Update on Squamous Cell Carcinoma of the Nail Unit: An Human Papillomavirus-Associated Condition.

Background: Squamous cell carcinoma (SCC) and SCC in situ (Bowen's disease) are the most common malignancies of the nail unit. They are frequently seen in men over 50 and most commonly affect the fingers. The role of high-risk human papillomavirus (HPV) infection has been identified as a key contributor to the development of nail unit SCC. Summary: In this review, we aimed to summarize the current state of our understanding of how HPV contributes to nail unit SCC, the role of genitodigital transmission of HPV, and the clinical features of HPV-associated nail unit SCC. We also review current advances in the treatment of nail unit SCC, with a focus on the potential role of HPV vaccination in the treatment and prevention of nail unit SCC. Key Messages: Nail unit SCC should be recognized as an HPV-associated disease. HPV vaccination may represent a non-surgical modality for the management of these challenging malignancies in the appropriate clinical setting.

Diagnosis and management of longitudinal erythronychia: A clinical review by an expert panel.

Longitudinal erythronychia (LE) is defined as a longitudinal red band of the nail(s) and is classified as localized (involvement of 1 nail) or polydactylous (involvement of more than 1 nail). The differential diagnosis is distinct for these classifications. The etiologies of localized longitudinal erythronychia are most frequently benign subungual neoplasms and less often malignancies. Polydactylous longitudinal erythronychia is typically secondary to regional or systemic diseases, including lichen planus and Darier disease. LE is a common but underrecognized clinical finding. Increased dermatologist awareness of the clinical characteristics and differential diagnosis for LE is necessary given the possibility for malignancy and associated systemic disease. In this clinical review, the clinical features, differential diagnosis, evaluation, and management of LE are described.

Pressure alopecias: A review.

Pressure-induced alopecias (PAs) are an infrequent group of scarring and nonscarring alopecias that occur after ischemic obstruction of capillaries that leads to circumscribed areas of hair loss. Initially described after prolonged surgeries or immobilization, type 1 PA occurs after sustained external pressure to the skin, mainly the scalp prominences. Alopecia induced by cosmetic procedures, referred in this review as type 2 PA, is reported with increased frequency in literature and predominantly emerges from pressure exerted by the volume of injectables. It is important to differentiate type 2 PA from vascular occlusion-induced alopecia because they represent distinct entities. Clinically, PA may present with erythema, swelling, and tenderness; however, alopecia might be the sole manifestation. Crusts and ulceration are associated with a worse outcome and a higher risk of scarring alopecia. Prompt diagnosis is paramount to prevent complications. Trichoscopy, although considered nonspecific, may provide relevant clues for an accurate diagnosis. Hair regrows in most cases, but prognosis depends on ischemia severity and timely treatment with reperfusion therapies or mobilization. Treatment of hair loss is usually not necessary because the disease in most cases is self-limited and reversible. The role of topical minoxidil and corticosteroids remains unknown.

Trichoscopic Patterns and Confocal Microscopy Features of Chemotherapy-Induced Alopecia.

Introduction: Chemotherapy-induced alopecia (CIA) can seriously affect the quality of life of cancer patients. Trichoscopic patterns and confocal microscopy (RCM) features of CIA have been scarcely studied. This study aimed to investigate the dermoscopic and RCM features of CIA in 19 females and 5 males, with CIA due to current or recent chemotherapy. Methods: Patients with CIA and current or recent (within 2 months) history of chemotherapy treatment were enrolled. After clinical examination, standard pictures were taken by digital camera (SLR Canon PowerShot G10) and trichoscopic images were captured by the Handyscope device (20x). Images of RCM were acquired by VivaScope 3000 with the VivaStack option. The trichoscopic and confocal images were acquired by three independent observers after central parting on three areas: vertex, middle, and frontal scalp. Results: A total of 24 patients were enrolled. CIA has features of anagen effluvium at trichoscopy but with low frequency of yellow dots and prominence of black dots. The simultaneous presence of pseudo-monilethrix and black dots at trichoscopy confirms the hypothesis that chemotherapy insults the hair follicle intermittently. At RCM, the presence of abnormal hair shaft morphology highlights that the insults affect hair shaft production. Conclusion: These are the first data in this field, so further studies with a higher number of patients analyzed are needed to confirm these findings.

Botulinum Toxin for Scalp Conditions: A Systematic Review.

