Persistent Keratoses in Vitiligo.

The occurrence of keratoses in patients with psoriasis under treatment with psoralens and ultraviolet A (PUVA) has been described as an entity called PUVA keratosis. Similar lesions were seen later in patients with vitiligo under the same treatment. We describe the presence of distinct keratoses in the vitiligo lesions of three women patients from Rio de Janeiro, Brazil. The lesions started after PUVA treatment with total body irradiation, cabin or topical, and persisted long after the therapy was finished. All patients presented small rounded keratotic papules on achromic areas of the feet. Biopsies showed mild acanthosis, compact orthokeratotic hyperkeratosis, and hypergranulosis with increase of stratum granulosum layers or size increase of keratohyaline granules. Inflammatory infiltrate was sparse or absent. Cytologic atypia was not observed. Histologic features were compatible with reactive keratosis. None of the patients had a history of previous actinic keratosis or non-melanoma skin cancer and had been treated before with PUVA therapy either orally or topically; however, lesions occurred only in areas exposed to sunlight and persisted for long periods, even without treatment with PUVA or narrowband ultraviolet B (NB-UVB). The authors discuss whether these lesions can be considered as PUVA keratosis or if the sun exposure may have played an important role in the reported cases.

[Pityriasis rubra pilaris]. / Pityriasis rubra pilaire.

Pityriasis rubra pilaris is a rare heterogeneous dermatosis associating three clinical signs to different degrees: follicular corneal papules, reddish-orange palmoplantar keratoderma and erythematosquamous lesions that may in some cases be very extensive, interspersed with patches of healthy skin. The aetiology is unclear, and in most cases, the trigger factors consist of trauma or infection, probably in subjects with an existing predisposition. In other cases, the condition is associated with immunological disorders or, in familial cases, genetic keratinisation abnormalities similar to ichthyosis. Given the widely varying signs, several classifications have been proposed, based on clinical criteria and outcomes. The outcome varies in accordance with the clinical forms involved. Therapeutic approaches are poorly qualified and there have been no clinical trials due to the rarity of the disease. However, the best results appear to have been obtained using oral retinoids, with second-line therapy comprising methotrexate and cyclosporine. The landscape of therapeutic strategy seems to be changing with the advent of new anti-tumour necrosis factor and anti-interleukin-12/23 antibodies.

Baicalin Scavenged Reactive Oxygen Species and Protected Human Keratinocytes Against UVB-induced Cytotoxicity.

Ultraviolet B (UVB), with a wavelength of 280-320 nm, represents one of the most important environmental factors for skin disorders, including sunburn, hyperpigmentation, solar keratosis, solar elastosis and skin cancer. Therefore, protection against excessive UVA-induced damage is useful for prevention of sunburn and other human diseases. Baicalin, a major component of traditional Chinese medicine Scutellaria baicalensis, has been reported to possess antioxidant and cytostatic capacities. In this study, we examined whether baicalin is also capable of protecting human keratinocytes from UVB irradiation. The results showed that baicalin effectively scavenged reactive oxygen species (ROS) elevated within 4 h after UVB radiation and reversed the UVB-suppressed cell viability and UVB-induced apoptosis after 24 h. Our results demonstrated the utility of baicalin to complement the contributions of traditional Chinese medicine in UVB-induced damage to skin and suggested their potential application as pharmaceutical agents in long-term sun-shining injury prevention.

Phrynoderma: a rare dermatologic complication of bariatric surgery.

Biliopancreatic diversion is a predominantly malabsorptive bariatric procedure that can lead to the development of several nutrition complications, including fat-soluble vitamin deficiencies. Routine supplementation with vitamins and trace elements and a strict medical follow-up are essential to prevent these nutrition risks. Vitamin A deficiency is common after bariatric surgery but rarely causes clinical symptoms. Case reports have described ophthalmological and fetal complications associated with vitamin A deficiency after malabsorptive bariatric surgery. Phrynoderma is a type of follicular hyperkeratosis located on the extensor surfaces of the extremities whose main cause is vitamin A deficiency. The simultaneous occurrence of phrynoderma and ocular symptoms secondary to hypovitaminosis A after bariatric surgery is exceptional. The authors describe a man who presented follicular hyperkeratosis with nyctalopia and xerophthalmia that had appeared 1 year after biliopancreatic diversion. He admitted poor compliance with diet and daily supplementation of vitamins and oligoelements. Serum vitamin A levels were decreased. Treatment with high doses of vitamin A was associated with a clear improvement of cutaneous and ocular lesions with complete resolution after 2 months. The patient was readmitted 2 years later because of the reappearance of cutaneous lesions and micronutrient deficiency. Revisional bariatric surgery was performed. The authors review and discuss the relationship between phrynoderma, malnutrition, and vitamin A deficiency.

