Consilium Medicum

Wheat-dependent exercise-induced anaphylaxis is a specific form of immunoglobulin E-mediated reaction whose clinical manifestations develop only when the consumption of wheat-containing products is combined with the action of co-factors (physical exertion, intake of non-steroidal anti-inflammatory drugs, or alcohol). Its diagnosis is significantly challenging due to the variability and delayed onset of clinical symptoms, which requires increased attention from allergists and immunologists. This paper presents an analysis of two clinical cases illustrating the age-related features of anaphylaxis in wheat allergy: in an adult patient with onset at 18 years of age, wheat-dependent exercise-induced anaphylaxis with clinically significant isolated sensitization to ω-5 gliadin (Tri a 19) was diagnosed, with clinical manifestations developing after a delayed onset following consumption of wheat-containing foods in combination with exposure to cofactors; in an 8-year-old child, classic wheat-induced anaphylaxis was identified, characterized by the immediate onset of clinical manifestations within 5–10 minutes after wheat ingestion, as well as polysensitization, characterized by high levels of specific immunoglobulin E (sIgE) to lipid transfer protein (Tri a 14) and moderate levels of specific immunoglobulin E to lipid transfer protein. In the first case, the clinical picture included recurrent episodes of urticaria, angioedema, gastrointestinal disorders, as well as a single syncopal episode, developing with a delayed onset after wheat ingestion and associated with physical exertion and nonsteroidal anti-inflammatory drugs intake. In the second case, in addition to reactions to wheat, the child had gastrointestinal symptoms after ingestion of hen's egg and cow's milk proteins, as well as concomitant atopic diseases, namely bronchial asthma and allergic rhinitis. Molecular allergy diagnostics in each case made it possible to identify the spectrum of sensitization to specific wheat allergens, verify the diagnosis accurately, predict the risk of future reactions, and develop personalized treatment strategies. The analysis confirms the heterogeneity of anaphylaxis to wheat allergens and the necessity of using modern diagnostic methods to optimize the treatment and prevention of life-threatening reactions.

Atopic dermatitis (AtD) is a common chronic skin disease. Its prevalence has been increasing over the past few decades, reaching 20% in children and 10% in adults. AtD can occur at any age, although 45% of all cases begin within first six months of life, with 80–90% presenting with their first symptoms by age five. AtD is characterized by a variable clinical presentation depending on age, disease severity, and ethnicity. Even milder forms have a negative impact on quality of life. The pathogenesis of AtD is complex and multifaceted, involving the interaction of several key mechanisms, including disruption of the epidermal barrier structure and immune response, altered skin microflora balance, genetic predisposition, and exposure to adverse environmental factors. AtD is characterized by overexpression of type 2 inflammatory cytokines, which suppress the expression of protective skin proteins, exacerbating barrier dysfunction. In addition to structural and immunological defects of the epidermal barrier, the skin microbiome plays a significant role in the development of AtD and its complications. In AtD, skin microbiome diversity is significantly reduced, with a predominance of Staphylococcus aureus. In addition to bacterial flora, AtD is characterized by an increased diversity of fungal flora. Not only the skin microbiome but also the gut microbiome plays a significant role in the development of AtD. Numerous factors influence the composition of the gut microbiota in newborns and children. Many of these factors are closely linked to the development of allergic diseases. In recent years, studies have been conducted on the use of pre- and probiotics as preventative measures and as part of combination therapy for AtD, but the results are quite contradictory. A number of pre- and probiotics can exert an immunomodulatory effect, thereby reducing the severity of AtD and prolonging the period of remission. An in-depth study of the interaction between the microbiological and immunological components of AtD pathogenesis seems promising for the development of new algorithms for diagnosis, treatment, and prevention.

