Israel Medical Association Journal

Background: The association between new-onset atopic dermatitis (AD) and the coronavirus disease 2019 (COVID-19) pandemic was scarcely documented in the literature.

Objectives: To evaluate the incidence of AD in a large nation-wide cohort over 6 years, focusing on changes in incidence following the onset of the COVID-19 pandemic.

Methods: This retrospective cohort study included all members of the largest HMO in Israel (n=4.8 million) from 2017 to 2022. Patients with newly diagnosed AD were identified using the ICD-10 code for AD (L20). Incidence rates were calculated as the number of new diagnoses per 1000 person-years. The pre-COVID period was 1/2017 to 1/2020, and post-COVID 2/2020 to 12/2022. Age-adjusted incidence rates were calculated based on the World Health Organization's standard population.

Results: The overall crude incidence of AD across the study period was 3.38/1000 person-years (PYs). From 2017 to 2022, there was a 36.97% increase in the crude incidence and a 40.44% increase in the age-adjusted incidence, with a mean annual incidence change of +6.5% and +7.1%, respectively. Both crude and adjusted annual incidence increases were significant (P < 0.001, R² = 0.98; P < 0.001, R² = 0.99, respectively). The incidence of AD at the follow-up before the COVID-19 pandemic was 3.07/1000 PYs, and after was 3.71/1000 PYs.

Conclusions: We observed a significant and nearly consistent annual increase in AD incidence from 2017 to 2022, across various sex and age groups. Further research is needed to explore the impact of the COVID-19 pandemic on rising trends in AD incidence.

Background: Allergic contact dermatitis (ACD), a prevalent skin disorder marked by delayed hypersensitivity reactions to specific allergens, is commonly diagnosed through patch testing. Previous studies have indicated lower rates of positive patch tests in summer months compared to winter months.

Objectives: To investigate whether there is a difference in the proportion of positive patch test results between summer and winter months.

Methods: A retrospective study was performed on 1128 patients, with 14 individuals undergoing two tests each, resulting in a total of 1142 patch tests. The tests were conducted at a major tertiary referral center between 2016 and 2020. The data set encompassed patient demographics and comprehensive patch test results.

Results: Of the 1142 tests conducted, 808 (70.8%) yielded a positive response. The most frequently administered test series was the European standard series, conducted for 1135 (99.3%) of the tests, with 559/1135 (49.2%) showing positive results, followed by the cosmetics series (394/1120, 35.1%) and fragrances series (61/118, 51.7%). No statistically significant difference was observed in the proportion of positive patch tests between summer and winter months (313/419, 74.7% vs. 175/245, 71.4%, respectively; P-value = 0.35). There was no statistically significant difference in the rate of testing each specific series between the summer and winter months, except for the fragrances series.

Conclusions: We found no significant difference in the positive patch test rates between the summer and winter months. Therefore, patch testing can be reliably conducted during the summer without an increased risk of false-negative results.

Background: Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive, soft-tissue sarcoma. The treatment is surgical and includes wide local excision (WLE) or Mohs micrographic Surgery (MMS). There is no consensus regarding the preferred type of surgery.

Objectives: To compare the outcomes of the two types of surgery (WLE and MMS).

Methods: This retrospective cohort study was based on the medical records of 59 patients with DFSP treated at Sheba Medical Center (using the WLE method) or Assuta Medical Center (using the MMS method) between 1995 and 2018. The data included demographics, clinical presentations, imaging, types of wound closures, pathological margin status, surgical defect sizes, recurrences, and follow-up.

Results: Of the 59 included patients, 18 (30.5%) underwent WLE and 41 (69.5%) underwent MMS. The mean age at diagnosis was 40.1 ± 14.4 years. The male-to-female ratio was 1.5:1. The main tumor location was the trunk (50% for WLE and 41.5% for MMS). The main type of closure for both procedures was primary closure. In 72.2% of WLE and 78.8% of MMS cases, the margins were free. The difference between the final surgical defect and the original tumor size was statistically significantly smaller in patients who underwent MMS. The median duration of follow-up was 6.6 years. There was no significant difference in the rate of recurrence.

Conclusions: MMS enables better tissue preservation and results in a minor surgical defect compared to WLE, with no difference in tumor recurrence between the two methods.

Background: Diagnosis of onychomycosis is based on potassium hydroxide (KOH), direct smear, culture, and polymerase chain reaction. Nail clippings are rarely used as a diagnostic tool.

Objectives: To evaluate nail clippings for the diagnosis of onychomycosis and to compare it to KOH smears.

Methods: Nail clipping specimens of 39 patients were collected: 34 with onychomycosis proved by positive culture and 5 from normal nails. The specimens were submitted to histological processing and then stained with periodic acid–Schiff (PAS) and Grocott-Gomori's methenamine silver (GMS) stains. For each nail, KOH smear was also performed. Two pathologists who had no information on the KOH smear and the culture results evaluated the nail clipping histology for the presence of fungal element. Their assessment was compared to the KOH smear and culture results.

