Israel Medical Association Journal

A 70-year-old female with a 10-year history of dermatomyositis involving the skin, muscles, and gastrointestinal system was diagnosed based on proximal muscle weakness, typical dermatomyositis-specific rashes, elevated creatine kinase, and muscle biopsy findings consistent with dermatomyositis. Myositis-specific autoantibodies were negative.

The patient initially received treatment with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) but experienced gastrointestinal intolerance to both methotrexate and azathioprine. Subsequently, she was managed with intravenous immunoglobulin (IVIg) for 4 years; however, due to a relapse of muscle involvement, rituximab was initiated and has been administered for the past 3 years.

Over the last year, the patient achieved remission in muscle involvement but experienced worsening dermatomyositis-specific skin manifestations, including heliotrope rash, Gottron signs, and holster sign [Figure 1A], accompanied by severe pruritus that significantly impaired her quality of life. The Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) activity score reached 17. Her skin condition remained refractory despite treatment with topical steroids and calcineurin inhibitors.

Background: Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine skin tumor with an increasing incidence in Western countries. Predominantly affecting older individuals, MCC represents less than 1% of malignant skin tumors.

Objectives: To characterize the clinical presentation, therapeutic interventions, and follow-up outcomes of MCC patients. To promote heightened clinical awareness regarding the early recognition and diagnosis of MCC.

Methods: We conducted a retrospective cohort study analyzing medical records of MCC patients at the Shaare Zedek Medical Center between 2015–2022. From 19 initially identified patients, 17 met the inclusion criteria. Data collection included demographic, epidemiological, clinical, and pathological characteristics.

Results: The study included 17 patients, predominantly of Jewish origin, with a mean age of 70.06 years; 58.8% female. Medical co-morbidities included 64.7% hypertension and 35.3% diabetes. MCC tumors were predominantly left-sided (58.8%), with varied locations including limbs, trunk, and face. Surgical treatment consisted of excision and primary closure (64.7%) or skin grafting (23.5%). The average tumor diameter was 3.41 cm clinically and 3.83 cm pathologically. Lymph node involvement occurred in 29.4% of cases; 23.5% showed metastatic disease at diagnosis, with metastases diffused in different body areas. Kaplan-Meier survival analysis showed no statistically significant differences across most variables, except for a significantly lower survival rate in patients with ischemic heart disease (P = 0.009).

Conclusions: Our study reveals unique characteristics of MCC, predominance of female patients, and a slightly younger average diagnosis age compared to existing literature. The 2-year survival rate in our cohort was 82%. The study underscores the importance of early detection and diagnosis of MCC, thereby enhancing clinical awareness and improving patient outcomes.

In the 1950s, ionizing radiation to the scalp was commonly used in Israel as a treatment for tinea capitis. Decades later, epidemiological studies identified an increased incidence of head and neck malignancies, particularly basal cell carcinoma, as well as intracranial tumors such as meningiomas among individuals who underwent this therapy in childhood. In addition to the oncologic risk, irradiated scalp skin presents significant reconstructive challenges due to chronic skin atrophy, hypovascularity, fibrosis, and impaired wound healing. In this study, we present our clinical experience with a modified, skin-sparing surgical protocol for managing reconstruction post excision of non-melanoma skin cancer of the scalp in patients previously irradiated for tinea capitis. The surgical strategy is tailored according to lesion size, depth, periosteal involvement, and scalp tissue quality. It incorporates components of the reconstructive ladder as appropriate. We present three representative cases highlighting key surgical challenges and considerations in this complex population.

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.

Psoriasis is a chronic, immune-mediated skin disease characterized by inflammatory lesions and systemic co-morbidities. Emerging evidence highlights the significant role of the microbiome in psoriasis pathogenesis. Dysbiosis of the skin and gut microbiota has been linked to increased disease severity and co-morbidities such as psoriatic arthritis and cardiovascular disease. In this review, we explored the microbiome's influence on immune responses in psoriasis and its potential as a therapeutic target. Microbial therapies, such as probiotics and fecal microbiota transplantation, hold promise for restoring microbial balance and improving outcomes. We also discuss how the microbiome modulates drug efficacy and toxicity, offering insights for personalized treatment approaches. While challenges remain in establishing causality and translating findings into clinical practice, leveraging the gut-skin axis may optimize psoriasis management and improve patient outcomes.

