) Biochemistry: M. Blumenberg (New York, USA), V. Dolžan (Slovenia) Immunology: A. Ihan (Slovenia), V. Kotnik (Slovenia) Genetics: P.E. Bowden (UK), D. Glavač (Slovenia) Pediatric Dermatology: V. Dragoš (Slovenia) Editorial Board T. Battelino (Slovenia), G. Burg (Switzerland), S. Chimenti (Italy), R. Hojs (Slovenia), A. Horvath (Hungary), Ch. W. Ihm (South Korea), S. Karpati (Hungary), N. Kecelj-Leskovec (Slovenia), H. Kerl (Austria), F. R. Kokelj (Italy), P. Kokol (Slovenia), R. Kokol (Austria), I. Krajnc (Slovenia), T. Lunder (Slovenia), B. Marinovic (Croatia), L. Mervic (Slovenia), M. Meurer (Germany), G. Micali (Italy), T. Planinšek-Ručigaj (Slovenia), J. Ring (Germany), M. Rogl-Butina (Slovenia), R. A. Schwartz (Newark, USA), M. Skerlev (Croatia), J. Soltz-Szots (Austria), A. Stary (Austria), A. Stanimirovic (Croatia), J. Szepietowski (Poland), M. Šitum (Croatia), V. Tlaker Žunter (Slovenia), L. Torok (Hungary), G. Trevisan (Italy), F. Vašku (Czech Republic), M. A. Waugh (UK), U. W. Wollina (Germany), W. I. Worret (Germany) Technical Editors T. Triglav (Slovenia) Editorial Office and Administration Department of Dermatovenerology, Zaloška 2, SI-1525 Ljubljana, Slovenia. Tel: +386 1 522 41 58, Fax: +386 1 522 43 33; E-mail: office@acta-apa.org The Journal is published quarterly. The yearly subscription is 55 EUR for individuals and 65 EUR for institutions plus postage. Indexed and abstracted by: BIOMEDICINA SLOVENICA, EMBASE/ Excerpta Medica and Index Medicus/MEDLINE Submission guidelines The submission guidelines, updated on 1 January 2012, can be accessed at the following URL address: http://www.acta-apa.org/submission-guidelines.pdf Orders and Payments Orders: Association of Slovenian Dermatovenerologists, Zaloška 2, SI-1525 Ljubljana, Slovenia Payments: Nova Ljubljanska banka, d.d., Zaloška 7, Ljubljana IBAN: SI 56020140089341717, SWIFT: LJBA2X, VAT: SI 32325029 Published by Association of Slovenian Dermatovenerologists, Zaloška 2, SI-1525 Ljubljana, Slovenia Founded by A. Kansky in 1992, Ljubljana Design and print Design: Modra Jagoda (www.modrajagoda.si) Copy Editor for articles: Donald F. Reindl Typesetting: Milan Števanec Printed on acid free paper ISO 9706 by: Tiskarna Pleško Journal Acta Dermatovenerologica Alpina, Pannonica et Adriatica is enlisted in Razvid medijev. Journal Acta Dermatovenerologica Alpina, Pannonica et Adriatica is financially supported by the Slovenian Research Agency (Javna agencija za raziskovalno dejavnost Republike Slovenije). Printed in 250 copies. Acta Dermatovenerol APA Acta Dermatovenerologica Alpina, Pannonica et Adriatica 2015;24(3) Table of Contents ^m Original articles Assessment of serum levels of granulocyte-macrophage colony-stimulating fac- 43 tor (GM-CSF) among non-segmental vitiligo patients: a pilot study AzmyAhmedAbdellatif, Amr Mohamed Zaki, Hamed MohamedAbdo, Dalia Gamal Aly, TarekAhmed Emara, Saflnaz El-toukhy, Hanaa Mohamed Emam, Mahetab Samir Abdelwahab Commercially available kits for manual and automatic extraction of nucleic acids 47 from formalin-fixed, paraffin-embedded (FFPE) tissues Boštjan J. Kocjan, Lea Hošnjak, Mario Poljak ^m Case reports Coexistence of systemic lupus erythematosus, Hashimoto's thyroiditis, and 55 bilateral breast cancer in the same patient: a random association? Elisa Molinelli, Katia Giuliodori, Anna Campanati, Valerio Brisigotti, Annamaria Offdani A rare variant of pilomatricoma: pseudobullous pilomatricoma 59 Hilal Kaya Erdogan, Zeliha Kaya, Qigdem Derya Aytop, ErsoyAcer A case of scar sarcoidosis developing in an old scar area on the forehead Cengiz Kocak, Ergin Yücel, Nazli Dizen Namdar, Hasan Tak 61 Belakne (adapalen) Adapalen je ZDRAVILO IZBORA ZA ZDRAVLJENJE BLAGIH DO ZMERNIH OBLIK AKEN. (European Evidence based Guidelines for the Treatment of Acne, JEADV 2012) Zdravilo Belakne i-r DELUJE NA VZROK nastajanja aken i T PROTIVNETNO f URAVNAVA ■ KOMEDOLITIČNO f PROTIBAKTERIJSKO DIFERENCIACIJO KERATINOCITOV ZA OPTIMALEN REZULTAT Belakne - v dveh oblikah gel 0,1% za mastno kožo Belakne krema 0,1% za suho, občutljivo kožo Skrajšan povzetek glavnih značilnosti zdravila Belakne 1 mg/g gel Belakne 1 mg/g krema Sestava: 1 g gela ali kreme vsebuje 1 mg adapalena. Indikacije: Zdravljenje blagih do zmernih aken s pretežno prisotnimi ogrci, papulami in pustulami na obrazu, prsih ali hrbtu. Odmerjanje: Zdravilo Belakne se uporablja pri otrocih starejših od 12 let in pri odraslih. Varnost in učinkovitost zdravila Belakne pri otrocih, mlajših od 12 let nista bili dokazani. Zdravilo Belakne je treba nanesti na aknozne spremembe kože enkrat na dan, najbolje po umivanju, zvečer pred spanjem. Tanko plast kreme ali gela je treba z blazinicami prstov nanesti na prizadeta mesta na koži tako, da se izogiba očem in ustnicam. Priporočljivo je, da se oceni izrazitost izboljšanja po 3 mesecih zdravljenja z zdravilom Belakne. Če je potrebno zdravljenje s perkutanimi protibakterijskimi zdravili ali benzoil peroksidom, jih je treba na kožo nanašati zjutraj, zdravilo Belakne pa zvečer. Kontraindikacije: Preobčutljivost za zdravilno učinkovino ali katerokoli pomožno snov. Posebna opozorila in previdnostni ukrepi: Če se pojavi preobčutljivostna reakcija ali hudo draženje, je treba uporabo zdravila prekiniti. Zdravilo Belakne ne sme priti v stik z očmi, usti, robovi nosu ali mukoznimi membranami. Če zdravilo po nesreči pride v stik z očmi, jih je treba izprati s toplo vodo. Ne sme se aplicirati