BACKGROUND: Many reports have described the use of botulinum toxin (BTX) in the treatment of scalp conditions, but no studies have synthesized these collective findings. OBJECTIVE: We conducted a systematic review to summarize the scalp conditions for which treatment with BTX has been described. METHODS: We searched PubMed/MEDLINE and Scopus for articles in English published before November 1, 2022, using the keywords "hair" or "scalp" and BTX-related search terms. Articles that described patients who received injections of BTX for the management of scalp conditions were included. RESULTS: Twenty-four original articles (12 case reports, 9 clinical trials, and 3 case series) were identified that described 309 patients with a scalp condition treated with BTX. Androgenetic alopecia, craniofacial hyperhidrosis, and scalp hyperseborrhea had the most robust data supporting the clinical efficacy of BTX. CONCLUSION: The current quality of evidence is highly variable and, for many conditions, limited to small observational studies. Botulinum toxin may be a promising therapeutic option for patients with various scalp conditions, but future studies are needed to better understand its efficacy and safety.

Monodactylous Longitudinal Melanonychia in Pediatric Skin of Color: A Case Series and Review.

Introduction: Longitudinal melanonychia, a pigmented longitudinal streak on the nail, is a common clinical finding that may be associated with subungual melanoma with varying presentation depending on race and skin tone. It has been long reported that darker skinned ethnicities have a higher prevalence of longitudinal melanonychia in the US population (e.g., African Americans with 77% prevalence) [Indian J Dermatol. 2021;66(4):445], but unfortunately, there are limited studies exclusively looking at longitudinal melanonychia in pediatric patients of color. Case Presentation: In this case series, we review the current literature and report the findings of 8 cases of longitudinal melanonychia in children with skin types IV or greater. Out of the 8 cases identified, only 4 returned to the clinic for monitoring (n = 4), and there was an average of 20.8 months between the initial and final visits. Of the patients that returned for follow-up, 2 showed no relevant changes in the nail pigmentation, 1 showed fading of the band, and 1 patient showed enlargement of the band to involve the whole nail. Conclusion: Although many sources recommend a conservative approach to treatment that involves monitoring and follow-up, our findings indicate that a wait-and-see method cannot be applied to all cases in the pediatric population due to disruptions in continuity of care. An individualized approach considering such factors should be employed for each patient, and certain high-risk features of the ABCDEF nail melanoma model may be relevant in pediatric cases.

Efficacy of Methotrexate Alone vs Methotrexate Plus Low-Dose Prednisone in Patients With Alopecia Areata Totalis or Universalis: A 2-Step Double-Blind Randomized Clinical Trial.

Importance: Poor therapeutic results have been reported in patients with alopecia areata totalis (AT) or universalis (AU), the most severe and disabling types of alopecia areata (AA). Methotrexate, an inexpensive treatment, might be effective in AU and AT. Objective: To evaluate the efficacy and tolerance of methotrexate alone or combined with low-dose prednisone in patients with chronic and recalcitrant AT and AU. Design, Setting, and Participants: This academic, multicenter, double-blind, randomized clinical trial was conducted at 8 dermatology departments at university hospitals between March 2014 and December 2016 and included adult patients with AT or AU evolving for more than 6 months despite previous topical and systemic treatments. Data analysis was performed from October 2018 to June 2019. Interventions: Patients were randomized to receive methotrexate (25 mg/wk) or placebo for 6 months. Patients with greater than 25% hair regrowth (HR) at month 6 continued their treatment until month 12. Patients with less than 25% HR were rerandomized: methotrexate plus prednisone (20 mg/d for 3 months and 15 mg/d for 3 months) or methotrexate plus placebo of prednisone. Main Outcome and Measures: The primary end point assessed on photos by 4 international experts was complete or almost complete HR (Severity of Alopecia Tool [SALT] score <10) at month 12, while receiving methotrexate alone from the start of the study. Main secondary end points were the rate of major (greater than 50%) HR, quality of life, and treatment tolerance. Results: A total of 89 patients (50 female, 39 male; mean [SD] age, 38.6 [14.3] years) with AT (n = 1) or AU (n = 88) were randomized: methotrexate (n = 45) or placebo (n = 44). At month 12, complete or almost complete HR (SALT score <10) was observed in 1 patient and no patient who received methotrexate alone or placebo, respectively, in 7 of 35 (20.0%; 95% CI, 8.4%-37.0%) patients who received methotrexate (for 6 or 12 months) plus prednisone, including 5 of 16 (31.2%; 95% CI, 11.0%-58.7%) who received methotrexate for 12 months and prednisone for 6 months. A greater improvement in quality of life was observed in patients who achieved a complete response compared with nonresponder patients. Two patients in the methotrexate group discontinued the study because of fatigue and nausea, which were observed in 7 (6.9%) and 14 (13.7%) patients receiving methotrexate, respectively. No severe treatment adverse effect was observed. Conclusions and Relevance: In this randomized clinical trial, while methotrexate alone mainly allowed partial HR in patients with chronic AT or AU, its combination with low-dose prednisone allowed complete HR in up to 31% of patients. These results seem to be of the same order of magnitude as those recently reported with JAK inhibitors, with a much lower cost. Trial Registration: ClinicalTrials.gov Identifier: NCT02037191.

