Development and validation of the Frontal Fibrosing Alopecia Severity Score.

BACKGROUND: Frontal fibrosing alopecia (FFA) is a scarring alopecia characterized by recession of the frontotemporal hairline and loss of the eyebrows. OBJECTIVE: To design and validate a scoring system to assess the severity of FFA. METHODS: The Frontal Fibrosing Alopecia Severity Score (FFASS) was developed; criterion validity was assessed by the Investigator's Global Assessment, and construct validity was evaluated by the convergence of other measures of severity (the Patient's Global Assessment], the rest of the clinical features, the Lichen Planopilaris Activity Index, and quality of life measures (Dermatology Life Quality Index and Hospital Anxiety Depression Scale). Intraobserver and interobserver reliability were determined. RESULTS: In total, 103 female patients were included. The FFASS showed significant correlation to the Patient's Global Assessment, occipital involvement, and the Lichen Planopilaris Activity Index. Intraobserver reliability was completed for 31 subjects and showed good correlation (intraclass correlation coefficient, 0.86; 95% confidence interval, 0.7-0.95; P < .001). Interobserver reliability showed excellent correlation (intraclass correlation coefficient, 0.97; 95% confidence interval, 0.95-0.99; P < .001). LIMITATIONS: The study was performed at a single institution, and only female patients were assessed. CONCLUSIONS: The FFASS is a statistically validated scale and a reliable measure of FFA severity, and it can be used in clinical practice and future research studies as an assessment tool.

Treatment of flat and elevated pigmented disorders with a 755-nm alexandrite picosecond laser: clinical and histological evaluation.

The novel picosecond lasers, initially developed for faster tattoo removal, have also shown great efficacy in endogenous pigmentary disorders. To describe the efficacy and safety profile of an alexandrite (755-nm) picosecond laser in a wide range of pigmented flat and elevated cutaneous lesions. A retrospective study was performed in which we collected all the clinical images of patients treated with the 755-nm alexandrite picosecond laser for 12 months (November 2016-November 2017). Clinical features were obtained from their medical charts. Patients treated for tattoo removal were excluded. All the images were analyzed by three blind physicians attending to a visual analogue scale (VAS) from 0 to 5 (0, no change; 1, 1-24% clearance; 2, 25-49% clearance; 3, 50-74% clearance; 4, 75-99% clearance; 5, complete clearance). Patient satisfaction was obtained from a subjective survey including four items: very satisfied, satisfied, non-satisfied, and totally dissatisfied. Thirty-seven patients were included (12 males; 25 females). The mean age of the study was 42.35 years. Twenty-five patients (68%) were treated for different pigmented flat disorders such as solar and mucosal lentigines (5), stasis dermatitis (4), or nevus of Ota (4), among other diagnoses. Twelve patients (32%) were treated for epidermal elevated lesions such as warts (5), epidermal nevi (2), and seborrheic keratosis (3), among other elevated lesions. Mean number of laser treatment was 3.02 sessions while mean follow-up after last laser treatment was 4.02 months. Mean VAS score of the three observers was 3.44 (61% of clearance) for pigmentary flat disorders and 3.60 (67%) for elevated lesions. Adverse effects reported were mild blistering in the first 2-5 days following laser treatment in some of the patients. Overall satisfaction among the patients included was high. The novel 755-nm picosecond alexandrite laser is effective not only for the resolution of pigmented flat lesions of different nature but also for the treatment of the more difficult elevated pigmented lesions.

In situ production of ROS in the skin by photodynamic therapy as a powerful tool in clinical dermatology.