na poškodovano (ureznine in odrgnine), od sonca opečeno ali ekcematozno kožo niti se ga ne sme uporabljati pri bolnikih s hudimi aknami ali aknami na večjih površinah telesa. Pri bolnikih, ki prejemajo retinoidna zdravila se je treba izogibati depilaciji z voskom. Hkratni uporabi zdravila Belakne in perkutanih keratolitikov ali eksfoliacijskih zdravil se je treba izogibati. Ob sočasni uporabi sredstev za luščenje (peeling), medicinskih ali abrazivnih mil, kozmetičnih izdelkov, ki kožo sušijo, adstringentov ali izdelkov, ki dražijo kožo (dišav, lupino limone ali izdelkov, ki vsebujejo alkohol), se lahko stopnjuje učinek draženja. Izpostavljanje sončni svetlobi ali umetnim UV žarkom (vključno s solariji) je treba med uporabo zdravila Belakne zmanjšati na minimum. Kadar se izpostavljenosti soncu ni moč izogniti, je treba uporabljati zaščitna sredstva in zdravljene predele kože zaščititi z obleko. Interakcije: Ni znanih interakcij pri sočasni uporabi zdravila Belakne z drugimi zdravili, ki jih lahko uporabljamo perkutano. Kljub temu pa zdravila Belakne ne smemo uporabljati skupaj z drugimi retinoidi ali zdravili s podobnim načinom delovanja. Izogibati se je treba uporabi zdravila Belakne skupaj z vitaminom A (vključno s prehranskimi dodatki). Adapalen ni fototoksičen in ne povzroča alergije na svetlobo, vendar pa varnost uporabe adapalena med večkratno izpostavljenostjo soncu ali UV sevanju ni bila dokazana. Večji izpostavljenosti soncu ali UV sevanju se je treba izogibati. Ker je absorpcija adapalena skozi kožo majhna, so interakcije s sistemsko uporabljenimi zdravili zelo malo verjetne. Nosečnost in dojenje: Ker je na voljo malo podatkov in zaradi možnega prehoda zdravila skozi kožo v krvni obtok, zdravljenje z zdravilom Belakne med nosečnostjo ni priporočljivo. V primeru nepričakovane nosečnosti je treba zdravljenje z zdravilom Belakne prekiniti. Zdravilo Belakne lahko uporabljate med dojenjem, vendar se zdravila ne sme nanašati na predel prsnega koša, da ne pride v stik z dojenčkom. Učinkov adapalena na dojenčka ni pričakovati, ker je sistemska izpostavljenost doječe matere zanemarljiva. Vpliv na sposobnost vožnje in upravljanja s stroji: Ni vpliva. Neželeni učinki: Suha koža, draženje kože, občutek toplote na koži, eritem, kontaktni dermatitis, občutek nelagod-ja na koži, pekoč občutek na koži, srbenje, luščenje kože, očitno poslabšanje aken, bolečina, oteklina, mehurji ali kraste na koži in draženje, rdečina, srbenje ali oteklina očesnih vek. Vrsta ovojnine in vsebina: Škatla s tubo po 30 g gela ali 30 g kreme. Režim izdaje: Rp Imetnik dovoljenja za promet: Belupo d.o.o., Dvoržakova 6, 1000 Ljubljana. Datum zadnje revizije besedila: 28.5.2012 Podrobnejše informacije o zdravilu in povzetek glavnih značilnosti zdravila so vam na voljo pri strokovnih sodelavcih in na sedežu podjetja Belupo. @BELUPO I Bodimo zdravi! BELUPO, d.o.o., Dvoržakova ulica 6, 1000 Ljubljana Tel: 01 300 95 10, faks: 01 432 63 11 E-pošta: info@belupo.si, www.belupo.si Acta Dermatovenerol APA Acta Dermatovenerologica Alpina, Pannonica et Adriatica 2015;24:43-45 doi: 10.15570/actaapa.2015.11 Assessment of serum levels of granulocyte-macrophage colony-stimulating factor (GM-CSF) among non-segmental vitiligo patients: a pilot study Azmy Ahmed Abdellatif1, Amr Mohamed Zaki1, Hamed Mohamed Abdo1, Dalia Gamal Aly2 H, Tarek Ahmed Emara2, Safinaz El-toukhy3, Hanaa Mohamed Emam2, Mahetab Samir Abdelwahab2 Abstract Introduction: Granulocyte-macrophage colony-stimulating factor (GM-CSF) is an essential factor in the growth and maturation of blood cells as well as modulation of the immune system. Few studies have investigated its involvement in the development of vitiligo, and no studies have been performed on Egyptian patients. Aim: To assess GM-CSF serum level among non-segmental Egyptian vitiligo patients and to determine its possible role in the eti-opathogenesis of the disease. Methods: Forty patients with non-segmental vitiligo and 40 age- and sex-matched subjects were assessed for levels of GM-CSF in serum using the ELISA technique. Results: The patients in this study showed lower levels of GM-CSF in serum compared to controls (mean ± SD was 33.4 ± 5.7 pg/ml versus 63.4 ± 7.4 pg/ml, respectively, p = 0.0001). No appreciable relation was detected between levels of GM-CSF in serum and age, sex, family history, and stressful events or disease activity, type, and extent, p > 0.05. Conclusions: GM-CSF serum level may be one of the determinants of the autoimmune hypothesis in the etiopathogenesis of non-segmental vitiligo. Keywords: GM-CSF, non-segmental vitiligo, Egyptian patients Received: 24 May 2015 | Returned for modification: 3 June 2015 | Accepted: 20 August 2015 Introduction Vitiligo is a chronic disorder that affects a large number of people all over the world. Genetic factors and several related genes are considered to play an important role in its development (1). Multiple theories have been proposed for its development, including the hydrogen peroxide theory, the cytotoxic metabolites theory, the neural theory, the growth factor theory, and the melanocytor-rhagy theory. Animal models and case reports also support the hypothesis that viral infections may play a role in the disease. However, none of these mechanisms are decisively proven (2). Several studies have demonstrated strong support for the autoimmune theory, which proposes that the loss of melanocytes could arise via