Aromatase inhibitor-induced hair loss in two adolescents.

Hair loss and thinning are possible complications in those undergoing endocrine therapies with aromatase inhibitors. Alopecia in pediatric patients undergoing endocrine therapy has not been previously reported. We describe two adolescents, 14 and 16 years of age, who developed androgenetic alopecia following treatment with anastrozole for idiopathic short stature. Accordingly, the possible adverse event of alopecia should be considered in the pediatric population undergoing treatment with aromatase inhibitors.

Patients' prediction of their wound healing time.

Understanding and managing patients' expectations can help improve their adherence to treatment for chronic wounds; however, little is known concerning about their expectations regarding healing time. Recruited subjects were asked to predict how long their wounds would take to heal and their charts were reviewed to retrieve real time of healing. We recruited 100 subjects from which 77% have healed. Fifty-three subjects (68.8%) had a longer healing time than they predicted (underestimated), and 17 (22.1%) had a shorter healing time than they predicted (overestimated). Subjects with shorter wound duration history tended to predict shorter healing time than subjects with longer wound duration (p < 0.01). However, wound duration did not affect prediction accuracy (p = 0.65). Subjects with chronic wounds seem more often to underestimate their time of healing. Wound duration significantly influenced patients' prediction time, although it did not make their prediction more accurate. Patient education about expectations may be important as patients often expect their wounds to heal faster than they actually do.

Statins may be associated with six-week diabetic foot ulcer healing.

Diabetic foot ulcers (DFUs) affect 1.5 million Americans annually, of which only a minority heal with standard care, and they commonly lead to amputation. To improve care, investigations are underway to better understand DFU pathogenesis and develop more effective therapies. Some currently used medications may improve healing. One small, randomized clinical trial found statins improve DFU healing. In this secondary analysis of a large multisite prospective observational cohort of 139 patients with DFUs receiving standard care, we investigated whether there was an association between 6-week DFU wound size reduction and use of a variety of medications including alpha-blockers, beta-blockers, angiotensin converting enzyme inhibitors (ACEi) and statins. We found no significant (p < 0.05) association between six-week wound reduction and use of any of the evaluated drugs; however, statins did trend toward an association (p = 0.057). This suggests a potential benefit of statins on DFU healing, and larger, targeted studies are warranted.

Epidermal skin grafting.

Autologous skin grafts, such as full- and split-thickness, have long been part of the reconstructive ladder as an option to close skin defects. Although they are effective in providing coverage, they require the need for a trained surgeon, use of anaesthesia and operating room and creation of a wound at the donor site. These drawbacks can be overcome with the use of epidermal skin grafts (ESGs), which can be harvested without the use of anaesthesia in an office setting and with minimal to no scarring at the donor site. ESGs consist only of the epidermal layer and have emerged as an appealing alternative to other autologous grafts for the treatment of acute and chronic wounds. In this article, we provide an overview of epidermal grafting and its role in wound management.

Evaluation of Donor Site Pain After Fractional Autologous Full-Thickness Skin Grafting.

Background: Despite the development of numerous wound treatment alternatives, 25% to 50% of leg ulcers and >30% of foot ulcers are not fully healed after 6 months of treatment. Autologous skin grafting is a time-tested therapy for these wounds; however, the creation of a new wound in the donor area yields a considerable limitation to this procedure. Innovation: Fractional autologous full-thickness skin grafting (FFTSG) is a technique wherein multiple small full-thickness skin grafts (FTSGs) are harvested with possibly minor donor-site comorbidities. The first device used to harvest FFTSG (ART™ system, Medline, Northfield, IL) is a device capable of harvesting >300 small FTSGs and transferring them to a target wound. Objective: To better evaluate patients' clinical experience, we sought to evaluate pain at the donor site associated with this procedure. Approach: Pain was assessed with numeric visual analog pain scales at days 1, 2, 4, and 7. Nine subjects underwent this procedure with only six of them reporting any level of pain on day 1, and none disclosing pain after day 2. Conclusion: In this study, we evidenced that this device manages to harvest FTSGs with minimal associated pain. Future research will need to evaluate other aspects of the procedure as well as long-term outcomes at the donor and recipient areas.

Pretibial Myxedema Masquerading as a Venous Leg Ulcer.

The authors report a case of pretibial myxedema (PTM) masquerading as a venous leg ulcer to alert wound care clinicians to this diagnostic possibility. Pretibial myxedema is a localized form of mucin cutaneous deposition characterized by indurated plaques most commonly on anterior legs. It is more likely to present in patients with Graves' disease, but it can be found in euthyroid patients as well. The physiopathology of PTM is complex, and there is an accumulation of highly hydrophilic glycosaminoglycans in the dermis. Minimal morbidity is associated with PTM, but the pruritus related to mucin deposition can be intense. The skin around venous leg ulcers and the skin changes related to PTM can have a similar clinical presentation, which may be a reason PTM is under-recognized.

A Novel Topical Wound Therapy Delivery System.

