Israel Medical Association Journal

Gross hematuria is uncommon in the neonatal period, with an estimated incidence of 0.21 per 1000 admissions in infants younger than one month. Although renal vein thrombosis is the most common cause, various etiologies, including congenital anomalies, must be considered. Anterior urethral valve (AUV) is a rare congenital anomaly that can cause severe obstruction and significantly impact the proximal urinary system [1].

Anatomically, AUV can cause obstruction of varying severity depending on the size and configuration of the valve [2]. The pathophysiology of AUV involves abnormal development of the urethral folds in the anterior urethra, typically at the penoscrotal junction, bulbar urethra, or penile urethra. These valves form cusp-like structures that allow antegrade flow of urine but obstruct during voiding, leading to progressive dilatation of the proximal urethra and upstream urinary tract [3].

Recent data from a matched cohort study at a high-risk pediatric center found that AUV patients demonstrate significantly lower creatinine levels at initial presentation and potentially better renal outcomes compared to posterior urethral valve (PUV) patients [4]. Prenatal diagnosis of anterior urethral anomalies is feasible as early as the second trimester, with characteristic findings including anterior urethral dilation and a keyhole sign on prenatal ultrasound [5]. Unlike PUV, which are more commonly reported, AUV presenting with gross hematuria in the neonatal period is exceptionally rare, making this case particularly noteworthy for clinicians.

Background: The incidence of autologous breast reconstruction has been steadily increasing in recent years. Deep inferior epigastric perforator (DIEP) flap reconstruction is considered the gold standard for breast reconstruction despite its demanding technical expertise, time intensiveness, and rigorous postoperative monitoring.

Methods: We retrospectively collected data from 102 DIEP flaps utilized for breast reconstruction in 70 patients treated at private clinics between 2013 and 2024. All surgeries were performed by a single, experienced surgeon.

Results: The mean age at surgery was 42.2 ± 8 years. Immediate reconstructions were conducted in 34 patients (48%); 46% of patients had prior radiation therapy. Only one patient received adjuvant radiation therapy. Free DIEP flaps vascularized by one (53%), two (32%), or three (10%) perforators were preferentially anastomosed to the internal mammary vessels. One patient underwent a muscle-sparing procedure due to the absence of available perforators. Total flap failure occurred in four cases (3.9%), three occurred as a unilateral loss in patients who underwent bilateral reconstruction. Postoperative revisions of the microvascular anastomosis were performed in three patients, with successful flap salvage in two (67%). Fat necrosis was diagnosed in 26 breasts (25%), only a minority of cases required follow-up surgery. All patients were managed completely in a private clinic, with none requiring hospitalization in the public system.

Conclusions: Free DIEP flap breast reconstruction necessitates meticulous surgical planning, a well-coordinated surgical team, and close postoperative monitoring. Nevertheless, this surgery can be safely and effectively performed in a private clinic setting, with complication rates comparable to that of the public setting.

Acne vulgaris is a common dermatological condition, affecting up to 85% of adolescents and increasingly observed in adults, particularly women. Its chronic nature and visible manifestations impose significant psychological and social burdens. This review provides an updated examination of acne pathogenesis that explores emerging therapeutic approaches informed by recent molecular, genetic, and microbiome research. Findings from clinical studies, molecular biology, and immunological research published in the past decade are presented in a comprehensive overview of current advancements in acne treatment. Key databases and recent consensus guidelines have been utilized to identify novel mechanisms and therapeutic innovations. Current understanding emphasizes the role of innate immunity (e.g., toll-like receptors, inflammasomes), sebocyte biology via peroxisome proliferator-activated receptors (PPAR) signaling, and strain-specific Cutibacterium acnes dynamics. Environmental and genetic factors, including androgen receptor gene polymorphisms and lifestyle contributors, influence disease expression. Emerging treatments include selective retinoids (trifarotene), PPAR modulators, interleukin-targeting biologics, probiotics, bacteriophages, and hormonal therapies with improved safety profiles. Microbiome modulation and narrow-spectrum antibiotics are gaining attention for precision management. Integrating molecular insights with clinical practice fosters a personalized, multidisciplinary approach to acne care. Future research should prioritize microbiome restoration, novel biologics, and strategies to minimize antimicrobial resistance.

This special dermatology issue of IMAJ (June 2025) highlights cutting-edge research, innovative therapeutic approaches, and comprehensive reviews that contribute significantly to advancements in dermatologic practice. Key themes include novel genetic insights, innovative treatments for pigmentary disorders such as melasma, seasonal variations affecting diagnostic procedures, practical management strategies for psoriasis, sophisticated surgical techniques, microbiome research, and the potential of humanized mouse models in dermatological studies.

Background: Radiofrequency-skin interaction is considered self-limited for treating acquired pigmentation such as melasma. Alternatively, skin perforation with microneedling radiofrequency (MNRF) may increase skin bioavailability for depigmenting-mediated ingredients or drugs for the treatment of melasma.