the destruction of pigment cells by the immune system. The occurrence of vitiligo with Addison's disease, alopecia areata, pernicious anemia, and Hashimoto's thyroiditis also favors the autoimmune hypothesis of the disease (3). Granulocyte-macrophage colony-stimulating factor (GM-CSF) is part of the family of hematopoietic cytokines. It is released by a range of cell types, including endothelial cells, activated T-cells, monocytes, macrophages, mitogen-stimulated B-cells, and fibroblasts in the form of a single-stranded glycoprotein that has 128 amino acids with a covalent bond (4). Granulocyte-macrophage colony-stimulating factor can stimulate stem cells to develop into various types of mature blood cells and has been primarily found to cause bone-marrow precursor cells to produce both macrophages and granulocyte colonies. It also arbitrates important functions in antitumor immune reaction and in host response to external stimuli. These crucial roles result from its ability to influence the function of mature and immature myeloid cells, such as eosino-phils, macrophages, dendritic cells (DCs), and granulocytes (5). Recent studies indicate that GM-CSF plays a central role in the pathogenesis of several autoimmune and inflammatory diseases, including multiple sclerosis, rheumatoid arthritis, and autoimmune and hereditary pulmonary alveolar proteinosis. It has been reported that its overexpression in the stomach can lead to autoimmune gastritis. Moreover, increased levels of GM-CSF autoantibodies have also been found in patients with Crohn's disease (6). The role of GM-CSF in autoimmune and inflammatory disorders makes it of interest for assessment in vitiligo. The data for this role comprise worsening disease in animals by targeting the GM-CSF gene or by blocking the GM-CSF antibody (7). To the best of our knowledge, few studies have considered the role of GM-CSF in the pathogenesis of vitiligo (8, 9), with no studies performed on Egyptian patients. Therefore, the aim of this work was to assess GM-CSF levels in the serum of Egyptian patients with non-segmental vitiligo. Patients and methods Patients This pilot study included 40 patients (25 females and 15 males) with non-segmental vitiligo. Patients were sub-classified into 20 patients with active vitiligo and 20 patients with stable disease. Forty volunteers served as controls (27 females and 13 males) and had the same age and sex as the patients. The clinical diagnosis was supported by the existence of well-demarcated, depigmented •Department of Dermatology, Venereology, and Andrology, Al-Azhar University, Cairo, Egypt. 'Department of Dermatology and Venereology, National Research Center, Giza, Egypt. 3Department of Medical Biochemistry, National Research Center, Giza, Egypt. a Corresponding author: dalia.g.aly@gmail. A. A. Abdellatif et al. Acta Dermatovenerol APA | 2015;24:43-45 patches, confirmed by Wood's lamp examination. We excluded patients receiving topical treatment for the previous 2 weeks or systemic treatment for the previous 2 months prior to the study, and those with any associated autoimmune or systemic disease. All patients and controls were selected from the National Research Center's dermatology clinic. All subjects gave informed consent to participate in this study. The work was approved by the research ethics board at the National Research Center in Giza, Egypt. Methods A complete history was taken from all subjects, followed by a clinical examination and measurement of GM-CSF levels in sera. The activity of vitiligo was defined based on the evolution of previously affected areas or the emergence of novel areas in the previous 3 months (10) and inactive disease was classified based on the lack of evolution of previously affected areas or emergence of new areas in the previous 6 months (11). The extent of vitiligo was assessed using the Rule of 9 following Hamzavi et al. (12), which is the approximate percentage of the body surface area involved. Skin phototype was determined according to the Fitzpatrick Scale, which is a numerical classification scheme for skin color (13). Assessment of GM-CSF serum levels Measurement of the GM-CSF levels in the sera of all patients and controls was carried out after drawing a 3 ml blood sample from each of them. Centrifugation of the samples was performed followed by freezing the sera, which was kept at -20 °C until assessment. GM-CSF assessment was performed by means of the Enzyme-Linked Immunosorbent Assay Human GM-CSF kit, Lab-sTM Inc. Biotechnology, Canada. The investigational methodologies were carried out based on the information supplied by the company. Calculation of results To calculate the concentration of patients' samples, the negative control absorbance was deducted from the observed one. Then the optical density of each standard was plotted against its concentration (pg/ml) using a logarithmic scale to construct the "standard curve." The equivalent concentration of Human GM-CSF in pg/ml in patients' samples was determined by plotting the subtracted absorbance value of all samples on the standard curve. Statistical analysis Statistical Package for the Social Sciences (SPSS) version 18 for windows SPSS; Inc, Chicago, IL was used for data analysis. Continuous data were expressed as mean and standard deviation. Number and percent were used to describe categorical information. A t-test was used for comparing between two means and a