The research on the skin microbiome in both normal and pathological conditions, particularly in cases of pyoderma and dermatoses complicated by infection, represents a promising frontier in dermatovenerology. This evolving field not only shifts perspectives on the pathophysiology of infectious diseases but also emphasizes the necessity for novel therapeutic approaches. Currently, technological advances, such as the amplification and sequencing of microbial genomic regions, have facilitated substantial progress in understanding the microbial composition of various tissues, including hollow organs and the skin. This progress has enabled the establishment of diagnostic criteria for dysbiosis, elucidating the role of such alterations in the pathogenesis of diverse diseases and the emergence of resistance among pathogenic microorganisms. There has been a notable increase in reported cases of skin infections primarily attributed to methicillin-resistant Staphylococcus aureus (MRSA). Patients in this category typically require additional diagnostic and therapeutic interventions, thereby increasing overall treatment costs. The diminishing efficacy of therapeutic regimens can largely be attributed to insufficient knowledge of the pharmacokinetics and pharmacodynamics of various agents, as well as their antimicrobial spectra and toxicities. This aspect is particularly critical when addressing the treatment needs of specific patient groups, including children, the elderly, military personnel, athletes, incarcerated individuals, and immunocompromised patients. The phenomenon of polyresistance to antibiotics and antifungal agents is escalating at a concerning rate, posing significant threats to public health. The antiseptic agent Miramistin®, based on benzyldimethyl-myristoylamino-propylammonium, exhibits bactericidal activity against both aerobic and anaerobic bacteria in monocultures and microbial consortia, including biofilms, as well as against hospital strains with multiple antibiotic resistances. Furthermore, it demonstrates fungicidal activity against the majority of pathogens causing superficial skin mycoses. Miramistin® solution is recommended for the prophylactic treatment of intact skin and wound surfaces. For enhanced therapeutic effect, Miramistin® 0.5% ointment is recommended, particularly under occlusive dressings. This formulation not only prevents infection of burn injuries but also stimulates regenerative processes, alleviates wound and perifocal inflammation, and promotes the formation of a dry scab by dehydrating necrotic tissue. In conclusion, integrating modern antiseptics into the comprehensive therapy of pyoderma and dermatological conditions of complex origin is an effective strategy for preventing secondary infections. Moreover, this approach minimizes the risk of complications and mitigates resistance to key antibacterial agents.

Background. Rosacea is a chronic inflammatory skin disease of the face of polyetiological nature and multifactorial genesis, including vascular, immune and neurogenic abnormalities. According to global international and domestic studies, the disease is widespread and has a significant impact on the quality of life of patients. One of the key links in pathogenesis is endothelial dysfunction associated with hyperexpression of vascular endothelial growth factor (VEGF), impaired microcirculation and rheological properties of the blood. In this regard, the development of rosacea therapy methods, taking into account deviations in the indicators of the functional activity of the vascular wall, is an urgent task of modern medicine.

Aim. Comparative evaluation of the clinical effectiveness of combination therapy for rosacea, taking into account the dynamics of hemostasis system indicators.

Materials and methods. The study involved 90 patients diagnosed with rosacea, clinically diagnosed with erythematotelangiectatic (ETR) and papulopustular (PPR) subtypes: women – 64 (71.11%), men – 26 (28.89%), average age – 40.24 ± 2.25 years, duration of the disease averaged 3.55 ± 1.20 years. Treatment groups are patients who were randomized into three equal groups of 30 people: the first group included 18 patients with ETR and 12 with PPR; the second group included 19 patients with ETR and 11 with PPR; the third group included 18 patients with ETR and 12 with PPR. The clinical efficacy was assessed based on the dynamics of the average values of the Rosacea Diagnostic Assessment Scale (Adaskevich V.P., 2004) and the Dermatological Quality of Life Index before the start of therapy, as well as after 4, 8, and 12 weeks of treatment. The functional state of the hemostasis system was assessed by thrombodynamics on a T-2 analyzer (GemaCor LLC, Russia), which simulates the spatiotemporal conditions of blood clotting before the start of therapy and after 12 weeks of treatment.

Results. The most pronounced reduction in clinical manifestations of rosacea, improvement in quality of life and normalization of thrombodynamic parameters were found in the combination therapy group (angioprotector and intravenous laser blood irradiation – ILBI). Intergroup analysis demonstrated statistically significant differences in favor of the scheme using ILBI.