Objectives: To examine the clinical feasibility of topical tranexamic acid (TA) mediated with MNRF-assisted transepidermal delivery in patients with mixed melasma.

Methods: The study protocol included 14 women with centrofacial or malar pattern of distribution of melasma (skin types II-VI; age 35–48 years). Patients underwent four treatments at 3-week intervals between treatments. Treatment protocol included non-insulated MNFR (Intensif, EndyMed Ltd, Caesarea, Israel) followed by TA (hexakapron 4%) solution application. The improvement was evaluated based on clinical photographs (Quantificare, Biot, France) and modified Melasma Area and Severity Index (mMASI) scores. Baseline Photographs were analyzed 3 months after the last treatment.

Results: In 13 patients (93%), mMASI scores were significantly lower after 3 months (mean 3.6) than at baseline (5.22). In one patient, mMASI was higher at 3 months compared to baseline. Overall, mMASI improved by 31% (P < 0.01). Physician and patient satisfaction was high. Minimal adverse reactions were recorded.

Conclusions: MNRF-assisted transepidermal delivery with topical TA is a safe and effective modality for the treatment of melasma.

Background: Identifying drug–drug interactions (DDIs) in dermatology can be cumbersome and time-consuming using traditional methods.

Objectives: To explore the potential of ChatGPT-4o, an artificial intelligence (AI)-based chatbot, to streamline the identification process.

Methods: ChatGPT-4o was tasked with assessing DDIs among commonly prescribed dermatological medications. The accuracy and reliability of the chatbot's outputs were compared against established references for 43 interactions.

Results: ChatGPT-4o successfully identified all evaluated interactions. It accurately described the interaction effects in 42 cases, with only one example of misdescription.

Conclusions: The findings highlight the potential of ChatGPT to serve as an effective and efficient alternative for identifying and understanding DDIs in dermatology, despite one noted error that emphasizes the need for ongoing verification against trusted references. Further research is needed to validate its use across a broader range of medications and clinical scenarios.

Nail psoriasis (NP) is a common manifestation of psoriasis, affecting up to 80–90% of patients with psoriatic arthritis and up to 60% of those with cutaneous psoriasis. Isolated NP also occurs in 5–10% of cases. It significantly impacts quality of life and may indicate or precede psoriatic arthritis. In this review, we summarized the clinical features of NP, highlighting patterns of matrix and nail bed involvement, and discussed differential diagnosis with onychomycosis. We outlined current topical, intralesional, systemic, and non-pharmacological treatment options, and proposed an evidence-based approach to diagnosis and management.

Psoriasis is a chronic immuno-inflammatory skin disorder characterized by rapid keratinocyte proliferation, forming thick, red patches with silvery scales. It affects 2–3% of the population, impacting skin, nails, and joints. Pathogenesis involves genetic, environmental, and immunological factors [1]. Triggers such as infections (especially Streptococcus), skin injuries, medications, stress, and alcohol can initiate or worsen the condition [1]. Psoriasis may follow a stable course or present in cycles of flare-ups and remissions. Skin involvement may manifest in any body area but is most common on the knees, elbows, trunk, and scalp [1]. Nail involvement appears in up to 60% of those with cutaneous psoriasis and 80% of those with psoriatic arthritis (PsA), with an 80–90% lifetime incidence [2,3]. Isolated nail psoriasis (NP), defined as nail changes without cutaneous psoriasis or with limited body surface involvement (< 5%), occurs in 5–10% of patients [4,5].

Mohs micrographic Surgery (MMS) is a specialized surgical technique for removal of skin tumors. It achieves the highest cure rates of any available treatment. At the same time, it spares healthy tissue and thus provides superior cosmetic and functional results. The technique is indicated mainly for tumors on the head and neck. Other bodily areas including the trunk and extremities have been found to be indications for MMS as well. These indications have been defined by a collaborative work of major dermatology and dermatologic surgery organizations. Knowledge of these indications, in particular on areas other than the head and neck, is prudent for appropriately managing these tumors.

Infantile hemangioma (IH) is the most common benign vascular tumor in infancy. Recent advances, particularly in beta-blocker therapy, have significantly improved the management of IHs. Early identification and treatment of IH may help reduce morbidity and associated complications. In this review, experts in pediatric dermatology in Israel who have experience in treating IH formulated national guidelines for the diagnosis and treatment of IHs, providing evidence-based recommendations for selecting appropriate therapeutic approaches. These Israeli national guidelines provide a structured approach to the diagnosis and treatment of IH, emphasizing early referral, appropriate treatment selection, and careful monitoring. The guidelines serve as a critical resource for pediatricians and dermatologists, ensuring optimal patient outcomes while minimizing complications.

