Frontal fibrosing alopecia: survey of severity assessment methods in routine clinical practice and validation of the International Frontal Fibrosing Alopecia Cooperative Group measurement guidance.

BACKGROUND: The lack of validated and responsive outcome measures in the management of frontal fibrosing alopecia (FFA) significantly limits assessment of disease progression and treatment response over time. AIM: To understand how FFA extent and progression is currently assessed in UK specialist centres, to validate components of the International FFA Cooperative Group (IFFACG) statement on FFA assessment, and to identify pragmatic advice to improve FFA management in clinic. METHODS: Consultant dermatologists with a specialist interest in hair loss (n = 17) were invited to take part. Preferred FFA assessment methods were explored using questionnaires and clinical scenarios. Participants were asked to identify and mark the current hairline in 10 frontal and 10 temporal hairline images (Questionnaire 1), with assessment repeated 3 months later to assess intraindividual variability (Questionnaire 2) and 12 months later to test whether interindividual accuracy could be improved with simple instruction (Questionnaire 3). RESULTS: All 17 clinicians (100%) completed the questionnaire at each time interval. We identified a wide variation in assessment techniques used by our experts. Measurements were perceived as the most accurate method of assessing frontal recession whereas photography was preferred for temporal recession. Inter-rater reliability between clinicians measuring the frontal hairline scenarios indicated a moderate strength of agreement [intraclass coefficient (ICC) = 0.61; 95% CI 0.40-0.85], yet intrarater reliability was found to be poor with wide limits of agreement (-8.71 mm to 9.92 mm) on follow-up. Importantly, when clear guidance was provided on how the hairline should be identified (Questionnaire 3), inter-rater reliability improved significantly, with ICC = 0.70, suggesting moderate agreement (95% CI 0.51-0.89; P < 0.001). A similar pattern was seen with temporal hairline measurements, which again improved in accuracy with instruction. CONCLUSION: We found that accuracy of measurements in FFA can be improved with simple instruction and we have validated components of the IFFACG measurement recommendations.

Dermal fillers: pathophysiology, prevention and treatment of complications.

Dermal fillers are increasingly used for soft tissue augmentation of the face and hands. The widespread use of dermal fillers for rejuvenation has led to a rise in reports of associated complications. Although the majority of complications are mild and transient, serious and long-lasting complications have been observed. This article discusses the key complications including pigmentary changes, hypersensitivity reactions, infections, nodule formation, granulomatous reactions, vascular occlusion and migration of filler material. A thorough literature review was performed in addition to the combined extensive authors' (GP and FA) experience. Complications from fillers are increasingly being recognized and highlighted in the literature partly reflecting the growth in the market. This article provides a comprehensive overview of the filler complications with mechanisms of prevention and treatment per complication. A thorough understanding of the preventative and management strategies for the associated dermal filler complications will help the physician to prepare the patient well, and deal with complications that may arise effectively.

Saggy skin as a presenting sign of angioimmunoblastic T-cell lymphoma.

Angioimmunoblastic T-cell lymphoma (AITL) is a rare, aggressive form of peripheral T-cell lymphoma that has a variety of cutaneous manifestations. To our knowledge, saggy skin has not been documented as one of these manifestations. We report a case of a patient with angioimmunoblastic T-cell lymphoma presenting initially with pruritus and saggy skin, which later progressed into erythroderma despite chemotherapy; the disease eventually resolved with autologous stem cell transplant. Appreciating the cutaneous manifestations of AITL may allow for earlier diagnosis and treatment.

The role of beliefs: lessons from a pilot study on illness perception, psychological distress and quality of life in patients with primary cicatricial alopecia.

BACKGROUND: While alopecia has been shown to have substantial psychological consequences, previous studies have not explicitly explored the key beliefs of patients with primary cicatricial alopecia (PCA) and the relationship between clinical and psychological measures. OBJECTIVES: To identify the key psychological factors and quality of life (QoL) of patients with PCA and the relationship between these factors and established clinical measures. METHODS: In total 105 patients with PCA were recruited from a specialist hair research clinic in Manchester, U.K. Patients completed the revised Illness Perception Questionnaire, Hospital Anxiety and Depression Scale (HADS) and Dermatology Life Quality Index. These psychological measures were correlated with disease activity in patients with lichen planopilaris (LPP) and frontal fibrosing alopecia, using the LPP Activity Index (LPPAI). RESULTS: Patients perceived PCA as a chronic condition with significant personal consequences and emotional impact, and reported that they had low levels of control over the condition and its treatment. Considerable levels of psychological distress were observed (mean HADS total score 11·3 ± 8·1). Impaired QoL was associated with strong beliefs that the symptoms were attributed to their disease (P < 0·001), and that alopecia had serious consequences (P < 0·001) and was distressing (P < 0·001). Disease activity (LPPAI) showed a significant positive correlation with HADS-Depression (r = 0·343, P = 0·026). CONCLUSIONS: Patients with PCA experience significant psychological distress and impaired QoL, both of which are associated with key beliefs about illness. Management of PCA should involve assessment of the beliefs and emotions that drive patients' psychological distress, as well as giving access to psychological therapy.