Over the past decade, the introduction of humanized mouse models, especially the transplantation of full-thickness human skin with autologous immune cells onto severe combined immunodeficient (SCID) mice, has transformed pre-clinical dermatology. These composite grafts vascularize and reinnervate within days, retain normal human architecture, evade graft-versus-host disease, and faithfully recapitulate complex cutaneous conditions such as psoriasis, atopic dermatitis, alopecia areata, androgenetic alopecia, vitiligo, pemphigus, and even intrinsic skin aging. Because the grafts respond to murine neuro-endocrine stress pathways yet remain immunologically human, investigators can track how psychological stress, cytokine networks, or targeted drugs shape disease onset, flare, and resolution in a living mini-patient. Unlike conventional murine models, which often capture only a single disease facet and vary by strain, humanized xenografts predict clinical efficacy, metabolism, and toxicity with far greater fidelity, enabling the discovery of pivotal mechanisms (e.g., vascular endothelial growth factor A-driven rejuvenation of aged skin [VEGF-A], voltage-gated potassium channel [Kv1.3], blockade in psoriasis, and alopecia areata) and accelerating the rational design of therapies from Janus kinase (JAK) inhibitors to neurokinin-1 receptor (NK-1R) antagonists. Although access to donor tissue and the need for pathogen-free facilities remain practical hurdles, these models now represent the gold standard for bridging bench and bedside in cutaneous research and for de-risking novel dermatologic and anti-aging interventions before they enter human trials.

Background: Acute skin infections, like cellulitis or erysipelas, are common and respond well to antibiotic treatment. However, complete resolution of the inflammatory process is often slow and associated with prolonged pain and reduced mobility. Several studies have indicated that acupuncture may effectively treat inflammatory skin diseases.

Objectives: To evaluate the efficacy of acupuncture for treating cellulitis in patients hospitalized in internal medicine departments.

Methods: In this pilot randomized sham-controlled trial, patients hospitalized with cellulitis in internal medicine departments were randomized to acupuncture or sham acupuncture, in addition to standard care. The primary outcome was the degree of improvement in the cellulitis score at day 4 of hospitalization. Secondary endpoints included patient pain self-assessment and local and systemic inflammatory signs.

Results: The study comprised 29 patients; 15 treated with acupuncture, 14 by a sham procedure. At day 4, patients in the acupuncture arm had an improved cellulitis score (4.1 ± 2.8) compared with the sham-control group (7.9 ± 3.3, P = 0.003). Pain intensity based on the Visual Assessment Scale was lower in the acupuncture group 3.8 ± 2.7 vs. 6.3 ± 2.8; P = 0.023. There was no difference in the rate of leukocyte change. However, C-reactive protein significantly decreased to 27.0 ± 22.1 mg/L at day 4 following acupuncture compared to 63.9 ± 51.9 mg/L (P = 0.025).

Conclusions: In our pilot study, we found acupuncture to be efficacious as an adjunctive therapy in the treatment of leg cellulitis. A large-scale trial on the effectiveness of acupuncture for skin infections is needed.

Almost three-quarters of a century ago an American surgeon named Frederick Edward Mohs, had the idea of excising skin cancers and examining the margins before the closure of the surgical wound. In this manner he thought the patient would get better treatment with the best cosmetic result.

Mohs micrographic surgery (MMS) in its present format has been used as a surgical method for treating skin cancers for the last 70 years. The method became popular with American dermatologists 54 years ago when the original Mohs technique was modified into its fresh tissue modality [2] and in the rest of the Western world and Israel more than 35 years ago. Variations of MMS started to appear and indications for surgery also expanded. At the beginning, MMS was indicated mainly for basal and squamous cell carcinomas–nonmelanoma skin cancers (NMSC). Knowledge has been collected and today the method is applicable for a variety of other skin cancers such as melanoma in situ, microcystic adnexal carcinoma, dermatofibrosarcoma protuberans (DFSP), and other adnexal and spindle cell tumors. In this issue of the Israel Medical Association Journal (IMAJ), Landov and colleagues [3] showed the value of MMS for the treatment of DFSP.

