Frontal fibrosing alopecia: a clinical review of 36 patients.

BACKGROUND: Frontal fibrosing alopecia (FFA) is a primary lymphocytic cicatricial alopecia with a distinctive clinical pattern of progressive frontotemporal hairline recession. Currently, there are no evidence-based studies to guide treatment for patients with FFA; thus, treatment options vary among clinicians. OBJECTIVES: We report clinical findings and treatment outcomes of 36 patients with FFA, the largest cohort to date. Further, we report the first evidence-based study of the efficacy of hydroxychloroquine in FFA using a quantitative clinical score, the Lichen Planopilaris Activity Index (LPPAI). METHODS: A retrospective case note review was performed of 36 adult patients with FFA. Data were collected on demographics and clinical findings. Treatment responses to hydroxychloroquine, doxycycline and mycophenolate mofetil were assessed using the LPPAI. Adverse events were monitored. RESULTS: Most patients in our cohort were female (97%), white (92%) and postmenopausal (83%). Apart from hairline recession, 75% also reported eyebrow loss. Scalp pruritus (67%) and perifollicular erythema (86%) were the most common presenting symptom and sign, respectively. A statistically significant reduction in signs and symptoms in subjects treated with hydroxychloroquine (P < 0·05) was found at both 6- and 12-month follow up. CONCLUSIONS: In FFA, hairline recession, scalp pruritus, perifollicular erythema and eyebrow loss are common at presentation. Despite the limitations of a retrospective review, our data reveal that hydroxychloroquine is significantly effective in reducing signs and symptoms of FFA after both 6 and 12 months of treatment. However, the lack of a significant reduction in signs and symptoms between 6 and 12 months indicates that the maximal benefits of hydroxychloroquine are evident within the first 6 months of use.

Cutaneous bioassay of salicylic acid as a keratolytic.

Keratolytic efficacy of topical preparations containing salicylic acid was studied in humans utilizing adhesive tape stripping and quantifying SC removal by protein analysis. In combination with tape stripping, squamometry was used to evaluate the influence of salicylic acid on skin surface scaliness and desquamation. Furthermore, skin barrier perturbation and skin irritancy was recorded and related to the dermatopharmacological effect of the preparations. In contrast to squamometry, tape stripping combined with protein analysis was sensitive in detecting keratolytic effect of salicylic acid within hours of application. Importantly, whereas the pH of the preparations only minimally influenced efficacy, local dermatotoxicity was significantly increased at acidic pH. This indicates that the quest to increase the amount of free, non-dissociated SA is, in fact, counterproductive as the more acidic preparations resulted in skin irritation and barrier disruption.

Dermatology--24th Hawaii Seminar. 7-12 February 2000, Big Island, HI, USA.

At this seminar, several encouraging developments were demonstrated in various areas of dermatology practice. Much attention was focused on topical tacrolimus, the US approval of which, for the treatment of atopic dermatitis is much anticipated. The general consensus from trials was that the drug is safe and effective, and it is hoped that it will be of use in pediatric cases. Additional data were presented regarding the use of cyclosporin in psoriasis patients, with some evidence that low doses could be delivered safely with adequate monitoring. Safety was an issue in many of the sessions, reflecting the increasing involvement of potentially toxic therapies within dermatology. The debate regarding the use of topical tretinoin during pregnancy continues, and pharmacokinetic evidence was presented to demonstrate that systemic absorption of the drug is minimal. The range of diseases treated by topical imiquimod may be expanded with data suggesting that it may have benefits in the treatment of basal cell carcinomas. Surgical dermatology also featured heavily in the meeting, reflecting the more interventional approaches favored by dermatologists today.

Multiple corticosteroid orally elicited allergic contact dermatitis in a patient with multiple topical corticosteroid allergic contact dermatitis.

Corticoid allergic contact dermatitis (ACD) may be topically or systemically elicited. Allergic contact dermatitis to topical corticosteroids is relatively common, whereas reports of orally elicited ACD to corticosteroids are rarer. Patients allergic to one corticosteroid often exhibit cross-reactivity to other corticoids. We have previously reported a 46-year-old woman with contact allergy documented by patch and provocative use testing to multiple topical corticosteroids. On further testing, she was thought to have multiple corticoid orally elicited ACD to triamcinolone, methyl prednisolone, dexamethasone, and prednisone. Oral provocation tests were performed in a single-blind fashion following the method of Alanko and Kauppinen [Diagnosis of drug eruptions: clinical evaluation and drug challenges. In, Skin Reactions to Drugs (Kauppinen K, Alanko K, Hannuksela M, Maibach HI, eds). Boca Raton, FL, CRC Press, 1998.]. The five oral corticosteroids tested were triamcinolone, methyl prednisolone, dexamethasone, prednisone, and hydrocortisone. Four of the five challenged corticosteroids (i.e., triamcinolone, methyl prednisolone, dexamethasone, and prednisone) produced a generalized maculopapular eruption in a delayed manner. The fifth challenged corticoid, hydrocortisone, had no adverse effect on this patient. This patient was unusual in that she exhibited polysensitivity to a spectrum of oral and topical corticosteroids. Hydrocortisone was identified as a corticosteroid for future clinical use. This is an important finding since corticosteroids are important emergency drugs.