Results: Of the 34 specimens that had positive culture, 25 were dermatophytes, 5 were molds, and 4 were candida. Clipping specimens were positive in 30 cases (88%): 23/25 dermatophyte, 4/5 molds, and 3/4 candida. Pathologists were able to classify the pathogens into dermatophytes and non-dermatophytes based on the morphology. PAS stain results were the same as GMS in evaluation of the nail specimen. KOH smear was positive in 29 nails (85%): 20/25 dermatophytes, all 5 molds, and 4 candida. In all five nails where the culture was negative, both clipping and KOH smear did not show fungal elements.

Conclusion: Nail clippings can serve as a rapid, inexpensive, and reliable method for evaluation of onychomycosis, comparable to KOH smear, with the advantage of pathogen group identification.

Background: Gestational hypertensive (GH) disorders remain a major obstetric problem.

Objective: To evaluate the incidence of gestational hypertensive disorders among participants undergoing intrauterine insemination (IUI) after exposure to various levels of sperm from sperm donation (SD).

Methods: A retrospective case-control study was conducted at a single tertiary medical center between 2011 and 2019. Participants conceived via IUI using SD from a single sperm bank and had a successful singleton birth. Group 1 conceived during 1–2 cycles of IUI from the same sperm donor; whereas Group 2 after 3+ cycles.

Results: Overall 171 patients (Group 1 = 81, Group 2 = 90) met inclusion criteria. Participants showed no differences in age, chronic medical conditions, or history of pregnancy complications. The groups differed in gravidity and parity. The factors positively associated with Group 1 included either preeclampsia or GH (11 [13.5%] vs. 1 [1.1%], P = 0.001) and GH alone (8 [9.9%] vs. 1 [1.1%], P = 0.014). Newborns from Group 1 had a statistically significant lower birth weight than those from Group 2 (3003 grams ± 564.21 vs. 3173 grams ± 502.59, P = 0.039). GH was more prevalent in Group 1 (P = 0.008) than a control group of 45,278 participants who conceived spontaneously. No significant differences were observed between Group 2 and the control group.

Conclusions: The incidence of GH and preeclampsia in participants was higher among those exposed to 1–2 cycles than those exposed to 3+ cycles of IUI.

Background: Erysipelas, an acute infection of the dermal and subcutaneous tissue, is normally treated with antibiotics. Previous data indicated that treatment with prednisone in combination with antibiotics results in significant acceleration of the healing phase.

Objectives: To investigate the effectiveness of corticosteroids combined with antibiotics for the treatment of erysipelas.

Methods: A retrospective study was conducted on hospitalized patients diagnosed with erysipelas between 2004 and 2011 at the Department of Dermatology at Sheba Medical Center, Israel. Data included epidemiology, medical background, and course of the disease as documented at admission and during hospitalization. 

Results: Data were collected on 173 patients (66% males) who were divided into two groups: a control group treated with antibiotics only (97 patients) and a study group treated with antibiotics and prednisone (76 patients). The study group presented with a more severe form of erysipelas (bullous) and those patients were hospitalized for a longer period (8.5 vs. 7 days). Nevertheless, the study group exhibited a 71% clinical improvement shortly after being treated with prednisone, without significant side effects. Short-term follow-up revealed more edema in the study group; however, long-term follow-up revealed a higher incidence of erythema and recurrence of erysipelas in the control group. The return to full function was faster in the study group than in the control group. 

Conclusions: Combining prednisone with antibiotics for the treatment of erysipelas should be considered, especially in severe cases. In addition, a prospective double-blind study should be conducted to verify these conclusions.

Background: While many are familiar with postpartum depression, the phenomenon of postpartum post-traumatic stress disorder (PTSD) is less well known and investigated. Objectives: To assess the prevalence of postpartum PTSD in a cohort of women in Israel, and to examine factors affecting its development.

Methods: Eighty-nine women completed several ratings immediately after delivery and one month later. The factors examined related to the pregnancy, childbirth expectations, and delivery. Rating scales comprised evaluations of attachment, personality, PTSD, and demographic variables.

Results: The prevalence of post-partum PTSD was 3.4% (complete PTSD), 7.9% nearly complete PTSD, and 25.9% significant partial disorder. Women who developed PTSD symptoms had a higher prevalence of "traumatic" previous childbirth, with subsequent depression and anxiety. They also reported more medical complications and “mental crises” during pregnancy as well as anticipating more childbirth pain and fear. Instrumental or cesarean deliveries were not associated with PTSD. Most of the women who developed PTSD symptoms delivered vaginally but received fewer analgesics with stronger reported pain. Women with PTSD reported more discomfort with the undressed state, stronger feelings of danger, and higher rates of not wanting more children.

Conclusions: The study results indicate a) the importance of inquiring about previous pregnancy and birthing experiences, b) the need to identify at-risk populations, and c) increased awareness of the disorder. The importance of addressing anticipatory concerns of pain prior to delivery and of respecting the woman’s dignity and minimizing the undressed state during childbirth should not be underestimated. A short questionnaire following childbirth may enable rapid identification of symptoms relevant to PTSD.