chi-square test for comparing between two qualitative variables. To correlate between two continuous variables, the Pearson correlation test was used. P < 0.05 was considered statistically significant. Results Out of the 40 patients with non-segmental vitiligo enrolled in this study, 25 were females (62.5%) and 15 were males (37.5%). Their Table 1 | Comparison between patients and controls for serum levels of granu-locyte-macrophage colony-stimulating factor. Variables Patients (n = 40) Controls (n = 40) P GMCSF (pg/ml) mean ± SD 33.4 ± 5.7 63.4 ± 7.4 0.0001* *Significant age ranged from 10 to 71 years with a mean ± SD of 31.1 ± 17.3 years. The control group comprised 27 females (67.5%) and 13 males (32.5%). Their age varied from 13 to 72 years with a mean of 30.50 ± 17.5 years. There was no statistical distinction between patients and controls regarding age and sex (p > 0.05). Among the 40 patients, 20 (50%) patients had active vitiligo and 20 (50%) had stable disease. Family history of vitiligo was positive in 10 (25%) of the patients. Stress was reported by 25 (62.5%) patients to be an aggravating factor for the disease. Clinical assessment of the patients revealed that 32 patients (80%) had generalized vitiligo, seven (17.5%) had acrofacial vitiligo, and only one (2.5%) had focal vitiligo. Skin phototype was divided into five categories: five (12.5%) patients had Type 2 skin phototype, 12 (30%) had Type 3, 21 (52.5%) had Type 4, and two (5%) had Type 5. On comparing the patients to the control group by serum levels of GM-CSF, we noted considerably lower GM-CSF levels in the sera of vitiligo patients; the mean ± SD was 33.4 ± 5.7 pg/ml versus 63.4 ± 7.4 pg/ml, respectively, p = 0.0001 (Table 1). No statistically significant difference was noted when comparing the GM-CSF levels in the sera of patients with various variables such as age, sex, family history, stress, disease activity, and type, p > 0.05 (Table 2). Moreover, no noteworthy association was detected between GM-CSF levels in the sera of patients for either skin phototype or disease extent (r = 0.1, -0.2, respectively, p > 0.05). Discussion A limited number of studies, in different populations, have been performed in an attempt to understand the mode of action of GM-CSF in vitiligo, but with conflicting results (9, 15, 16) because the GM-CSF levels in either sera or lesional vitilgo skin was quite variable. Low levels of GM-CSF have been recognized circulating in the sera of individuals that rise in inflammatory diseases or immune reactions (15). Nevertheless, in the current study we observed a decreased GM-CSF serum level in Egyptian patients with non-segmental vitiligo compared to their age- and sex-matched controls. Human melanocytes have receptors for GM-CSF (18, 19), Table 2 | Granulocyte-macrophage colony-stimulating factor serum level by patient variables. Variables Granulocyte-macrophage colony-stimulating factor (mean ± SD) P Age (years) 10-40 32.4 ± 5.6 0.08 > 40 36.0 ± 5.5 Sex Male 34.5 ± 7.5 0.4 Female 32.8 ± 4.4 Family history Negative 34.0 ± 6.3 0.3 Positive 31.8 ± 3.3 Stress Negative 32.3 ± 5.1 0.3 Positive 34.1 ± 6.1 Vitiligo activity Active 32.4 ± 6.5 0.3 Stable 34.4 ± 4.8 Vitiligo type Generalized 32.9 ± 5.7 0.5 Acrofacial 34.6 ± 5.7 Acta Dermatovenerol APA j 2015;24:43-45 GM-CSF and vitiligo whereby GM-CSF can work as a mitogenic stimulator on them, indicating that its deficiency may play a role in the depigmentation process in the disease (20). Few reports were in agreement with our findings, such as that by Moretti et al. (16), who demonstrated increased tumor necrosis factor (TNF)-a and interleukin (IL)-6 and decreased GM-CSF and basic fibroblast growth factor (BF-GF) in lesional vitiligo skin. Martinez-Esparza et al. (17) also showed a decrease of GM-CSF in lesional vitiligo lesions. Moreover, Yu et al. (8) noted that vitiligo patients with active disease had a reduction in the formation of GM-CSF via mononuclear cells. There is increasing proof that cytokines play a vital function in the autoimmune process occurring in vitiligo, explaining the depigmentation process taking place in the disease. Our findings together with those of the previous studies point to an imbalance in cytokine levels in vitiligo, which could impair the normal lifespan and function of melanocytes and thus recovery from vitiligo. Moretti et al. (16) found increased TNF-a and IL-6, which are par-acrine inhibitors of melanocytes, and decreased GM-CSF and BF-GF, which have a stimulating effect on melanocytes, which could be linked to this hypothesis. It should be noted that the previous studies were carried out on vitilignous skin whereas our work was performed on serum. We believe that the correlation of serum cytokine levels with the epidermal cytokine microenvironment needs to be explained in greater detail. Interestingly, Campbell et al. (21) demonstrated that mice deficient in GM-CSF were found to have a noticeable decrease in the frequency and pathology of collagen-induced arthritis. This contrasted with our results because our patients with vitiligo (whether active or stable disease) had low GM-CSF serum levels compared to controls, indicating that its reduction helped in the initiation and/or progression of the disease. Conversely, Tu et al. (9) noted that the sera of vitiligo patients with either the generalized or focal subtypes showed an increase in GM-CSF levels. In addition, patients