Conradi-Hünermann-Happle syndrome: Clinical and trichoscopic findings.

Conradi-Hünermann-Happle syndrome (CHHS) is a rare genodermatosis resulting from mutations in the EBP (emopamil binding protein) gene. Dermatologic manifestations may include cicatricial alopecia, ichthyosis, follicular atrophoderma, pigmentary abnormalities, and nail dystrophy. In addition to genetic testing and clinical findings, trichoscopic findings may aid in the diagnosis. In this case report, we discuss the trichoscopic findings in a 3-year-old girl with CHHS and how these findings help us understand the pathophysiology of this disease.

Alopecia After Cosmetic Injection Procedures: A Review.

BACKGROUND: Cosmetic procedures for antiaging carry inherent risks of adverse events. One that has not yet been well characterized is transitory or permanent alopecia. This is attributable to numerous mechanisms including pressure, ischemia, inflammation, and necrosis. Cases of postcosmetic procedure alopecia have been reported after mesotherapy as well as hyaluronic acid filler, deoxycholic acid, and botulinum toxin injections. OBJECTIVE: This review serves to describe the currently known causes of postcosmetic procedure alopecia and the mechanisms by which alopecia is attained. Furthermore, this review highlights the risk of unregulated mesotherapy injections for cosmetic enhancement and to bring attention to the increasing number reports of alopecia after these procedures. METHODS: A systematic review of the literature from 2000 to 2022 was conducted looking for keywords such as "alopecia," "cosmetic procedures," "mesotherapy," and "hyaluronic acid" in Google Scholar and PubMed. RESULTS: Ten articles met the criteria set forth in the authors' literature review. Many of the procedures resulted in partial or complete resolution of alopecia. CONCLUSION: Alopecia after cosmetic injection procedures is an underreported adverse effect. More research is needed to further characterize the risk of alopecia after mesotherapy and other injection procedures.

Anagen Effluvium after Neurointerventional Radiation: Trichoscopy as a Diagnostic Ally.

Minimally invasive procedures for vascular brain lesions are being performed more frequently. Radiation exposure caused by endovascular embolization of cerebral aneurysms may give rise to nonscarring scalp alopecia located in the treated area. Clinical and trichoscopic features of this type of alopecia are similar to alopecia areata (AA). Herein, we performed a comprehensive review to describe the clinical and trichoscopic characteristics of radiation-induced anagen effluvium. Predominant trichoscopic findings include black dots, yellow dots, short vellus hairs, and absence of exclamation marks hairs. It is important to consider this diagnosis in patients who have recently undergone such procedures that can easily be misdiagnosed as AA.

Nails Involvement in Winiwarter-Buerger Disease.

Introduction: Buerger disease, or thromboangiitis obliterans, is an inflammatory and occlusive process involving small and medium size arteries and veins, which generally affects the lower limbs of young adult male with the habit of smoking. Case Presentation: This paper reports 2 patients who developed nail lesions as the first sign of Buerger disease. Conclusion: Signs and symptoms of Buerger's disease are secondary to the inflammatory process and arterial occlusion which results in severe ischemia. Involvement of nails is not common, but we found 2 different clinical features which have not been previously reported in the literature: chronic paronychia, and proximal leukonychia or onycholysis and nail bed erosion.

Trichotillomania: What Do We Know So Far?

Trichotillomania is defined as an obsessive-compulsive or related disorder in which patients recurrently pull out hair from any region of their body. The disease affects mainly female patients, who often deny the habit, and it usually presents with a bizarre pattern nonscarring patchy alopecia with short hair and a negative pull test. Trichoscopy can reveal the abnormalities resulting from the stretching and fracture of hair shafts, and biopsy can be necessary if the patient or parents have difficulties in accepting the self-inflicted nature of a trichotillomania diagnosis. Trichotillomania requires a comprehensive treatment plan and interdisciplinary approach. Physicians should always have a nonjudgmental, empathic, and inviting attitude toward the patient. Behavioral therapy has been used with success in the treatment of trichotillomania, but not all patients are willing or able to comply with this treatment strategy. Pharmacotherapy can be necessary, especially in adolescents and adult patients. Options include tricyclic antidepressants, selective serotonin reuptake inhibitors, and glutamate-modulating agents. Glutamate-modulating agents such as N-acetylcysteine are a good first-line option due to significant benefits and low risk of side effects. Physicians must emphasize that the role of psychiatry-dermatology liaison is extremely necessary with concurrent support services for the patient and parents, in case of pediatric patients. In pediatric cases, parents should be advised and thoroughly educated that negative feedback and punishment for hair pulling are not going to produce positive results. Social support is a significant pillar to successful habit reversal training; therefore, physicians must convey the importance of familial support to achieving remission. This is a review article that aims to discuss the literature on trichotillomania, addressing etiology, historical aspects, clinical and trichoscopic features, main variants, differential diagnosis, diagnostic clues, and psychological and pharmacological management.

