A phase 2a study investigating the effects of ritlecitinib on brainstem auditory evoked potentials and intraepidermal nerve fiber histology in adults with alopecia areata.

Reversible axonal swelling and brainstem auditory evoked potential (BAEP) changes were observed in standard chronic (9-month) toxicology studies in dogs treated with ritlecitinib, an oral Janus kinase 3/tyrosine kinase expressed in hepatocellular carcinoma family kinase inhibitor, at exposures higher than the approved 50-mg human dose. To evaluate the clinical relevance of the dog toxicity finding, this phase 2a, double-blind study assessed BAEP changes and intraepidermal nerve fiber (IENF) histology in adults with alopecia areata treated with ritlecitinib. Patients were randomized to receive oral ritlecitinib 50 mg once daily (QD) with a 4-week loading dose of 200 mg QD or placebo for 9 months (placebo-controlled phase); they then entered the active-therapy extension and received ritlecitinib 50 mg QD (with a 4-week loading dose of 200 mg in patients switching from placebo). Among the 71 patients, no notable mean differences in change from baseline (CFB) in Waves I-V interwave latency (primary outcome) or Wave V amplitude on BAEP at a stimulus intensity of 80 dB nHL were observed in the ritlecitinib or placebo group at Month 9, with no notable differences in interwave latency or Wave V amplitude between groups. The CFB in mean or median IENF density and in percentage of IENFs with axonal swellings was minimal and similar between groups at Month 9. Ritlecitinib treatment was also not associated with an imbalanced incidence of neurological and audiological adverse events. These results provide evidence that the BAEP and axonal swelling finding in dogs are not clinically relevant in humans.

Publication rates on the topic of racial and ethnic diversity in dermatology versus other specialties.

BACKGROUND: The population of the U.S. is becoming more diverse every year. The field of dermatology is not following the same trend. OBJECTIVE: To assess the promotion of diversity in the field of dermatology by analyzing publications focused on diversity, compared to other specialties. METHODS: The PubMed database was systematically searched to identify publications focused on diversity from January 2008 to July 2019. The search criteria were as follows: dermatology/radiology/ophthalmology/ anesthesiology/orthopedic surgery/family medicine/ internal medicine/general surgery AND diversity/ diverse/racial/race/ethnic/ethnicity/cultural/culture/competency/competence. Comparisons were made using single-factor ANOVA and two-group t-tests. A qualitative analysis was performed for publications in the field of dermatology. RESULTS: From January 2016 to July 2019, there were 25 publications focused on diversity in dermatology (Mean=6.25, SD=2.06), compared to 6 in radiology (Mean=1.50, SD=1.29, P=0.01), two in ophthalmology (Mean=0.50, SD=0.58, P=0.01), two in anesthesiology (Mean=0.50, SD=1.00, P=0.01), 12 in orthopedic surgery (Mean=3.00, SD=1.41, P=0.04), 23 in family medicine (Mean=5.75, SD=2.22, P=0.75), 9 in internal medicine (Mean=2.25, SD=1.71, P=0.02), and 7 in general surgery (Mean=1.75, SD=0.50, P=0.02). CONCLUSIONS: Although the field of dermatology has suffered from a lack of racial/ethnic diversity, efforts to promote diversity via increased publications in the last four years have been stronger in dermatology compared to many other fields.

Dermatosis Papulosa Nigra: A Quality of Life Survey Study.

Background: Dermatosis papulosa nigra (DPN) is a skin condition characterized by pigmented sessile and pedunculated papules on the body, particularly on the face and other sun-exposed areas, that can cause cosmetic disfigurement and varying degrees of distress and psychosocial concern among patients. Objective: We sought to evaluate the effect of DPN on quality of life (QoL). Methods: A 39-item questionnaire was administered to 50 African-American (AA) adults, 48 women and two men, with an average age of 51.7 years and visible DPN lesions at a dermatology clinic. We collected demographic information, family history, prior treatment, as well as type(s), frequency, duration of lesions, and attitudes about lesions. Dermatologic QoL (DLQI) survey scores were used to quantify the effect that DPN had on QoL. RESULTS: Most subjects reported lesions on the face (86%); 49 percent reported between 10 to 30 lesions on the body. The average age of diagnosis was 44.7 years (±15.51 years). Further, 84 percent of subjects reported having a firstdegree relative with DPN. Most patients reported little to no symptoms from their DPN (82%), while 36 percent had previously visited a physician due to their DPN. Electrocautery and cryosurgery were the most common methods of DPN removal. All subjects who had their DPN lesions removed reported improvement in the appearance of their skin. The average (standard deviation) DLQI score was six points (±5.42 points), which indicates that DPN has a moderate effect on QoL. Conclusion: Our study results reveal the high likelihood of a family history of DPN in subjects with the condition. Overall, most subjects reported few symptoms of DPN and their QoL was only moderately affected by DPN. Still, patients might benefit from the removal of DPN lesions.

