Same But Different: An 18-Month Cross-Sectional Study of Cosmetic Procedures in Patients With Skin Phototype I-III Versus IV-VI in Toronto, Canada.

BACKGROUND: Patients with darker skin phototypes self-report less facial aging than their lighter-skinned counterparts. However, the association of skin phototype with the type of cosmetic procedures received, is yet to be established in a Canadian context. OBJECTIVE: To compare the pattern of nonsurgical cosmetic procedures performed on people with different Fitzpatrick SPTs. MATERIALS AND METHODS: Cross-sectional study of patient encounters from October 2020-April 2022. Charts and photographs were reviewed and analyzed for age, sex, SPT, and procedure type. Participants were stratified by SPT into 2 cohorts: SPT I-III and SPT IV-VI. SPTs were collapsed into groups based on definitions of "skin of color" (SPT IV-VI) in previous literature. RESULTS: We analyzed 350 patients with mean age 43.4, of whom 320 (91%) were female and 30 (9%) were male. The SPT I-III cohort was older (mean age 45 vs 38.5 years, p < .0001) and more frequently underwent neuromodulator injection. The SPT IV-VI cohort more frequently underwent microneedling, platelet-rich plasma, or electrodessication. CONCLUSION: There are distinct patterns of cosmetic procedures performed. The SPT I-III cohort more commonly received procedures to manage facial aging. The SPT IV-VI cohort was younger and more commonly underwent procedures to manage hyperpigmentation.

Diversity in Dermatology? An Assessment of Undergraduate Medical Education.

BACKGROUND: A lack of representation of skin of color (SoC) in dermatology curricula is well-documented across North American medical schools and may present a barrier to equitable and comprehensive undergraduate medical education. OBJECTIVES: This study aims to examine representation in dermatologic educational materials and appreciate a link between bias in dermatologic education and student diagnostic ability and self-rated confidence. DESIGN: The University of Toronto Dermatology Undergraduate Medical Education curriculum was examined for the percentage photographic representation of SoC. A survey of 10 multiple-choice questions was administered to first- and third-year medical students at the University of Toronto to assess diagnostic accuracy and self-rated confidence in diagnosis of 5 common skin lesions in Fitzpatrick skin phototypes (SPT) I-III (white skin) and VI-VI (SoC). RESULTS: The curriculum audit showed that <7% of all images of skin disease were in SoC. Diagnostic accuracy was fair for both first- (77.8% and 85.9%) and third-year (71.3% and 72.4%) cohorts in white skin and SoC, respectively. Students' overall self-rated confidence was significantly greater in white skin when compared to SoC, in both first- (18.75/25 and 17.78/25, respectively) and third-year students (17.75/25 and 15.79/25, respectively) (P = .0002). CONCLUSIONS: This preliminary assessment identified a lack of confidence in diagnosing dermatologic conditions in SoC, a finding which may impact health outcomes of patients with SoC. This project is an important first step in diversifying curricular materials to provide comprehensive medical education.

A Case of Topical Ruxolitinib Treatment Failure in Alopecia Areata.

Alopecia areata (AA) is an autoimmune-mediated, nonscarring form of hair loss. Despite its prevalence, current management options are limited, especially when the disease has progressed to alopecia totalis (AT) or alopecia universalis (AU). Recent evidence that janus kinase (JAK) signaling contributes to AA pathogenesis prompted the investigation of JAK inhibitors such as tofacitinib and ruxolitinib as possible oral treatments. However, the potential for significant adverse effects with systemic JAK inhibition makes local administration a more attractive option. Yet, a paucity of data exists on topical JAK inhibition in AA. A success of topical ruxolitinib (0.6% cream) use in a young patient with AU has been reported to date. Here we report the treatment of a 66-year-old with AA with the same formulation of topical ruxolitinib, where it failed to induce hair growth. Our report demonstrates the importance of examining the factors contributing to variation in treatment response in a clinical trial of topical JAK inhibitors in AA. It is likely that both intrinsic factors specific to individual patients and extrinsic factors relating to treatment regimen are involved. Furthermore, characterisation of the specific JAKs overexpressed in AA may better target medication. Finally, this report highlights the need to compare the outcomes of topical vs oral ruxolitinib administration in patients with severe AA, AT, and AU and may support the possibility that extensive disease is more adequately treated with oral administration of ruxolitinib.