with active vitiligo exhibited raised levels of GM-CSF serum compared to patients with inactive disease, suggesting that GM-CSF could play a role in the development of vitiligo. Determining whether or not raised GM-CSF levels play a role in triggering the autoimmune process in vitiligo needs to be evaluated. The exact explanation for the partially overlapping results regarding the formation of GM-CSF in the disease and the mechanisms behind its role in vitiligo is not clearly known. Does its in vitro role differ from in vivo, and from one autoimmune disorder to another, or even in the same disorder? Can its increase as well as decrease be related to the pathogenesis of vitiligo, and can this be a part of multiple factors such as the family history, which was quite high in our study? This remains to be evaluated. We believe that the confined presence of GM-CSF could be sufficient to modify tolerance and trigger an autoimmune reaction by T-helper cells via activation of DCs. Dendritic cells may exert their tolerogenic roles via the production of regulatory cells (Tregs) which are activated by tolerogenic DCs (22). It is probable that GM-CSF activates Tregs through a diverse method and that the development of these cells directly affects the DCs phenotype and function. This could be in agreement with the idea that T cells ought to be resistant to low levels of GM-CSF so as to prevent an exaggerated response to the low levels of GM-CSF produced by the innate immune system (23). To conclude, GM-CSF may be one of the determinants of the autoimmune hypothesis claimed in the etiopathogenesis of non-segmental vitiligo. Future larger-scale studies are warranted to confirm our findings. References 1. Elassiuty YE, Klarquist J, Speiser J, Yousef RM, El Refaee AA, Hunter NS, et al. Heme oxygenase-1 expression protects melanocytes from stress-induced cell death: implications for vitiligo. Exp Dermatol. 2011;20:496-501. 2. Aly DG, Salem SAM, Abdel-Hamid MF, Youssef NS, El Shaer MA. Endothelin-1 and its A and B receptors: are they possibly involved in vitiligo? Acta Dermatovenerol Croat. 2013;21:12-8. 3. Noël M, Gagné C, Bergeron J, Jobin J, Poirier P. Positive pleiotropic effects of HMG-CoA reductase inhibitor on vitiligo. Lipids Health Dis. 2004;10:3-7. 4. Hamilton J, Anderson GP. GM-CSF biology. Growth Factors. 2004;22:225-31. 5. Francisco-Cruz A, Aguilar-Santelises M, Ramos-Espinosa O, Mata-Espinosa D, Marquina-Castillo B, Barrios-Payan J, et al. Granulocyte-macrophage colony-stimulating factor: not just another haematopoietic growth factor. Med. Oncol. 2014;31:774. 6. Shiomi A, Usui T. Pivotal roles of GM-CSF in autoimmunity and inflammation. Mediators Inflamm. 2015^015:568543. doi: 10.1155/2015/568543. 7. Goldstein JI, Kominsky DJ, Jacobson N, Bowers B, Regalia K, Austin GL, et al. Defective leukocyte GM-CSF receptor (CD116) expression and function in inflammatory bowel disease. Gastroenterol. 2011;141:208-16. 8. Yu HS, Chang KL, Yu CL, Li HF, Wu MT, Wu CS. Alterations in IL-6, IL-8, GM-CSF, TNF-a, INF-y release by peripheral mononuclear cells in patients with active vitiligo. J Invest Dermatol. 1997;108:527-9. 9. Tu CX, Gu JS, Lin XR. Increased interleukin-6 and granulocyte-macrophage colony-stimulating factor levels in the sera of patients with non-segmental vitiligo. J Dermatol Sci. 2003;31:73-8. 10. Ines D, Sonia B, Riadh BM, Amel el G, Slaheddine M, Hamida T, et al. A comparative study of oxidant-antioxidant status in stable and active vitiligo patients. Arch Dermatol Res. 2006;298:147-52. 11. Dammak I, Boudaya S, Ben Abdallah F, Turki H, Attia H, Hentati B. Antioxidant enzymes and lipid peroxidation at the tissue level in patients with stable and active vitiligo. Int J Dermatol. 2009;48:476-80. 12. Hamzavi I, Jain H, McLean D, Shapiro J, Zeng H, Lui H. Parametric modeling of narrowband UV-B phototherapy for vitiligo using a novel quantitative tool: the Vitiligo Area Scoring Index. Arch Dermatol. 2004;140:677-83. 13. Fitzpatrick, TB. Soleil et peau [Sun and skin]. J Med Esthet. 1975;2:33-4. French. 14. Schmid, MA, Kingston D, Boddupalli S, Manz MG. Instructive cytokine signals in dendritic cell lineage commitment. Immunol Rev. 2010;234:32-44. 15. Lacey DC, Achuthan A, Fleetwood AJ, Dinh H, Roiniotis J, Scholz GM, et al. Defining GM-CSF and macrophage-CSF dependent macrophage responses by in vitro models J Immunol. 2012;188:5752-65. 16. Moretti S, Spallanzani A, Amato L, Hautmann G, Gallerani I, Fabiani M, et al. New insights into the pathogenesis of vitiligo: imbalance of epidermal cytokines at sites of lesions. Pigment Cell Res. 2002;15:87-92. 17. Martinez-Esparza, M, Jimenez-Cervantes C, Solano F, Lozano JA, Garcia-Borron JC Mechanisms of melanogenesis inhibition by tumor necrosis factor-alpha in B16/F10 mouse melanoma cells. Eur J Biochem. 1998;255:139-46. 18. Bagby GC, McCall E, Bergstrom KA, Burger D. A monokine regulates colony-stimulating activity production by vascular endothelial cells. Blood. 1983;62:663-8. 19. Lee FT, Yokota T, Otsuka L. Isolation of cDNA for a human granulocyte-macrophage colony-stimulating factor by functional expression in mammalian cells. Proc Natl Acad Sci U S A. 1985;82:4360-4. 20. Imokawa G, Yada Y, Kimura M, Morisaki N. Granulocyte/macrophage colony-stimulating factor is an intrinsic keratinocyte-derived growth factor for human melanocytes in UVA-induced melanosis. Biochem J. 1996;313:625-31. 