An Atypical Presentation of PLEVA: Case Report and Review of the Literature

Pityriasis lichenoides et varioliformis acuta (PLEVA) is a rare, self-limited, cutaneous disorder of unknown etiology. Clinically, PLEVA is characterized by the sudden onset of scaly, erythematous macules and papules localized to the trunk and proximal extremities. We report the case of a patient who presented with multiple erythematous papules and plaques on the palms, forearms, and dorsal feet. J Drugs Dermatol. 2019;18(7):690-691.

Alopecia in Association with Malignancy: A Review.

The interaction between hair and malignancy is complicated. Various hair abnormalities can manifest in oncology patients as a clinical manifestation, the result of cancer therapy, or due to a paraneoplastic condition. The mechanisms of these changes remain unclear. Alopecia is one of the common clinical presentations occurring in oncology patients that affects their quality of life. The condition can concomitantly develop during the course of malignancy or when patients undergo cancer treatment. It is important for physicians to understand alopecia in association with malignancy as it may be an important associated finding or provide the clues to aid diagnosis. The aim of this review is to summarize the clinical characteristics of alopecia that occur in cancer patients and their relationship with the type of malignancy and its treatment.

A Retrospective Review of Treatment Results for Patients With Central Centrifugal Cicatrical Alopecia.

INTRODUCTION: Central centrifugal cicatricial alopecia (CCCA) is a form of scarring alopecia primarily affecting women of African descent on the crown of the scalp. Limited data exists regarding evidence-based treatment for CCCA.

OBJECTIVE: To examine photos of subjects with CCCA before and after treatment in order to evaluate results of treatment and compare results of different treatment regimens.

METHODS: Photographs of 15 subjects with CCCA before and after treatment were evaluated by two blinded investigators who assigned disease severity scores to photographs based on a published scale: Central Scalp Alopecia Photographic Scale in African American Women.

RESUTLS: Median change in severity score (post-treatment severity score - pre-treatment severity score) was 0.5 (P = 0.58) for all 15 subjects receiving a series of 7 to 8 intralesional steroid injections along with topical steroids (Class I/II) +/- minoxidil and +/- anti-dandruff shampoo, indicating worsening of disease after treatment. Subjects receiving minoxidil versus those who did not (0.25 vs 0.5; P = 0.38) and subjects receiving anti-dandruff shampoo versus those who did not (0.0 vs 0.5; P = 0.42) demonstrated no statistically significant difference in pre- and post-treatment severity scores. Of 15 subjects, 5/15 (33.3%) had decreased severity scores, 8/15 (53.3%) had increased severity scores, and 2/15 (13.3%) had no change in severity scores.

CONCLUSIONS: Although no statistically significant difference was found in pre- versus post-treatment disease severity, this may indicate intralesional steroid injections and topical steroids +/- minoxidil and +/- anti-dandruff shampoo halt disease progression.

J Drugs Dermatol. 2017;16(4):317-320.

Approach to treatment of medical and cosmetic facial concerns in skin of color patients.

Facial concerns in skin of color (SOC) patients vary and can be a source of emotional and psychological distress. This article discusses 4 common facial concerns in SOC patients: acne, rosacea, facial hyperpigmentation, and cosmetic enhancement. Treatment recommendations are provided as well as management pearls.

Factors affecting the severity of central centrifugal cicatricial alopecia.

BACKGROUND: Central centrifugal cicatricial alopecia (CCCA) is a type of scarring hair loss primarily seen in African-American women. The risk factors that affect the severity of disease remain unclear. OBJECTIVES: This study was designed to elucidate risk factors that may be associated with severity of CCCA. METHODS: A cross-sectional survey study was conducted. Women with biopsy-confirmed CCCA responded to a questionnaire and were grouped according to a photographic scale of central scalp alopecia. The severity of disease was considered: grade 1 and 2 disease was interpreted as early-stage CCCA, and grade 3-5 disease was interpreted as advanced-stage CCCA. Data from the questionnaire were compared with levels of severity to determine the strength of associations with severity of disease. RESULTS: A total of 38 women with biopsy-confirmed CCCA were recruited to participate in this study. Early-stage CCCA was seen in 22 subjects (57.9%), and advanced-stage CCCA was noted in 16 subjects (42.1%). The average duration of hair loss was 5.7 years in early-stage disease and 10.1 years in advanced-stage disease. There was a positive correlation between duration of hair loss and degree of hair loss (Spearman's correlation 0.471, P = 0.003). CONCLUSIONS: This study reports on data sourced from patients with biopsy-confirmed CCCA and examines the relationships between various factors and severity of CCCA. The findings demonstrate that duration of hair loss is positively associated with severity of disease and that androgen-related conditions are prevalent in those affected with CCCA.