INTRODUCTION: Wound care dressings have evolved over time, from bandaging to the development of occlusive dressings to negative pressure wound therapy. A novel therapeutic delivery system dressing has been cleared by the United States Food and Drug Administration. This semi occlusive wound dressing has been developed to provide local, continuous delivery of aqueous topical agents, such as therapeutics (anesthetics, antiseptics, antibiotics, steroids, topical beta-blockers, immune modulatory agents, growth factors, and fibrinolytic agents, among others), at a rate of about ¾ mL per day, thus maintaining a hydrated environment and providing topical treatment. This type of system may be beneficial in situations where systemic therapies cannot be used, wounds are small and few, wounds may need frequent application of medication or moisture, or low and steady delivery of medications is needed. OBJECTIVE: The authors assessed a delivery system dressing with different types of liquid medications for the management of hard-to-heal, chronic lower extremity wounds. MATERIALS AND METHODS: Patients aged ≥ 18 and ≤ 90 years with stalled chronic wounds > 30 days' duration were selected for the use of a topical delivery system, which consists of a semi occlusive wound dressing and fluid delivery unit that can provide local application of small therapeutic quantities of medication directly to the wound. RESULTS: Several successful cases with the use of this device are presented in which pain relief, enhancement of epithelial migration, inflammation reduction, bacterial control, and wound size reduction were achieved. CONCLUSIONS: This delivery system dressing is an effective and safe treatment option for wounds. Advantages include reduced potential of systemic side effects, flexibility in what can be delivered, constant rate of medication delivery, and convenience.

Central centrifugal cicatricial alopecia: challenges and solutions.

Central centrifugal cicatricial alopecia (CCCA) is the most common scarring alopecia among African American women. Data about epidemiology, etiology, genetic inheritance, and management are scarce and come from individual reports or small series. CCCA has been associated with hot combing and traumatic hair styling for years; however, studies fail to confirm it as the sole etiologic factor. It has been shown in a small series that CCCA can be inherited in an autosomal dominant fashion, with a partial penetrance and a strong modifying effect of hairstyling and sex. CCCA presents clinically as a central area of progressive irreversible hair loss that expands to the periphery. A patchy form has also been described. Dermoscopy is helpful to identify the optimal site for the biopsy, which establishes the diagnosis. Well-designed randomized controlled trials are needed to discover the optimal management. At this point, patients are advised to avoid traction and chemical treatments; topical and intralesional steroids, calcineurin inhibitors, and minoxidil can be helpful in halting the progression.

A Review of Cellular and Acellular Matrix Products: Indications, Techniques, and Outcomes.

BACKGROUND: Wound healing is a dynamic process whereby cells, growth factors (GFs), and the extracellular matrix (ECM) interact to restore the architecture of damaged tissue. Chronic wounds can be difficult to treat due to the increased presence of inflammatory cells that degrade the ECM, GF, and cells necessary for wound healing to occur. Cellular and acellular matrix products can be used in the management of a variety of chronic wounds including venous, diabetic, and pressure ulcers and other conditions such as burns, epidermolysis bullosa, pyoderma gangrenosum, and surgical wounds. These matrices provide cells, GF, and other key elements that act as a scaffold and promote reepithelialization and revascularization of the wound bed. METHODS: This article focuses on cellular and acellular matrix products that have been well-studied clinically with positive results in randomized clinical trials and widely available matrices for chronic nonhealing wounds. We present trial results as well as their indications, techniques, and outcomes. RESULTS: There are a variety of matrix products available on the market. Some of these products are used to treat chronic wounds, for example, diabetic foot ulcers, venous leg ulcers, pyoderma gangrenosum, and pressure ulcers. In this review, we found that wounds of different etiologies have been treated with a variety of matrices, with successful outcomes compared with standard wound care. CONCLUSIONS: Both cellular and acellular matrix products are useful in the management of a variety of chronic wounds. These matrices provide cells, GF, and other key elements that promote reepithelialization and revascularization of the wound bed while preventing degradation of the ECM. The treatment of chronic wounds with matrix products in combination with standard wound care has been proven to aid in wound healing when added to standard of care.

Patient Preference in Dermatologist Attire in the Medical, Surgical, and Wound Care Settings.