21. Campbell IK, Rich MJ, Bischof RJ, Dunn AR, Grail D, Hamilton JA. Protection from collagen-induced arthritis in granulocyte-macrophage colony-stimulating factor-deficient mice. J Immunol. 1998;161:3639-44. 22. Biondo M, Nasa Z, Marshall A, Toh BH, Alderuccio F. Local transgenic expression of granulocyte-macrophage colony-stimulating factor initiates autoimmunity. J Immunol. 2001;166:2090-9. 23. Himes SR, Sester DP, Ravasi T, Cronau SL, Sasmono T, Hume DA. The JNK are important for development and survival of macrophages. J Immunol. 2006;176:2219-28. 45 vedno pri roki Diprosone® I dermalna raztopina 100 ml I krema 30 g in 50 g I mazilo 30 g in 50 g ia; Elocom 1 mg/g dermalna raz Ime zdravila: ELOCOM 1 mg/g mazilo, Elocom 1 mg/g krema, Elocom 1 mg/g dermalna raztopina • SESTAVA: 1 g mazila/ srbecih dermatoz, ki se ocizovejo na kortikosteroidnoterapi|o, kot so npr psonaza,aitopcnidermatitisterd^e^irl/aili atrofiji kaše, ppkoralnem dermatitise, perlpralnem in t)enltplnem pkeritese, pleninoem izpeščaje, bakteniskih oeežbah (npr impetige, pioderm), viresnih okežbah (npr. herpes simplekse, herpes zostre, noricah, navadnih bradavicah, kor-dilomih (condylomptp pceminpSp), moleskih (mollescem corSpgiosem), parazitskih in glivičnih okežbah (npr. s kandido Etam dot draženja ml i p^boJljo/osto, je treba bolnik ez drav il o ukiniti in mpevestmukríPPnotelprpl|o.Če pricra do po|ava lo, pa mi pride do re )či tudi zn Različne for So popolno ukinitvi ze in lahko tudi za ilo Elocom kre že v obliki dermatitisa z močno pordelostjo kože ter zbpdpjočim in pe ........a, na primer z intermitertnim zdravl ) spremenijo videz nekaterih lezlj ter tako otežijo p in dojenje Med na to pa se mi la Elocom za lokalno uporabi jo in dojenjem se sme bolnica z niso ra lom Elocom le po nasvete zdravnika. Ne glede v čase gosečnooi pri človeku Poknlnn eperaba korSlknpteroldav pri brejih zvalidlah^h in dobro kontroliranih štedij z zdravilom Elocom pri nosečnicah, tedi ni znano tveganje za pojav takšnih ečinkov pri človeškem plode. ^b rT treba kot p" ^ lokalno epo^ih kortlkosteroidih epoištevati možnost, da bo mater ali plod. Ni zrano,, pl|PptOkoÍalspl|l^ eporaba lsslrtlčlestler□idovlp■odl do njlhovir apOdstne sPstemcke absorpciji, za sodijosehp kozp,jemžen|e kuže, dermptltls, mankracja kežr^, lvtočlnsPkl izcaščajin tltlPnblekttl,rol|e. l=>rl eporabi lo,lOnlnlh koliko teroidog o lphko pediptričnibolniki bolj občetljlvlzp sepresjo hlpotplpmo-hlP|Ofana-pdrenplneosi in npstpnek Imetnik dovoljenja za promet: Merck Sharp & Dohme, inovatvne zdravila d.o.o., Šmartinska cest Slovenija • Datum zadnje revizije besedila: 09.082013 Diprosone® krema 30 g in 500 g mazilo 30 g in 500 g Ime zdravila: Oiprorone 0,5 mg/g mazilo Diprosone 0,5 mg/g mazilo • SES mdicrano za lajšanje k^netmh zrakov in srbenja ppi dPetmptsaah, kel se od kortikosteroidnih zdravil (pkne, rosacepe, kožni elkesi, viresne in glivične infekcije). • Posebna opozorila pi: Če se pri eporabi zdravila Diprosone krema pojavi draženje pli senzibilizpajp, morate z zdravljenjem jo. Če imp bolnik okežbo, me predpišite estrezen pntimikotik pli antibiotik. V primere, ud ekiniti, dokler ni dosežen estrezen nadzor okežbe. Vsak od neželenih ečinkov, ki so jih opisovali pri sistemski eporpbi kortikosteroidov, vklječno s sepresjo radledvične žleze, se lphko pojavi tedi pri lokalni eporpbi kortikosteroidov, še posebej pri dojenčkih in otrocih. Sistemska absorpcija lokalnih kortikosteroidov je povečana, če zdravimo obsežne telesne površine pli če eporabljpmo oklezvni povoj. V tem primere pli če prlčpkejete dolgotrajno eporabo zdravila, epoštevpjte estrezne previdnostne ekrepe, še posebej pri dojenčkih in otrocih. Uporaba v pediptriji: Pediptrični bolniki so lphko bolj občetljlvl od odraslih bolnikov bp sepresjo hlpotplpma• hlpoflzno-renplne (HHS) osi zpradi eporpbe lokalnih kortikosteroidov in ra ečinke eksogenih kortikosteroidov, in sicer zaradi večje absorpcije, ki je posledica velikega razmerja med površino kože in telesno maso. Pri otrocih, ki so p lokalne kortikosteroide, so poročali o sepresiji hlpoSplpmo-hlpofano-renplne osi, Ceshingovem sindrome, zastoje rasti v višino in pridobivana telesne mpse ter intrpkrpniplni hlpertenzljl. Zraki sepresije radledvične žleze pri otrocih so npr. nizka plazemskp koncentracija kortizolp in neodzvnost np stimelpcjo z ACTH. Znpki lrSrakranalne hipertenzije pa so rrpvzročl aletgl|slsp reakcije. Cetll in btepsil plkohoP| phko povzrdčl lokalle kožne reakpi|e(npr.| kkntpktni dermprltlst. Zdravilo Diprosone kremp ni namenjeno okelprni eporpbi.. • Norečnorl in dojenje Ker varnosti eporpbe lokalnih kortikosteroidov pri nosečih ženskah še niso egotovill, smete zdravila z te skepine predpisati v čase nosečnosti le, če pričakovana korist zdravljenja matere eprpviči morebitno tveganje zp plod. Pri nosečih ženskah ne smete predpisovati zdravil iz te skepine v večji količini pli zp daljši čas. Ker ni znpno, pli phko lokplnp eporpbp kortikosteroidov vodi do odločiti, pli raj mati preneha dojiti pli pa epoPrabjpjp zjd^vilo, epošmvajoč pomembnort zdravila za mpler. • Neželeni ucinki Pogosti neželeni ecinki so pekoč občutek, srbenje, draženje, sehp kcžp, folikelitis, hipertrihozp, pkram podobni izpeščaji, hipopigmentpcijp, periorplnl dermptltls, plergjski kontaktni dermptSlS, mpceraci|p kože, ptrofljp kože, strlje, miliprip in sekendprne okežbe. Prosimo, preberite celoten seznam porocanih neželenih učinkov zdravila v poglavju 4.8 Povzelka (lavnih značilnosti zdravila. • Način in režim izdaje zdravila: Predpisovanje in izdpjp zdrpvia je le np recept. • Imetnik dovoljenja za promet: Merck Sharp & Dohme, inovatvra zdravila d.o.o., Šmprtinskp cestp 140, 1000 L|ebl|pra, Slovenjpa Oatum zadnje revizije besedila: 13.01.2014 Diprosalic® dermalna raztopina 100 ml mazilo 30 g in 50 g I Ime zdravila: Oiproralic 0,5 mg/30 mg v 1 g mazilo, Diprosplic 0,5 mg/30 mg v 1 g kremp, Diprosp dermplrrp raztopina Sestava: 1 g mpzilp vsebeje 0.5 mg betpmeSpaora v obliki 0,64 mg beSpmeS mg salicilne kisline. 