Hair loss in patients with skin of color.

Hair loss in skin of color patients can vary from the very simplest of diagnoses to a unique diagnostic challenge requiring extensive knowledge of historical symptoms, haircare practices, and previous treatments. There are several disorders in the literature that are noted to be more common in patients of African descent as compared to Caucasian populations. These disorders include central centrifugal cicatricial alopecia, dissecting cellulitis, discoid lesions of lupus erythematosus, traction alopecia, seborrheic dermatitis, and hair breakage. While there is no definitive prevalence data for the various forms of hair loss in the skin of color population, it is clear that these disorders are a concern for many patients in this population along with common hair loss concerns, such as telogen effluvium and pattern hair loss. A careful detailed clinical examination, history, and potential histopathology will guide the clinician to appropriate management. Hair disorders in skin of color patients may present unique challenges to the clinician, and knowledge of accurate clinical presentation and treatment approaches is essential to providing quality care.

Rosacea in skin of color: not a rare diagnosis.

BACKGROUND: The prevalence of rosacea in skin of color is not well characterized and may be underestimated. Physicians may not recognize and diagnose rosacea correctly in skin of color. PURPOSE: To assess the prevalence of rosacea in skin of color and determine if patients of color with rosacea symptoms are receiving a diagnosis of rosaceaMethods: We analyzed the National Ambulatory Medical Care Survey (NAMCS) for 1993-2010 for racial and ethnic distribution of patients with rosacea. Common reasons for visit in rosacea patients were tabulated and frequency of rosacea diagnosis was compared in patients of each race with the relevant reasons for visit. RESULTS: Of all patients diagnosed with rosacea, 2.0% were black, 2.3% were Asian or Pacific Islander, and 3.9% were Hispanic or Latino of any race. Leading reasons for visit associated with rosacea included "other diseases of the skin", skin rash, and discoloration or abnormal pigmentation. Rosacea was the primary diagnosis for 8.3% of whites and 2.2% of blacks complaining of "other diseases of the skin", for 2.0% of whites and 0.6% of blacks complaining of skin rash, and for 3.0% of whites and 0.0% of blacks complaining of discoloration or abnormal pigmentation. The percentage of rosacea patients who were black or Asian/Pacific Islander did not change significantly over time. LIMITATIONS: No specific reason-for-visit code indicating rosacea exists in the NAMCS. Prevalence may be underestimated if some patients do not visit a physician for treatment. CONCLUSIONS: Patients of color rarely receive a diagnosis of rosacea, even when they have symptoms suggesting it. Rosacea has not become more commonly diagnosed in skin of color in recent years.

Palmoplantar papules and hyperkeratosis in a deaf man.

A 31-year-old man presented with a history of extensive thickened skin of the palms and soles since the age of 7. The patient reported difficulty in ambulating and in using his hands secondary to his skin condition and associated pain. He also reported being seen by numerous specialists in the past for his hands, feet, and fingernails. He tried various topical medications, none of which were successful in minimizing the lesions on the hands and feet. Pertinent review of systems was positive for complete deafness diagnosed at 9 months of age. The patient did not speak and used sign language to communicate. His family history was significant for two brothers, both of whom are deaf and who have a similar skin condition of their hands and feet, but with lesser severity than the patient. The patient had no other medical issues.

Management of keloids in the United States, 1990-2009: an analysis of the National Ambulatory Medical Care Survey.

BACKGROUND: Keloids can cause significant morbidity during wound healing, but the most common current treatment practices for keloids are not well-established. OBJECTIVE: To determine the main treatments used for keloids in the United States and demographics of patient visits for keloids. METHODS: The National Ambulatory Medical Care Survey for 1990-2009 was queried for visits with a diagnosis of keloids. Leading medical and procedural treatments, patient demographic characteristics, physician specialties, reasons for visit, and comorbidities were assessed. RESULTS: There were an estimated 427,500 visits per year for keloids, with a slight decline in frequency of visits over time (p = .001). Triamcinolone was the leading medical treatment, and excision or destruction of a lesion was the leading procedural treatment. Sixty-two percent of patients were female, and 23.7% were African American. Mean age was 36.6. Dermatologists managed slightly more than half of visits, and plastic surgeons were second most used. CONCLUSIONS: Keloids are managed using a variety of treatments, primarily triamcinolone and excision or destruction of a lesion. High-quality evidence is lacking for the efficacy of most existing keloid treatments. New treatments that improve on the present standard of care would improve outcomes.

Approaches to the evaluation of lip hyperpigmentation.