Background: Cardiac amyloidosis (CA) is characterized by the extracellular deposition of misfolded protein in the heart. Precise identification of the amyloid type is often challenging, but critical, since the treatment and prognosis depend on the disease form and the type of deposited amyloid. Coexistence of clinical conditions such as old age, monoclonal gammopathy, chronic inflammation, or peripheral neuropathy in a patient with cardiomyopathy creates a differential diagnosis between the major types of CA: amyloidosis light chains (AL), amyloidosis transthyretin (ATTR) and amyloidosis A (AA).

Objectives: To demonstrate the utility of the Western blotting (WB)-based amyloid typing method in patients diagnosed with cardiac amyloidosis where the type of amyloid was not obvious based on the clinical context.

Methods: Congo red positive endomyocardial biopsy specimens were studied in patients where the type of amyloid was uncertain. Amyloid proteins were extracted and identified by WB. Mass spectrometry (MS) of the electrophoretically resolved protein-in-gel bands was used for confirmation of WB data.

Results: WB analysis allowed differentiation between AL, AA, and ATTR in cardiac biopsies based on specific immunoreactivity of the electrophoretically separated proteins and their characteristic molecular weight. The obtained results were confirmed by MS.

Conclusions: WB-based amyloid typing method is cheaper and more readily available than the complex and expensive gold standard techniques such as MS analysis or immunoelectron microscopy. Notably, it is more sensitive and specific than the commonly used immunohistochemical techniques and may provide an accessible diagnostic service to patients with amyloidosis in Israel.

Background: A limited program for kidney donation from uncontrolled donation after cardiocirculatory determination of death (uDCDD) was implemented at four hospitals in Israel in close cooperation with Magen David Adom (MDA), the national emergency medical service.

Objectives: To assess the outcome of transplantations performed between January 2017 and June 2022.

Methods: Donor data included age, sex, and cause of death. Recipient data included age, sex, and yearly serum creatinine levels. A retrospective study of out-of-hospital cardiac arrest cases treated by MDA during 2021 were analyzed to assess their compatibility as potential uDCDD donors.

Results: In total, 49 potential donors were referred to hospitals by MDA. Consent was obtained in 40 cases (83%), organ retrieval was performed in 28 cases, and 40 kidneys were transplanted from 21 donors (75% retrieval rate). At 1-year follow-up, 36 recipients had a functioning graft (4 returned to dialysis) and mean serum creatinine 1.59 ± 0.92 mg% (90% graft survival). Outcome after transplantation showed serum creatinine levels (mg%) at 2 years 1.41 ± 0.83, n=26; 3 years 1.48 ± 0.99, n=16; 4 years 1.07 ± 1.06, n=7; and 5 years 1.12 ± 0.31, n=5. One patient died of multiple myeloma at 3 years. The MDA audit revealed an unutilized pool of 125 potential cases, 90 of whom were transported to hospitals and 35 were declared dead at the scene.

Conclusions: Transplant outcomes were encouraging, suggesting that more intensive implementation of the program may increase the number of kidneys transplanted, thus shortening recipient waiting lists.

Stevens-Johnson Syndrome (SJS), or toxic epidermal necrolysis, is a rare syndrome that develops after an allergic reaction to a medication [1,2]. It affects the skin and the mucocutaneous tissue. Individuals diagnosed with SJS are rarely referred to a rehabilitation medicine (RM) facility.

The annual prevalence of SJS is about one in one million. The skin is covered with blisters. Usually, it affects about 10 % of body surface area. The patients are treated usually by ophthalmologists, dermatologists, allergologists, and immunologists. When severe complications occur, plastic surgeons and intensive care physicians may also be involved. Few publications were found that linked SJS with comprehensive rehabilitation treatment [3-5].

Background: Limited data exist regarding the safety of ultrasound-guided femoral nerve blockade (US-FNB) in patients with hip fractures treated with anti-Xa direct oral anticoagulants (DOAC).

Objectives: To compare the safety outcomes of US-FNB to conventional analgesia in patients with hip fractures treated with anti-Xa DOAC.

Methods: This observational exploratory prospective study included 69 patients who presented to our emergency department (ED) in 3 years with hip fracture and who were treated with apixaban or rivaroxaban. Patients received either a US-FNB (n=19) or conventional analgesics (n=50) based on their preference and, and the presence of a trained ED physician qualified in performing US-FNB. Patients were observed for major bleeding events during and 30 days after hospitalization. The degree of preoperative pain and opioid use were also observed.

Results: We found no significant difference in the number of major bleeding events between groups (47.4% vs. 54.0%, P = 0.84). Degree of pain measured 3 and 12 hours after presentation was found to be lower in the US-FNB group (median visual analog scale of pain improvement from baseline of -5 vs. -3 (P = 0.002) and -5 vs.-4 (P = 0.023), respectively. Opioid administration pre-surgery was found to be more than three times more common in the conventional analgesia group (26.3% vs.80%, P < 0.0001).

Conclusions: Regarding patients treated with Anti-Xa DOAC, US-FNB was not associated with an increase in major bleeding events compared to conventional analgesia, although it was an effective means of pain alleviation. Larger scale randomized controlled trials are required to determine long-term safety and efficacy.