1 g dermalne raztopine vsebeje 0,5 mg betpmeSpaora v obliki 0,64 mg be in 20 mg splicilne kisline. • Terapevtske indikacije: Zdravilo Dip m in ek nernulprnlm ek velgpris in drege ihtotične pli splicilno kislino pli pli kp zdravil: pkne, rospceae, kož Zato lahko pride po ^rajnem zdravj ih učinkov. Ce uporaba mazila povzroči i tn, ga nasnnemoPnorabe. Bakterijske in glvične okuž priporočamo občasno p zdravljenje začasno prekiniti, in sicer vedno, tadrnr po ne 5 M O M ■t- Acta Dermatovenerol APA | 2015;24:47-53 FFPE DNA/RNA extraction methods Discussion Our inventory identified at least 69 commercial kits specifically developed for manual, automated, or fully automated extraction of nucleic acids from FFPE tissue specimens. The majority of commercial FFPE DNA/RNA kits employ proteolytic treatment with proteinase K to release nucleic acids from FFPE tissues. Purification of DNA/RNA molecules from lysis fluid is mostly based on silica or resin adsorption technology, although alcohol precipitation and cellulose-based purification are used as well. Many of the available kits allow removal of paraffin using special solubilisators or allow melting of paraffin directly in tissue lysis buffers, which can reduce the loss of tissue during the extraction procedure. An incubation step at an elevated temperature for partial removal of formalin cross-links of the released DNA/RNA is surprisingly used in more than half of the available kits. This particular treatment generally allows the release of longer fragments of nucleic acids, which might result in better performance in downstream assays. Sixteen identified kits allow automated, walk-away purification of DNA/RNA from lysed FFPE tissues obtained through manual external preparations, which represents a major bottleneck for these methods and also their main drawback. Only two systems—the Siemens Tissue Preparation System/VERSANT Tissue Preparation Reagents kit and the MagCore HF16 Automated DNA/ RNA Purification System/MagCore Genomic DNA FFPE One-Step Kit—have an integrated paraffin-melting/tissue-lysis step and therefore allow complete automation of nucleic acid extraction from FFPE tissues. Because the majority of FFPE DNA/RNA extraction kits were launched in the last few years, they generally lack documented performance in peer-reviewed literature. However, recent head-to-head comparison studies suggest that these kits might differ significantly in terms of DNA yield, purity, and quality (12, 18). Therefore, it seems that the transition to one of the available FFPE DNA/RNA commercial kits will not be so straightforward and will require extensive comparisons with the established lab protocol in advance. The final decision in choosing a particular kit will probably also depend on the price and required accompanying lab equipment. Although we identified an abundance of commercial kits specifically developed for extraction of nucleic acids from FFPE tissue specimens, many researchers are still using rather old-fashioned, crude, and probably less effective in-house methods for extracting nucleic acids from FFPE. We hope that this inventory and the accompanying comprehensive list of available commercial kits will encourage researchers to strongly consider using them in diagnostic and research settings when dealing with FFPE tissue specimens, similar to what occurred during the last decade for the great majority of other clinical specimen types. References 1. Bonin S, Stanta G. Nucleic acid extraction methods from fixed and paraffin-embedded tissues in cancer diagnostics. Expert Rev Mol Diagn. 2013;13:271-82. 2. Dietrich D, Uhl B, Sailer V, Holmes EE, Jung M, Meller S, et al. Improved PCR performance using template DNA from formalin-fixed and paraffin-embedded tissues by overcoming PCR inhibition. PLoS One. 2013;8:e77771. 3. Coates PJ, d'Ardenne AJ, Khan G, Kangro HO, Slavin G. Simplified procedures for applying the polymerase chain reaction to routinely fixed paraffin wax sections. J Clin Pathol. 1991;44:115-8. 4. Sepp R, Szabo I, Uda H, Sakamoto H. Rapid techniques for DNA extraction from routinely processed archival tissue for use in PCR. J Clin Pathol. 1994;47:318-23. 5. Jackson DP, Lewis FA, Taylor GR, Boylston AW, Quirke P. Tissue extraction of DNA and RNA and analysis by the polymerase chain reaction. J Clin Pathol. 1990;43:499-504. 6. Shi SR, Cote RJ, Wu L, Liu C, Datar R, Shi Y, et al. DNA extraction from archival formalin-fixed, paraffin-embedded tissue sections based on the antigen retrieval principle: heating under the influence of pH. J Histochem Cytochem. 2002;50:1005-11. 7. Heller MJ, Robinson RA, Burgart LJ, TenEyck CJ, Wilke WW. DNA extraction by sonication: a comparison of fresh, frozen, and paraffin-embedded tissues extracted for use in polymerase chain reaction assays. Mod Pathol. 1992;5:203-6. 