Tumor characteristics of Mohs surgery patients in Ottawa, Canada versus Houston, Texas--a consequence of access to care?

BACKGROUND: Ontario is one of the most underserved provinces in Canada for providing Mohs micrographic surgery (MMS). A new MMS clinic was opened in Ottawa, Ontario, in June 2009 to help combat the increasing incidence of nonmelanoma skin cancer (NMSC) in this region. OBJECTIVE: To prospectively compare MMS cases completed in Ottawa with cases completed in Houston, Texas, and examine the differences in tumor characteristics. MATERIALS AND METHODS: The first 150 cases performed in Ottawa were prospectively compared with 150 consecutive cases performed at a Mohs surgery clinic in Houston, Texas. Patient demographics, tumor diagnosis, primary or recurrent disease, tumor dimension, number of surgical stages, defect size, complexity of the procedure, and closure method were compared. RESULTS: The average preoperative tumor area was three times as great in Ottawa as in Houston. Almost one entire additional stage was required to clear the tumors treated in Ottawa. Postoperative defects were 87% larger in Ottawa. The number of advanced reconstructive repairs was significantly higher in Ottawa (93%) than Houston (14%). CONCLUSIONS: A significantly higher NMSC disease burden and greater surgical complexity was observed in the tumors treated in Ottawa than in Houston.

A case report about adalimumab-induced radiologically isolated syndrome: A significant side effect of tumour necrosis factor inhibitors.

Tumor necrosis factor-α antagonists have become a therapeutic mainstay for various inflammatory diseases including Hidradenitis Suppurativa. Despite their clinical efficacy, these medications have been associated with the rare development of demyelinating diseases. We report a 29-year-old male who developed neurological symptoms while taking adalimumab, a tumor necrosis factor-α antagonist, for treatment of Hidradenitis Suppurativa. The patient was subsequently diagnosed with radiologically isolated syndrome based on magnetic resonance imaging findings. The exact temporal relationship between demyelinating disease and tumor necrosis factor-α antagonists is poorly understood. Also, there remain a few effective treatment options for severe inflammatory diseases like Hidradenitis Suppurativa. In cases where a patient exhibits clinical stability and structural resolution following the development of neurological symptoms after tumor necrosis factor-α antagonist therapy, and there is a lack of other effective treatments to control extensive inflammatory disease, restarting the tumor necrosis factor-α antagonist could be considered provided there is neurology approval and close monitoring.

Can it make me white again? A case report of 88% phenol as a depigmenting agent in vitiligo.

Vitiligo is the most common depigmenting disorder. However, therapies prove to be time-consuming, costly, or slow to show efficacy. Here, we present a case of a 74-year-old female with vitiligo who underwent full-body depigmentation treatment 50 years ago. Brown patches of repigmentation appeared on the patient's face and arms and were eventually treated with 88% phenol. Patient was later switched to compounded 3% glutathione cream for a more sustained effect. Phenol was an accessible, economical, and easily administrable therapeutic option that can result in short-term depigmentation.

Onychomadesis following hand, foot, and mouth disease in a pregnant woman: A case report.

Hand, foot, and mouth disease is an enteroviral infection characterized by vesicles on the hands, feet, and oral mucosa. Given its rising incidence among adults, it is important to recognize its variable presentations and sequelae. These include onychomadesis, a complication of hand, foot, and mouth disease that is well described in children, with limited reports in adults. We present the unique case of a pregnant woman who developed onychomadesis following hand, foot, and mouth disease, with no adverse pregnancy outcomes. This case illustrates that (1) onychomadesis can occur in pregnant women with hand, foot, and mouth disease; (2) onychomadesis is typically a benign change that can occur following hand, foot, and mouth disease; and (3) onychomadesis is not necessarily associated with more severe disease or adverse pregnancy outcomes.

Reliability of Histopathology for the Early Recognition of Fibrosis in Traction Alopecia: Correlation with Clinical Severity.