Conclusion. Combination therapy with troxerutin and ILBI provides the best clinical and vascular results in the treatment of rosacea and can be considered as a promising direction in the treatment of rosacea.

Background. Despite the widespread adoption of minimally invasive techniques for the correction of pectus excavatum (PE), the formation of postoperative scars persists as a clinically significant concern among adolescents. The heightened propensity for hypertrophic scarring within this demographic is associated with potential adverse functional and aesthetic outcomes. However, data regarding the efficacy of local anti-scar therapies in this population are limited.

Aim. To assess the impact of topical therapy with a gel composed of heparin, allantoin, and cepalin on both the morphological and functional characteristics of postoperative scars, as well as on the quality of life (QoL) in adolescents after surgical correction of PE.

Materials and methods. This prospective, controlled, comparative study included 60 patients between the ages of 12 and 16 years who underwent surgical correction of PE. The subjects were divided into test group (n = 30), which received topical therapy, and control group (n = 30), which did not receive topical therapy for scar tissue. The patients in the test group received topical gel for 3 months, starting on Day 14 post-surgery. Efficacy was assessed on Days 7 and 90 using a subjective scale that incorporated morphological and functional scar parameters, along with QoL scores. Statistical analysis employed Student's t-test.

Results. In the test group, a statistically significant enhancement was observed across all evaluated parameters, including reductions in scar density and vascularization, diminished pigmentation and tissue tension severity, along with alleviation of subjective symptoms and improvements in aesthetic characteristics. The mean total score declined from 22.4 ± 4.1 to 14.3 ± 3.2 points, representing a 36% reduction (p < 0.001). In contrast, the control group exhibited minimal and statistically insignificant changes, with scores shifting from 19.1 ± 5.3 to 17.2 ± 5.0 points (p = 0.078). Clinical improvement was documented in 90% of patients in the test group, with 77% demonstrating pronounced improvement. Furthermore, enhanced tolerance to physical activity and increased subjective QoL assessments were also noted.

Conclusion. The early use of a topical anti-scar therapy gel comprising heparin, allantoin, and cepalin correlates with improved morphological and functional attributes of postoperative scars in adolescents with PE. The findings suggest the potential integration of this therapeutic approach into rehabilitation protocols following surgical correction of PE. The study's limitations include the lack of randomization and the relatively small sample size, which necessitate further research using validated assessment scales.

Isotretinoin is the treatment of choice for moderate-to-severe acne vulgaris, however, its use is predictably accompanied by a wide spectrum of adverse effects (AEs), primarily affecting the skin and mucous membranes. Their development is primarily driven by RAR(retinoic acid receptors)-γ-mediated dysfunction of sebaceous and other exocrine glands, disruption of keratinocyte terminal differentiation with consequent thinning of the stratum corneum and hydrolipid mantle, increased transepidermal water loss, and reduced stratum corneum hydration. This literature review provides a systematic overview of current evidence on the pathomechanisms, clinical features, and management strategies for mucocutaneous toxicity of systemic isotretinoin. Beyond the most common AEs – cheilitis, xerosis, photosensitivity, and retinoid dermatitis – the review addresses meibomian gland dysfunction, dryness of the mucous membranes, isotretinoin-induced skin fragility, telogen effluvium and periungual pyogenic granulomas. The majority of isotretinoin-induced mucocutaneous adverse effects have been shown to be dose-dependent and potentially reversible, responding well to lifestyle modification, specialized emollient therapy, and daily omega-3 fatty acid supplementation. Where required, targeted pharmacological intervention with topical anti-inflammatory, antimicrobial, and other agents is indicated. Furthermore, accumulated clinical evidence indicates that low-dose and "step-up/step-down" isotretinoin regimens achieve clinical outcomes non-inferior to conventional high-dose regimens in acne vulgaris management, while offering a substantially more favorable safety profile and greater patient adherence – supporting their preferential use across the majority of clinical settings. Additional clinical value is provided by evidence-based management recommendations for the principal cutaneous and mucosal AEs, presented in a structured tabular format, the implementation of which allows clinicians to achieve high treatment outcomes in patients with acne vulgaris without the need for dose modification or discontinuation of therapy.