IMPORTANCE: Patients' perceptions of their physician can affect subjective and objective outcomes. Physician attire influences patients' perceptions of their physician and consequently may affect patient outcomes. OBJECTIVE: To determine patient preferences for different types of dermatologist attire in dermatology medical, surgical, and wound care clinics. We hypothesized that patients in the dermatology medical setting would prefer professional attire, while patients in the dermatology surgical and wound care setting would prefer surgical scrubs. DESIGN, SETTING, AND PARTICIPANTS: This study analyzed responses to a cross-sectional, anonymous survey by English-speaking dermatology patients (aged 18 years or older) at general, surgical, and wound care clinics in an academic center in Miami, Florida. Patients who could not read and understand the survey were excluded. Participants received pictures of a physician wearing business attire, professional attire, surgical attire, and casual attire, and responded by indicating which physician they preferred for each of 19 questions. Frequencies of responses were recorded, and χ2 and regression tests were performed. MAIN OUTCOMES AND MEASURES: Response frequencies. RESULTS: Surveys were administered to 261 persons, and 255 participated and completed enough of the questions to be included in the outcome analyses (118 men, 121 women, 22 unknown [did not answer sex question]), mean (SD) age, 56.3 (18.6) years; about 49% of those who reported their sex were men; 56% were Hispanic; and 85% were white. Approximately 72% of respondents held a college degree or higher. About 63%, 24%, and 13% of respondents were medical, surgical, and wound care dermatology patients, respectively. Roughly 73%, 19%, 6%, and 2% of cumulative responses were for professional, surgical, business, and casual attire, respectively. Respondents who received a picture of a black male or black female physician were more likely to exclusively prefer professional attire: unadjusted odds ratios (ORs) 3.21 (95% CI, 1.39-7.42) and 2.78 (95% CI, 1.18-6.51), respectively, compared with respondents who received a picture of a white male physician. Nonwhite and unemployed respondents were less likely to prefer professional attire exclusively: ORs, 0.28 (95% CI, 0.1-0.83) and 0.28 (95% CI, 0.08-0.99), respectively. Respondents preferred professional attire in all clinic settings, though respondents in the dermatology surgery clinic were less likely to prefer professional attire compared with respondents in the medical dermatology clinic: race-adjusted OR, 0.74 (95% CI, 0.56-0.98). Wound care and medical dermatology respondents preferred professional attire comparably. CONCLUSIONS AND RELEVANCE: In this study, most patients preferred professional attire for their dermatologists in most settings. It is possible that patients' perceptions of their physicians' knowledge and skill is influenced by the physicians' appearance, and these perceptions may affect outcomes.

Female pattern hair loss.

CONTEXT: Female pattern hair loss (FPHL) also known as female androgenetic alopecia is a common condition afflicting millions of women that can be cosmetically disrupting. Prompt diagnosis and treatment are essential for obtaining optimal outcome. This review addresses the clinical presentation of female pattern hair loss, its differential diagnosis and treatment modalities. EVIDENCE ACQUISITION: A) Diffuse thinning of the crown region with preservation of the frontal hairline (Ludwig's type) B) The "Christmas tree pattern" where the thinning is wider in the frontal scalp giving the alopecic area a triangular shaped figure resembling a christmas tree. C) Thinning associated with bitemporal recession (Hamilton type). Generally, FPHL is not associated with elevated androgens. Less commonly females with FPHL may have other skin or general signs of hyperandrogenism such as hirsutism, acne, irregular menses, infertility, galactorrhea and insulin resistance. The most common endocrinological abnormality associated with FPHL is polycystic ovarian syndrome (PCOS). RESULTS: The most important diseases to consider in the differential diagnosis of FPHL include Chronic Telogen Effluvium (CTE), Permanent Alopecia after Chemotherapy (PAC), Alopecia Areata Incognito (AAI) and Frontal Fibrosing Alopecia (FFA). This review describes criteria for distinguishing these conditions from FPHL. CONCLUSIONS: The only approved treatment for FPHL, which is 2% topical Minoxidil, should be applied at the dosage of 1ml twice day for a minimum period of 12 months. This review will discuss off-label alternative modalities of treatment including 5-alfa reductase inhibitors, antiandrogens, estrogens, prostaglandin analogs, lasers, light treatments and hair transplantation.

Minoxidil induced hypertrichosis in a 2 year-old child.

We report a case of a 2 year-old male patient who developed generalized hypertrichosis after 2 months of treatment with 5% minoxidil foam for alopecia areata. This report highlights the danger of prescribing  topical minoxidil to young children and the need to correctly instruct caretakers about its administration.

Vellus hairs in the frontal scalp in early female pattern hair loss.

BACKGROUND: Dermoscopy of the scalp (trichoscopy) is a technique to evaluate the skin of the scalp and the hair disorders. It clinically helps to establish early female pattern hair loss (FPHL) without the need for more invasive techniques. OBJECTIVES: This work intends to demonstrate new adjunct criteria for the clinical diagnosis of FPHL by determining the number of short vellus hairs encountered in the frontal area of the scalp of female patients with FPHL. MATERIALS AND METHODS: We retrospectively reviewed the trichoscopy images from 45 women affected by FPHL in initial stages, at 20 fold magnification dermoscopy at 2 cm from the hairline into the frontal area of the scalp. RESULTS: A total of 45 patients images included had more than 20% variability at dermoscopy, criteria utilized to diagnose and included them in the study. All patients were graded as Ludwig I severity, 14 patients had frontal accentuation. The average number of vellus hairs in the frontal area at 20-fold magnification of all patients was of 12.02 vellus hair in the frontal area. When comparing the Ludwid I pattern group versus the Ludwig I with frontal accentuation pattern group there was no statistical difference between the two clinical groups. CONCLUSIONS: All 45 patients analyzed in this study were clinically diagnosed with FPHL. The number of vellus hairs in the frontal area was greater than the average found in normal subjects. Most patients (80%) with FPHL had more than or equal to seven vellus hairs per 20-fold magnification field in the frontal area, therefore we suggest that the presence of more than 6 vellus hairs in the frontal scalp at 20-fold magnification can be used as an additional criterion of FPHL.