Photodynamic therapy (PDT) is a clinical modality of photochemotherapy based on the accumulation of a photosensitizer in target cells and subsequent irradiation of the tissue with light of adequate wavelength promoting reactive oxygen species (ROS) formation and cell death. PDT is used in several medical specialties as an organ-specific therapy for different entities. In this review we focus on the current dermatological procedure of PDT. In the most widely used PDT protocol in dermatology, ROS production occurs by accumulation of the endogenous photosensitizer protoporphyrin IX after treatment with the metabolic precursors 5-methylaminolevulinic acid (MAL) or 5-aminolevulinic acid (ALA). To date, current approved dermatological indications of PDT include actinic keratoses (AK), basal cell carcinoma (BCC) and in situ squamous cell carcinoma (SCC) also known as Bowen disease (BD). With regards to AKs, PDT can also treat the cancerization field carrying an oncogenic risk. In addition, an increasing number of pathologies, such as other skin cancers, infectious, inflammatory or pilosebaceous diseases are being considered as potentially treatable entities with PDT. Besides the known therapeutic properties of PDT, there is a modality used for skin rejuvenation and aesthetic purposes defined as photodynamic photorejuvenation. This technique enables the remodelling of collagen, which in turn prevents and treats photoaging stygmata. Finally we explore a new potential treatment field for PDT determined by the activation of follicular bulge stem cells caused by in situ ROS formation.

Analysis and evaluation of the operational characteristics of a new photodynamic therapy device.

One of the key aspects of photodynamic therapy is the light source that is used to irradiate the lesion to be treated. The devices used must ensure that their emission spectrum matches the absorption spectrum of the photosensitizer, so that treatment radiation is delivered only on the target area, without irradiating healthy tissue at superficial or deep levels. Irradiance values must be adequate in order to avoid thermal damage, exceed the oxygen replenishment rate and avoid long treatment times. Furthermore, the device should be user-friendly, inexpensive, and able to be adapted to different photosensitizers. We have developed an easy-to-use and highly customizable device based on LED technology. Its innovative geometric design allows radiation to be delivered to a small treatment surface, since the LEDs are arranged in three arms, the configuration of which directs their radiation on the treatment point. Different high-power color LEDs are disposed on the arms, and can be independently selected based on the most effective wavelengths for exciting the different photodynamic therapy photosensitizers. We have tested the prototype in 5 different patients (1 actinic keratose, 1 actinic cheilitis, 1 superficial basal cell carcinoma and 2 Bowen's disease) and after 1-2 sessions of total cumulative dose of 25-50 J / cm2, 100% clearance of lesions were obtained. Our device can be used by any professional in the field, whether for medical or research purposes. It facilitates the development of treatment protocols and trials with different photosensitizers.

Effect of Nail Thickness on Visible Radiation Transmittance: Implications for New Photodynamic Therapy Technologies in Onychomycosis.

Photodynamic therapy is taking importance as a nonintrusive treatment for nail onychomycosis. Knowledge of true transmittance values across nails could lead to qualitative and quantitative improvements in light-based treatments. We have characterized the spectral transmittance of healthy and fungally infected human fingernails and toenails according to nail thickness, and we propose a surface transmittance model for the small-scale optimization of light-based treatments. Transmittance of fingernails and toenails was analyzed by means of spectroradiometric measurements under solar-simulated visible light radiation (400 nm to 750 nm). The nail thickness was measured by means of microscope measurement. Transmittance was highest at longer wavelengths and decreased gradually as the wavelengths became shorter but with a significant nail transmittance of around 20% in the blue region of the spectrum. In the case of nails affected by onychomycosis, transmittance fell to under 10% because of the thickness of the nails, with no changes in spectral characteristics of transmitted light. Nail thickness is the main variable controlling exponentially light transmission in the visible spectrum and not only red radiation is effective for nail onychomycosis PDT. Blue light, the spectral band more effective for PPIX absorption is also effectively transmitted.

Low-level light-assisted photodynamic therapy using a wearable cap-like device for the treatment of actinic keratosis of the scalp.