Examination of the relationship between the Myers-Briggs Type Indicator and empathetic response.

This study investigated the potential relationship between the Myers-Briggs Type Indicator and level of empathetic responding. Analyses indicated that the Thinking-Feeling scale was significantly associated with ratings of empathy for 49 graduate students in counselor education. Sex and graduate grade point average were also related significantly to empathic responding. Results are discussed in terms of their significance for research.

Infliximab for severe, treatment-resistant psoriasis: a prospective, open-label study.

BACKGROUND: Infliximab, a mouse-human chimeric monoclonal antibody directed against tumour necrosis factor-alpha, has been shown to be effective for moderate to severe psoriasis, but there are few data published on its use in recalcitrant, treatment-resistant disease or in combination with other antipsoriatic therapies. OBJECTIVES: To report our experience with infliximab in the treatment of patients attending a tertiary referral service with severe recalcitrant disease. METHODS: All patients attending a tertiary referral service for severe psoriasis who were treated with infliximab between 2002 and July 2005 were entered into a prospective, open-label study. Details on disease phenotype, clinical course and adverse events were recorded together with measures of disease severity [Psoriasis Area and Severity Index (PASI), Dermatology Life Quality Index, clinical photography] at baseline, weeks 2 and 6, and then at 2-monthly intervals throughout the treatment period. RESULTS: Twenty-three patients were treated with infliximab during the study; one patient had pustular psoriasis and was therefore excluded from statistical analysis. All had severe disease (baseline PASI 26.5+/-6.7, mean+/-SD, n=22) and had received at least two systemic therapies for psoriasis in the past; 16 were taking one or more concomitant therapies at the time of treatment initiation. At week 10, 95% had achieved a 50% or greater improvement in baseline PASI (PASI 50), and 77% had achieved a 75% or greater improvement (PASI 75). Efficacy was sustained in the longer term, with eight of 10 patients on treatment for more than 11 months maintaining at least a PASI 50. Only one patient had treatment withdrawn due to lack of efficacy, two suffered severe systemic infections including extrapulmonary tuberculosis (splenic abscess) and cellulitis, and six have discontinued due to adverse effects including infusion reactions (two), severe thrombocytopenia (one), hepatitis (one) and malignancy (two). CONCLUSIONS: Data from this open-label study suggest that infliximab is a rapidly effective treatment for patients with severe, treatment-resistant disease, although approximately 25% of patients had to discontinue therapy due to the development of serious adverse effects. Long-term follow-up, continued pharmacovigilance, and further controlled comparative studies will be required to evaluate fully the risks associated with infliximab in the context of this already difficult to treat population.

1,2-Benzisothiazolin-3-one (Proxel): irritant or allergen? A clinical study and literature review.

The isothiazolinone, 1,2-benzisothiazolin-3-one (Proxel), is a popular preservative, as well as a skin sensitizer and irritant. Patch test studies have been performed with different concentrations and vehicles. The current suggested patch test concentration is 0.1% BIT in petrolatum (pet). This article evaluates the effects of patch testing at this concentration and reviews the current literature. An irritancy patch test was performed on 56 controls, using BIT in concentrations of 0.002% and 0.05% in aqueous dipropylene glycol (Proxel GXL) and 0.1% in pet. 10 had positive readings at 4 days with 0.1% BIT in petrolatum, 9 of which were negative at retest. 0.1% BIT is, therefore, irritant and not a suitable concentration for patch testing. Literature review revealed 15 patch test studies, with varying testing techniques. Additional studies with adequate controls and experimental tests should be invaluable in furthering our insight into BIT sensitization and irritation.

Diagnosis of congenital antral web by ultrasound.

Historically, the first case of congenital prepyloric membrane in an infant was documented in 1933 [1]. Since then cases have been reported only sporadically in the literature [2-8]. This is a case of congenital antral web which was identified by real-time ultrasonography, confirmed by barium meal study, and proven at gastrotomy.

Successful treatment of severe psoriasis and psoriatic arthritis with adalimumab.