Background: Allergic rhinitis (AR) is a common illness. Worldwide prevalence varies between 5% and 50% depending on self-reported surveys, test-based studies, geographic location, and age. Despite the clinical relevance of AR in the Israeli population, few studies have characterized the sensitization profiles and key pollen aeroallergen.

Objectives: To describe the most common aeroallergens eliciting a positive skin prick test (SPT) in AR patients across three different main climate zones in Israel.

Methods: We evaluated SPT of aeroallergen sensitization in 1308 AR patients from three topographically and climatically different areas of Israel, describing humidity levels, temperature, and urbanization.

Results: The overall prevalence of positive SPT among patients presenting with AR symptoms was 86%. Indoor aeroallergen sensitization was observed in 76% of patients. Monosensitization was noted in 20% of patients, and polysensitization was noted in 65%. Among the 1308 cases of AR, the top four aeroallergens were mites, olive tree pollen, grass pollen, and cat dander. The top aeroallergen in Israel's central district were mites (62%), olive tree pollen (36%), and grass pollen (30%). In the coastal plains, mites (92%), cat dander (36%), and olive tree pollen (33%) were most prevalent, and in the south mites (77%), olive tree pollen (30%), and grass pollens (26%) were most common.

Conclusions: The top four aeroallergens eliciting a positive SPT were mites, olive tree pollen, grass pollen, and cat dander. Identification of a major aeroallergen can tailor the allergist's SPT panels and specify which aeroallergen should be used for immunotherapy.

Background: Hidradenitis suppurativa (HS) is a chronic relapsing inflammatory skin disease associated with a heavy burden of morbidity and cost.

Objectives: To provide standardized estimates of trends in HS incidence and prevalence among patients in Israel between 2016 and 2019.

Methods: We conducted a population-based analysis of routinely collected electronic health records data from Clalit Health Services, the largest nationwide public health service provider in Israel. Age- and sex-adjusted rates were reported by using the standard European population as a reference.

Results: The study included 3488 HS incident cases. The mean ± SD age of onset was 30.3 years and was similar in males and females. HS was more common among Jews with low and medium socioeconomic status. The annual HS incidence rate increased throughout the study period. HS prevalence increased from 0.12% in 2016 to 0.17% in 2019.

Conclusions: HS prevalence and incidence rates steadily rose among the Israeli population between 2016 and 2019. Awareness of these findings can help provide an optimal allocation of healthcare resources by policymakers and health service providers and prevent delays in diagnosis.

Background: Solid organ transplant recipients (SOTRs) are at increased risk for both skin and internal malignancies (IM). The risk of IM after the occurrence of non-melanoma skin cancer (NMSC) has been studied in the general population but very little is known about this association in SOTRs.

Objectives: To evaluate the risk of IM following a prior diagnosis of post transplantation NMSC in SOTRs.

Methods: This single center retrospective cohort study included a study population of 329 SOTRs from Rabin Medical Center who had a post-transplant diagnosis of skin malignancy, internal malignancy, or both from 2012 to 2018.

Results: In total, 135 (41.03%) SOTRs were diagnosed with IM without a preceding diagnosis of NMSC while only 42 (12.76%) patients diagnosed with IM had a preceding diagnosis of NMSC. SOTRs with a diagnosis of NMSC showed a significantly decreased risk of developing subsequent IM (hazard ratio [HR] 0.64, 95% confidence interval [95%CI] 0.44–0.94, P = 0.02) compared to those without a prior NMSC diagnosis. Liver and lung transplant patients showed a significantly decreased risk of developing subsequent IM after a diagnosis of NMSC (HR 0.09 and 0.43, respectively). When stratified by type of IM, only patients who were diagnosed with a hematological malignancy had a significantly lower risk of developing this malignancy if they had a prior NMSC (HR 0.26).

Conclusions: The findings of this study suggest a protective effect of NMSC on subsequent IM in the organ transplant population.