Sunscreen photopatch testing: a series of 157 children.

BACKGROUND: Photoprotection including sunscreen use in children is encouraged by health campaigns. While sunscreen chemicals are common causes of photoallergic (PA) contact reactions in adults, limited data are available in children. OBJECTIVES: To assess the frequency of PA and contact allergy (CA) to sunscreens in children aged < 18 years undergoing investigation for suspected photosensitivity. METHODS: Retrospective analysis of data on children who underwent photopatch testing to a standard series of nine ultraviolet (UV) filters and to sunscreen products in a single photoinvestigation centre (2000-11). Duplicate series of UV filters and the children's own sunscreen products were applied to the back, with readings taken at sample removal, and at 24 and 48 h after 5 J cm(-2) UVA exposure of one series. RESULTS: The analysis comprised 157 children (aged 3-17 years, 69 male and 88 female). In total 10 children (6·4%) showed positive photopatch responses to UV filters and/or their sunscreen products (4·5% to UV filters, 5·7% to their sunscreen products). The responsible UV filters most often identified were benzophenone-3 and octyl methoxycinnamate. Additionally, CA reactions were observed in nine children (5·7%), with 16 children (10·2%) showing PA and/or CA to UV filters and/or sunscreen products. CONCLUSIONS: This is the largest series of photopatch testing reported in children, and shows that both sunscreen PA and CA are quite frequent in those undergoing photoinvestigation. Photopatch testing should be considered in children presenting with features of photosensitivity.

Latex allergy: assessment of knowledge, appropriate use of gloves and prevention practice among hospital healthcare workers.

BACKGROUND: Healthcare workers and patients are often exposed to natural rubber latex (NRL) through contact with gloves and various healthcare products, which can potentially cause allergic reactions, with varying degrees of severity. In 2008, the Royal College of Physicians published their first evidence-based guidance on occupational health interventions for latex allergy, which emphasized the importance of healthcare workers having knowledge of latex allergy. AIM: This study aimed to survey the knowledge of healthcare workers (n = 156) about latex gloves and NRL allergy, routine prevention practice and the appropriate use of gloves in patient care. METHODS: Healthcare workers in a large teaching hospital were surveyed using a standard questionnaire. RESULTS: We found that only 1% of healthcare workers were able to correctly match the appropriate gloves to the specifically designed procedure. More than half (n = 74.53%) were unable to recognize the presentation of type 1 allergy to NRL. Of the 156 participants, 131 (84%) considered that they would benefit from training about NRL allergy and the use of different types of gloves in clinical care. CONCLUSIONS: This survey indicates the importance of education regarding appropriate use of gloves and prevention of NRL allergy among healthcare workers, and dermatologists should play an important role in facilitating this.

Lichen planopilaris following hair transplantation and face-lift surgery.

Cosmetic surgical procedures, including hair transplantation and face-lift surgery, are becoming increasingly popular. However, there is very little information regarding the associated development of dermatological conditions following these procedures. Lichen planopilaris (LPP) is an uncommon inflammatory hair disorder of unknown aetiology that results in permanent alopecia and replacement of hair follicles with scar-like fibrous tissue. Frontal fibrosing alopecia (FFA), a variant of LPP, involves the frontal hairline and shares similar histological findings with those of LPP. We report 10 patients who developed LPP/FFA following cosmetic scalp surgery. Seven patients developed LPP following hair transplantation, and three patients developed FFA following face-lift surgery. In all cases there was no previous history of LPP or FFA. There is currently a lack of evidence to link the procedures of hair transplantation and cosmetic face-lift surgery to LPP and FFA, respectively. This is the first case series to describe this connection and to postulate the possible pathological processes underlying the clinical observation. Explanations include Koebner phenomenon induced by surgical trauma, an autoimmune process targeting an (as yet, unknown) hair follicle antigen liberated during surgery or perhaps a postsurgery proinflammatory milieu inducing hair follicle immune privilege collapse and follicular damage in susceptible individuals.

Clinical applicability of T-cell interferon-a release assay for tumour necrosis factor-a inhibitor therapy in severe psoriasis.

Many studies have found that screening and treatment of latent tuberculosis (TB) before starting treatment with tumour necrosis factor (TNF)-a inhibitors reduces associated TB infections. The new T-cell interferon-a release assay (TIGRA), is more specific and sensitive for detection of latent TB compared with the tuberculin skin test (TST). We report results of TIGRA in our first 63 patients commencing TNF-a inhibitors for severe psoriasis. Of the 63 patients, 5 (7.9%) had a positive TIGRA result and were started on treatment for latent TB. We found that the only risk factor for TB associated with a positive TIGRA was a history of travel to countries with high TB incidence. To our knowledge, this is the first study to identify the background risk (7.9%) of latent TB in an endemic UK population. This result emphasizes the importance of TIGRA testing to reduce the risk of TB in patients treated with TNF-a inhibitor.