Hyperpigmentation of the lips is a common condition. It is associated with a wide variety of conditions that include physiologic changes, genodermatoses, inflammatory diseases, endocrinologic disorders, drugs and chemicals, benign and malignant neoplasm, and other non-melanotic conditions. The aim of this article is to provide a clinical approach to hyperpigmented lesions on the lips based on the extent of lesions, the age of onset, and associated systemic involvements. In this review, we present an algorithm to guide the diagnosis of and plan for therapeutic intervention for pigmented lesions of the lips. The algorithm is based on the typical clinical presentation of each entity and should not be taken as an absolute indicator of diagnosis. Although the differences in color can help to differentiate among pigmented lesions, the interpretation of color can be subjective and is influenced by the amount and location of the pigment within the mucosa. The limitations of this review are that some data are based on case reports and small case series that may not reflect true association.

Top dermatologic conditions in patients of color: an analysis of nationally representative data.

BACKGROUND: Some dermatologic disorders are known to be much more common in patients of color, but the leading dermatologic disorders in patients of color have not yet been described on the basis of nationally representative data. PURPOSE: To determine the leading dermatologic disorders for each major racial and ethnic group in the United States. METHODS: We queried the National Ambulatory Medical Care Survey (NAMCS) for the leading diagnoses in patient visits to U.S. dermatologists from 1993 to 2009. The leading diagnoses were tabulated for each racial and ethnic group, and the top conditions were compared between groups. In a separate analysis, visits for skin conditions regardless of physician specialty were analyzed for leading diagnoses in each racial and ethnic group. RESULTS: The top five diagnoses for African-American patients in dermatology clinics were acne, unspecified dermatitis or eczema, seborrheic dermatitis, atopic dermatitis, and dyschromia. For Asian or Pacific Islander patients, the top five were acne, unspecified dermatitis or eczema, benign neoplasm of skin, psoriasis, and seborrheic keratosis. By contrast, in Caucasian patients, the top five were actinic keratosis, acne, benign neoplasm of skin, unspecified dermatitis or eczema, and nonmelanoma skin cancer. In Hispanic patients of any race, the leading diagnoses were acne, unspecified dermatitis or eczema, psoriasis, benign neoplasm of skin, and viral warts. When the leading dermatologic diagnoses across all physician specialties were assessed, the top diagnoses for African-Americans were unspecified dermatitis or eczema, acne, dermatophytosis of scalp and beard, sebaceous cyst, and cellulitis or abscess; for Asians or Pacific Islanders were unspecified dermatitis or eczema, acne, atopic dermatitis, urticaria, and psoriasis; and for Caucasians were acne, unspecified dermatitis or eczema, actinic keratosis, viral warts, and sebaceous cyst. For Hispanics of any race, they were unspecified dermatitis or eczema, acne, sebaceous cyst, viral warts, and cellulitis or abscess. For a sole diagnosis of a dermatologic condition, only 28.5% of African-Americans' visits and 23.9% of Hispanics' visits were to dermatologists, as compared to 36.7% for Asians and Pacific Islanders and 43.2% for Caucasians. LIMITATIONS: The data are based on numbers of ambulatory care visits rather than numbers of patients. Data on race or ethnicity were not collected for some patients. CONCLUSIONS: Several dermatologic disorders are much more commonly seen in patients of color. Acne and unspecified dermatitis or eczema are in the top five for all major U.S. racial and ethnic groups. There may be an opportunity to improve the care of patients of color by ensuring they have equal access to dermatologists.

Patient satisfaction and complications following laser hair removal in ethnic skin.

BACKGROUND: Laser hair removal (LHR) is increasingly popular for the treatment of unwanted hair. To date, there have been few studies to evaluate patient satisfaction and complications after LHR among people of color. OBJECTIVES: To determine patient satisfaction and complications with long-pulsed Nd:YAG laser assisted hair removal in dark-complexioned skin individuals from the patient's point of view. PATIENTS/METHODS: A survey questionnaire was administered to subjects with Fitzpatrick skin type VI between the ages of 21-70 years who had been treated with long-pulsed Nd:YAG for unwanted hair. Questions were comprised of those related to satisfaction and complications from treatment with LHR. Satisfaction was recorded on a linear analogue scale (LAS=not at all satisfied; 100=extremely satisfied). RESULTS: Fifty patients (female 41, male 9) completed the survey. All patients were satisfied with Nd:YAG LHR treatment with the mean satisfaction score of 84.2. All patients favor LHR treatment as compared to alternative methods. The majority of patients (79.3%) who had completed six or more LHR treatments were removing their hair less frequently than before LHR treatment. Hyperpigmentation after treatment was noted in three patients (6%), which lasted for 3-10 days. No hypopigmentation, blistering, or scarring was observed. All patients completing the study would recommend LHR for patients with unwanted hair with the mean recommendation score of 91.5. CONCLUSIONS: Nd:YAG laser-assisted hair removal gives a high rate of patient satisfaction in terms of hair reduction with minimal complication among subjects of color.