BACKGROUND: Daylight photodynamic therapy (dlPDT) is a painless and increasingly cost-effective treatment for actinic keratosis (AK). New protocols avoid incubation, minimizing pain and adverse events. However, it is time-consuming and dependent on specific weather conditions. In patients with AK of the scalp, we evaluated the efficacy of indoor photodynamic therapy (PDT) using a wearable low-level light therapy (LLLT) device, without pre-incubation with a photosensitizing agent. METHODS: In this pilot study, 27 patients with thin and moderately thick AK (Olsen Grades I-II) underwent a single 15-minute session of LLLT using a wearable cap-like device immediately after application of methyl-aminolevulinate (MAL) cream, with no prior preparation of the affected area. Treatment efficacy was quantified by measuring the reduction in AK lesion number and the AK quality of life (AKQoL) score. All AK lesions were mapped at baseline for follow-up 2 months later. Paired pre/post scalp biopsies from 5 patients were analysed using histological and immunohistochemical techniques (p53, p27, cyclin D1, p63, and Ki67 expression). Data were analysed using the Wilcoxon signed-rank test. RESULTS: In all patients we observed a global reduction in the number of AK lesions (71%; p < 0.0001) and AKQoL score (from 5.6 to 4.4; p = 0.034) 2 months after treatment. Histology and immunohistochemistry of skin biopsies from 5 patients also revealed marked improvements after LLLT. No patients reported any pain during treatment. CONCLUSION: PDT using LLLT is a rapid, painless, and efficacious modality for the treatment of AK.

An unusual case of lymphomatoid papulosis type E with extensive necrosis.

Lymphomatoid papulosis type E (LyP) is a recently described subtype of LyP characterized by an angioinvasive infiltrate of atypical lymphocytes expressing CD30. We present a case of type E LyP with extensive cutaneous necrosis in the histopathological evaluation which was misdiagnosed as an ulcerative form of bacterial skin infection. The remarkable cutaneous necrosis showed in our case might be related to the angiodestructive infiltrate that was present in this circumstance.

Hormonal and Gynecological Risk Factors in Frontal Fibrosing Alopecia: A Case-Control Study.

INTRODUCTION: Frontal fibrosing alopecia (FFA) is a condition that likely involves an interplay of autoimmune, hormonal, and environmental factors in its pathogenesis. There is a lack of comparative studies demonstrating the presence of hormonal background differences in FFA patients compared to the general population. MATERIALS AND METHODS: A single-center case-control study was designed, including 104 female FFA patients and 208 controls. Patients and controls were interviewed, and extensive data regarding their gynecological and hormonal background were recorded. RESULTS: One hundred four cases and 208 age-matched controls were included in the study. A significant difference of 2 years in the age of menopause was detected with a consistent mean increase in fertile life for the control group of 1.7 years. After the multivariate analysis, we found previous intake of tamoxifen to be a risk factor for the development of FFA (OR 14.89). The only protective factor identified was the previous use of an intrauterine device (IUD) (OR 0.22). CONCLUSIONS: An earlier menopause and tamoxifen intake might promote or maintain FFA, while the use of an IUD might protect from developing FFA. Our results support the previously proposed hypothesis of an underlying hormonal mechanism in the etiopathogenesis of FFA and point out low-estrogen environments as an ideal condition for FFA development.

Impact of Folliculitis Decalvans on Quality of Life and Subjective Perception of Disease.

Folliculitis decalvans (FD) is a primary neutrophilic scarring alopecia characterized by perifollicular papules, crusts, and pustules frequently located on the vertex. FD may affect young men and women. Since it may lead to hair loss, it can have a negative impact on patients' quality of life. Nevertheless, studies have focused on clinical, prognostic, and therapeutic aspects without considering the psychological impact of FD. In our study, we found that FD patients experienced a considerable impact on their quality of life. Interestingly, almost half of the patients considered that their alopecia was related to a poor medical care in their past. To our knowledge, this is the first description of the impact of FD on patients' quality of life, and it highlights the importance of psychological support for these patients.