Adalimumab, a fully human-derived recombinant monoclonal antibody against tumour necrosis factor-alpha, has been shown to be effective for the treatment of patients with moderately to severely active rheumatoid arthritis. We report two patients with long-standing recalcitrant psoriasis and psoriatic arthritis who, after multiple treatment failures with conventional and experimental antipsoriatic medications, both responded to treatment with adalimumab. Significant clinical improvement was noted in both skin and joint disease in the two patients after several weeks of treatment with adalimumab. We are unaware of previous published reports of adalimumab therapy in patients with psoriasis and psoriatic arthritis.

Physical and physiological effects of stratum corneum tape stripping.

BACKGROUND/AIMS: Tape stripping of human stratum corneum has been performed to measure stratum corneum mass, barrier function, drug reservoir and percutaneous penetration. However, the technique itself requires further development to facilitate interpretation. METHODS: In this study we quantified stratum comeum (SC) tape stripping and water kinetic parameters utilizing three types of adhesive tapes, in an in vivo randomized clinical trial. Stratum corneum was tape stripped, and the mass of SC removed by each tape was quantified utilizing a protein assay. Transepidermal water loss (TEWL) was measured and barrier disruption and SC water kinetics calculated. Three commonly utilized acrylate adhesive tapes were utilized and a comparison made between them. RESULTS: Each type of tape successfully stripped the stratum corneum, but the rayon tape did not induce SC barrier disruption. Neither the type of tape nor the site stripped significantly influenced the mass of SC removed. Water kinetic parameters did not differ significantly for the tapes that did induce barrier disruption. Individual variation in barrier disruption to water following tape stripping was demonstrated. CONCLUSION: The tapes utilized removed a similar amount of SC. The tapes have a different propensity to cause barrier disruption. Some individuals do not demonstrate increased TEWL despite an equivalent mass of SC being removed compared to those who do show a response.

Provocative use test of nickel coins in nickel-sensitized subjects and controls.

BACKGROUND: Consensus exists on levels of nickel release that are well tolerated in exposure to nickel-containing items in direct and continuous contact with skin (e.g. watches). The clinical relevance of nickel-containing coins eliciting nickel dermatitis associated with extensive occupational exposure (e.g. coins handled by cashiers) has not been determined. OBJECTIVES: To examine whether nickel-containing coins might be an elicitor of allergic contact dermatitis (ACD) in occupational settings with extensive exposure to coins (i.e. cashiers). METHODS: Eighteen subjects (10 nickel sensitized and eight non-nickel sensitized) completed this study after screening of history, physical examination and diagnostic patch testing (5% nickel sulphate). Each volunteer handled 10 coins (nickel-containing coins or non-nickel-containing coins) in a cross-over design at 5-min intervals (5 min handling followed by 5 min rest) for 8 h per day, for a total of 12 days excluding the weekend. One hand was gloved while the other was not during coin handling. Visual scoring and bioengineering measurements were recorded at each of four predetermined sites at baseline (day 1), end of day 5 and day 12 (last day of exposure). RESULTS: There were no statistical differences for either visual or bioengineering data comparing: (i) nickel-sensitized vs. non-nickel-sensitized subjects handling nickel-containing coins at day 1, day 5 and day 12; (ii) day 12 vs. day 1 (baseline) for nickel-sensitized subjects handling nickel-containing coins; (iii) handling of nickel-containing coins vs. non-nickel-containing coins by nickel-sensitized subjects at day 5 and day 12; (iv) gloved hand vs. ungloved hand of nickel-sensitized subjects handling nickel-containing coins at day 12. Limitations of the method and clinical extrapolation are detailed. CONCLUSIONS: Individuals handling these nickel-containing coins daily did not develop ACD, as judged by visual signs or bioengineering parameters.

Efficacy of corticosteroids in acute experimental irritant contact dermatitis?

BACKGROUND/AIMS: Topical corticoids are used to treat irritant contact dermatitis (ICD) in humans. However, their clinical efficacy remains sub judice. This study was designed to assess the efficacy of low- and medium-potency corticosteroids on irritant dermatitis. METHODS: We induced an acute ICD via open application of sodium lauryl sulphate (SLS) on the hands of subjects. The dorsal side of hands was irritated with 10% SLS five times in one day. Once on day 1 and twice daily on days 2-5, 1% hydrocortisone, 0.1% betamethasone-17-valerate and vehicle cream (petrolatum) were applied subsequently. Visual grading, bioengineering techniques and squamometry were used to quantify skin response. RESULTS: Corticosteroids were found ineffective in treating the surfactant-induced irritant dermatitis when compared with the vehicle and with the untreated control. CONCLUSION: The counterintuitive result (in a relatively realistic and robust model) should be interpreted with caution until verified with other irritants of varying physicochemical properties.