Papel da dermatoscopia na distinção entre tinea nigra e nevo melanocítico acral / Role of Dermoscopy in Distinguishing Tinea Nigra from Acral Nevus

A dermatoscopia é uma ferramenta prática e não invasiva que pode ser usada para distinguir a tinea nigra de outras lesões que parecem macroscopicamente semelhantes, incluindo o nevo melanocítico acral. Sob a dermatoscopia, a tinea nigra se apresenta com um padrão de deposição de pigmento marromacinzentado espiculado, enquanto o nevo melanocítico acral geralmente se apresenta como deposição de pigmento marrom em um padrão de sulco paralelo.

Dermoscopy is a practical, non-invasive tool that can be used to distinguish tinea nigra from other lesions that appear macroscopically similar, including acral nevus. Under dermoscopy, tinea nigra presents with a pattern of spiculated gray-brown pigment deposition, whereas acral nevus most often presents as brown pigment deposition in a parallel furrow pattern.

Hormonal Contraceptives and Dermatology.

Hormones play a significant role in normal skin physiology and many dermatologic conditions. As contraceptives and hormonal therapies continue to advance and increase in popularity, it is important for dermatologists to understand their mechanisms and dermatologic effects given the intricate interplay between hormones and the skin. This article reviews the dermatologic effects, both adverse and beneficial, of combined oral contraceptives (COCs), hormonal intrauterine devices (IUDs), implants, injections, and vaginal rings. Overall, the literature suggests that progesterone-only methods, such as implants and hormonal IUDs, tend to trigger or worsen many conditions, including acne, hirsutism, alopecia, and even rosacea. Therefore, it is worthwhile to obtain detailed medication and contraceptive histories on patients with these conditions. There is sufficient evidence that hormonal contraceptives, particularly COCs and vaginal rings, may effectively treat acne and hirsutism. While there are less data to support the role of hormonal contraceptives in other dermatologic disorders, they demonstrate potential in improving androgenetic alopecia and hidradenitis suppurativa.

Fibrosing alopecia in a pattern distribution.

BACKGROUND/OBJECTIVES: Fibrosing alopecia in a pattern distribution (FAPD) is a newly recognized form of scarring alopecia sharing characteristics of both androgenetic alopecia (AGA) and lichen planopilaris. The existing literature on FAPD and current understanding of the epidemiology, pathogenesis, clinical features, diagnosis, and treatment of this disease are reviewed. METHODS: PubMed searches were performed to identify all articles discussing FAPD. The references of articles were used to identify additional articles. RESULTS: A total of 15 articles were found describing FAPD in a total of 188 patients (164 women and 24 men; average age, 53.8). CONCLUSIONS: FAPD affects the androgen-dependent scalp and is typically associated with hair follicle miniaturization. The scalp affected by FAPD shows features of both lichen planopilaris and AGA, and FAPD may possibly represent an exaggerated inflammatory response to damaged hair follicles, triggered by AGA. Physical examination and trichoscopic evidence of follicular inflammation and, occasionally, fibrosis are important to identify the condition, and a dermoscopy-guided biopsy can confirm the diagnosis. Unless recognized, clinicians may misdiagnose FAPD as AGA associated with seborrheic dermatitis. Data on treatment modalities are limited; however, based on pathogenesis, combined therapy with anti-inflammatory and hair growth-promoting agents is warranted.

Trichoscopy for the Hair Transplant Surgeon-Assessing for Mimickers of Androgenetic Alopecia and Preoperative Evaluation of Donor Site Area.

Preoperative diagnostic confidence and donor site assessment are important for all hair transplant surgery patients. While the majority of patients seek hair transplantation for male or female pattern hair loss (androgenetic alopecia [AGA]), there are mimickers that must be differentiated from patterned hair loss, as they alter the candidacy of the patient for transplantation. They are termed mimickers as they also can present with patterned hair loss. The use of trichoscopy has become increasingly popular for such use. Patterned hair loss mimickers, which include the underappreciated alopecia areata incognita (AAI) and fibrosing alopecia in patterned distribution (FAPD), can be identified clinically with key trichoscopic findings such as yellow dots and peripilar casts, respectively, that correlate with their histologic diagnosis. Donor hair density and putative hair pathology of the safe donor area can also by assessed via trichoscopy. This article discusses the use of trichoscopy, particularly for diagnosing mimickers of patterned hair loss as well as preoperative donor site assessment.