8. Melzak KA, Sherwood CS, Turner RFB, Haynes CA. Driving forces for DNA adsorption to silica in perchlorate solutions. J Colloid Interface Sci. 1996;181:635-44. 9. Steinau M, Patel SS, Unger ER. Efficient DNA extraction for HPV genotyping in formalin-fixed, paraffin-embedded tissues. J Mol Diagn. 2011;13:377-81. 10. Kocjan BJ, Maver PJ, Hosnjak L, Zidar N, Odar K, Gale N, et al. Comparative evaluation of the Abbott RealTime High Risk HPV test and INNO-LiPA HPV Genotyping Extra test for detecting and identifying human papillomaviruses in archival tissue specimens of head and neck cancers. Acta Dermatovenerol Alp Pannonica Adriat. 2012;21:73-5. 11. Jenko K, Kocjan B, Zidar N, Poljak M, Strojan P, Zargi M, et al. In inverted papillomas HPV more likely represents incidental colonization than an etiological factor. Virchows Arch. 2011;459:529-38. 12. Janecka A, Adamczyk A, Gasinska A. Comparison of eight commercially available kits for DNA extraction from formalin-fixed paraffin-embedded tissues. Anal Biochem. 2015;476:8-10. 13. Gilbert MT, Haselkorn T, Bunce M, Sanchez JJ, Lucas SB, Jewell LD, et al. The isolation of nucleic acids from fixed, paraffin-embedded tissues—which methods are useful when? PLoS One. 2007;2:e537. 14. Bohmann K, Hennig G, Rogel U, Poremba C, Mueller BM, Fritz P, et al. RNA extraction from archival formalin-fixed paraffin-embedded tissue: a comparison of manual, semiautomated, and fully automated purification methods. Clin Chem. 2009;55:1719-27. 15. van Eijk R, Stevens L, Morreau H, van Wezel T. Assessment of a fully automated high-throughput DNA extraction method from formalin-fixed, paraffin-embedded tissue for KRAS, and BRAF somatic mutation analysis. Exp Mol Pathol. 2013;94:121-5. 16. Hennig G, Gehrmann M, Stropp U, Brauch H, Fritz P, Eichelbaum M, et al. Automated extraction of DNA and RNA from a single formalin-fixed paraffin-embedded tissue section for analysis of both single-nucleotide polymorphisms and mRNA expression. Clin Chem. 2010;56:1845-53. 17. Henniq B. DNA/RNA extraction from FFPE tissue samples. Mater Methods. 2011;1:31. 18. Potluri K, Mahas A, Kent MN, Naik S, Markey M. Genomic DNA extraction methods using formalin-fixed paraffin-embedded tissue. Anal Biochem. 2015;486:17-23. 53 Canes-Nail™ Do zdravih nohtov v dveh korakih in le 6-tih tednih 2. korak Nadaljevanje zdravljenja okuženega dela kože s protiglivično kremo 4 tedni / \ Canespor !0 mg/g krema Bifonazol nanesite I* no Canespor 10 mg/g krema bifonazol IS E kreme nanesite lx na dan ¡3 V Zdravljenje v dveh korakih omogoča: • Hitro in temeljito odstranjevanje okuženega dela nohta • Dnevno viden napredek1 • Enostavno zdravljenje brez bolečin1 • Globinsko odstranjevanje glivic2 Podrobni prikaz zdravljenja okuženega dela nohta si lahko ogledate na www.canesnail.si Skrajšan povzetek glavnih značilnosti zdravila Ime zdravila: Canespor 10 mg/g krema. Sestava: 1 g kreme vsebuje 10 mg bifonazola. Terapevtske indikacije: za zdravljenje kožnih mikoz, ki jih povzročajo dermatofiti, kvasovke, plesni in druge glivice (npr. Malassezia furfur) ter okužbe s Corynebacteriumom minutissimum: tinea pedum, tinea manuum, tinea corporis, tinea inguinalis, pityriasis versicolor, površinske kandidoze in eritrazma. Odmerjanje in način uporabe: Kremo Canespor uporabljamo enkrat na dan, najbolje zvečer pred spanjem. Na prizadeto kožo nanesemo tanko plast zdravila in ga vtremo. Učinek je trajnejši, če kremo Canespor uporabljamo pravilno in dovolj dolgo. Običajno traja zdravljenje: mikoz na stopalu in med prsti (tinea pedum, tinea pedum interdigitalis) - 3 tedne; mikoz po telesu, rokah in v kožnih gubah (tinea corporis, tinea manuum, tinea inguinalis) - 2 do 3 tedne; okužb rožene plasti kože, blagih, kroničnih, površinskih okužb (pityriasis versicolor, eritrazma) - 2 tedna; površinskih kandidoz kože - 2 do 4 tedne. Za površino v velikosti dlani zadostuje večinoma že majhna količina kreme. Otroci: Pregled kliničnih podatkov kaže, da uporaba bifonazola pri otrocih ne povzroča škodljivih učinkov. Kljub temu naj se bifonazol pri dojenčkih uporablja le pod zdravniškim nadzorom. Kontraindikacije: Preobčutljivost za bifonazol, cetil in stearilalkohol ali katerokoli pomožno snov. Posebna opozorila in previdnostni ukrepi: Bolniki z anamnezo preobčutlji-vostnih reakcij na druge imidazolske antimikotike (npr. ekonazol, klotrimazol, mikonazol) morajo previdno uporabljati zdravila, ki vsebujejo bifonazol. Paziti je treba, da zdravilo ne pride v stik z očmi. Krema Canespor vsebuje cetil in stearilalkohol, ki lahko povzroči lokalne kožne reakcije (npr. kontaktni dermatitis). Pri bolnikih, ki so preobčutljivi za cetil in stearilalkohol, je priporočljivo, da namesto kreme Canespor uporabljajo raztopino Mycospor. Medsebojno delovanje z drugimi zdravili in druge oblike interakcij: Ni podatkov o medsebojnem delovanju z drugimi zdravili. Nosečnost in dojenje: Prve 3 mesece nosečnosti smejo ženske bifonazol uporabiti šele potem, ko zdravnik oceni razmerje koristi in tveganja. Dojenje: Ni znano, ali se bifonazol pri človeku izloča v materinem mleku. Doječe matere smejo bifonazol "t uporabiti šele potem, ko zdravnik oceni razmerje koristi in tveganja. Med obdobjem dojenja ženska bifonazola ne sme uporabljati v predelu prsi. Plodnost: Predklinične študije niso pokazale, da bi bifonazol © vplival na plodnost samcev ali samic. Neželeni učinki: Splošne težave in spremembe na mestu aplikacije: bolečine na mestu uporabe, periferni edemi (na mestu uporabe); bolezni kože in podkožja: kontaktni