Traction alopecia (TA) is hair loss caused by prolonged pulling or repetitive tension on scalp hair; it belongs to the biphasic group of primary alopecia. It is non-scarring, typically with preservation of follicular stem cells and the potential for regrowth of early lesions especially if traction hairstyles are stopped. However, the alopecia may become permanent (scarring) and fail to respond to treatment if the traction is excessive and prolonged. Hence, the ability to detect fibrosis early in these lesions could predict patients who respond to treatment. Histopathological diagnosis based on scalp biopsies has been used as a gold standard to delineate various forms of non-scarring alopecia and to differentiate them from scarring ones. However, due to potential discrepant reporting as a result of the type of biopsy, method of sectioning, and site of biopsy, histopathology often tends to be unreliable for the early recognition of fibrosis in TA. In this study, 45 patients were assessed using the marginal TA severity scoring system, and their biopsies (both longitudinal and transverse sections) were systematically assessed by three dermatopathologists, the aim being to correlate histopathological findings with clinical staging. Intraclass correlation coefficients were used to determine the level of agreement between the assessors. We found poor agreement of the identification and grading of perifollicular and interfollicular fibrosis (0.55 [0.23-0.75] and 0.01 [2.20-0.41], respectively), and no correlation could be drawn with the clinical severity score. Better methods of diagnosis are needed for grading and for recognition of early fibrosis in TA.

Baseline sebum IL-1α is higher than expected in afro-textured hair: a risk factor for hair loss?

OBJECTIVE: To investigate changes in sebum cytokines in response to hair cosmetics. Design and setting A prospective study at a University hospital. METHODS: We used a novel method for scalp surface sebum collection (Sebutape(®)) on three visits, sequentially a week apart, to investigate changes in six cytokines in 36 healthy women before and after shampoo and compared various chemical treatments (ammonium thioglycolate, "lye" sodium hydroxide and "no-lye" guanidine hydroxide relaxers) performed by a professional hairdresser. RESULTS: Significant levels detected were IL-1 alpha (IL-1α) and IL-1 receptor antagonist (IL-1ra), which were higher in untreated scalp vs. forehead: P < 0.001. Baseline levels of scalp sebum IL-1α were 18 times higher than IL-1ra. The levels of IL-1α decreased uniformly after shampoo (visit 1) and various chemical treatments (both crown and vertex all P < 0.001 - visit 2) but increased on follow-up at visit 3. Decreases in IL-1ra mimicked IL-1α at the vertex [after shampoo (P = 0.018) and visit 3 (P = 0.014)], but not on the crown, a finding which may suggest site-specific scalp predisposition to inflammation. The ratio of IL-1ra/IL-1α increased in all groups after all chemical treatments and on follow-up (all P < 0.001) but was surprisingly not significantly different from natural hair that underwent shampoo. LIMITATIONS: A wider cytokine panel may reveal response differences in treatment groups. CONCLUSIONS: Baseline inflammatory scalp cytokines are higher than expected and reduce with shampooing. Scrutiny of the influence of hair moisturizer formulations and shampoo intervals and studies investigating pro-fibrotic cytokines are required. This may elucidate the predilection of afro-textured hair to scarring alopecia.

Chronic actinic dermatitis: clinical cases, diagnostic workup, and therapeutic management.

BACKGROUND: We report four cases of chronic actinic dermatitis (CAD) occurring in middle-aged men with significant outdoor exposure. OBJECTIVE: The aim of this report is to show the spectrum of presentations of patients with CAD and to outline the proper diagnostic workup of these individuals. METHODS: Phototesting was performed to determine the minimal erythema doses to ultraviolet (UV)A (315-400 nm) and UVB (280-315 nm) and photopatch testing and patch testing for each individual with the North American Contact Dermatitis Group Standard series and the Chemotechnique Plant series, supplemented by the Hausen Plant series and the patients' own products. RESULTS: All patients were men, over 45 years, who worked outdoors or had outdoor hobbies. Two had a past known history of allergic contact dermatitis. Two had atopic dermatitis. Three had positive reactions to Compositae plants and sesquiterpene lactone; one had a reaction to lichen acid mix. All had photocontact dermatitis or contact dermatitis to sunscreen chemicals, including benzophenone 3 (oxybenzone), butyl methoxydibenzoylmethane (avobenzone), and ethylhexyl methoxycinnamate (octinoxate). All reacted to fragrance mix; two reacted to balsam of Peru and two to colophony. All had biopsies showing an eczematous pattern. CONCLUSION: CAD is persistent, with a classic presentation, and requires a specific diagnostic workup. Effective therapeutic options exist for patients with CAD.