[Phrynoderma secondary to vitamin A deficiency in a patient with biliopancreatic diversion]. / Frinoderma secundario a déficit de vitamina A en un paciente con derivación biliopancreática.

Biliopancreatic diversion (BPD) is a malabsorptivebariatric procedure can lead to the development of several nutritional complications, including fat-soluble vitamins deficiencies. Routine supplementation with vitamins and trace elements and a close follow-up long-term can prevent these nutritional risks. Vitamin A participates in ocular metabolism, epithelial differentiation, growth, and embryogenesis. Have been described several cases of ophthalmological and fetal complications associated with vitamin A deficiency in patients who have undergone BPD. Few information exists in literature about dermatologic manifestations that may occur in these patients. Phrynoderma is a type of follicular hyperkeratosis located on the extensor surfaces of the extremities whose main cause is vitamin A deficiency. We report an exceptional case of severe cutaneous and ocular complications in a patient who had undergone BPD with poor adherence to treatment and postoperative follow-up. Our patient presented simultaneously the characteristic skin lesions of phrynoderma with nytalopia and xerophthalmia in a setting of low serum levels of vitamin A. Treatment with high doses vitamin A obtained the resolution of both processes. We review and discuss the relationship between phrynoderma, malnutrition and vitamin A deficiency.

Athlete's nodule.

Three cases of athlete's nodule on the feet are reported. In case 1, a 30-year-old man, who had been an amateur football player, presented with nodules on the lateral side of the feet and on the right lateral malleolus with a duration of 1 year. In case 2, a 22-year-old man, who had participated in karate and track-and-field, presented with nodules on the lateral side of the feet and on the right lateral malleolus with a duration of 10 years. In case 3, a 25-year-old man, who had skied, presented with a nodule on the right lateral malleolus with a duration of 4 years. The biopsy specimens from the lesion demonstrated hyperkeratosis, acanthosis of the epidermis and thickness of the dermis. In 1991, Cohen et al. proposed the concept of athlete's nodule which indicated an acquired cutaneous nodule caused by chronic stimuli with sports. Histopathology of the athlete's nodule shows hypertrophy of the epidermis and dermis. To the best of our knowledge the term "athlete's nodule" has not been used in Japan, but it is a useful term to refer to the lesion induced by athletics or the use of sporting equipment.

Comparison of the efficacy and tolerability of 3% diclofenac sodium gel and 5% imiquimod cream in the treatment of actinic keratosis.

BACKGROUND: Topical diclofenac and imiquimod have been reported to be effective in the treatment of actinic keratosis, but a study to compare these two drugs has not been reported yet. OBJECTIVE: To compare the efficacy and safety of topical 3% diclofenac gel plus hyaluronic acid and 5% imiquimod cream in the treatment of actinic keratosis. METHODS: Forty-nine patients with actinic keratosis were enrolled in this randomized comparative open-label study. Twenty-four patients applied 3% diclofenac gel once a daily to their lesions, while the other 25 patients were treated with a 5% imiquimod cream three times a week for 12 weeks. Patients were examined before treatment and every month of the treatment. Assessments were made by investigators according to the Investigator and the Patient Global Improvement Indices (IGII) and (PGII). RESULTS: According to the IGII results, a complete response was observed in 12% of the diclofenac group and 22% of the imiquimod group. For the PGII scores, a complete response was observed in 28% of the diclofenac group and 23% of the imiquimod group. There were no significant differences between the two groups (p > 0.05). Both treatments were well tolerated, with most adverse events related to skin. CONCLUSION: The two drugs were found to be equally effective and safe in the treatment of actinic keratosis but complete remission was very low. Therefore, topical treatments with these two drugs were not seen to be completely effective, and combined therapies and further studies are needed.

Aminolevulinic acid photodynamic therapy for actinic keratoses/actinic cheilitis/acne: vascular lasers.

The combination of newer laser and light sources, the long-pulsed pulsed dye laser (LP PDL) and intense pulsed light, with topical aminolevulinic acid photodynamic therapy (PDT) has achieved enhanced efficacy and rapid treatment and recovery, while diminishing unwanted side effects. In particular, LP PDL PDT has been shown to be safe and effective in the treatment of actinic keratoses, actinic cheilitis, photodamage, and acne vulgaris with minimal discomfort, rapid treatment and recovery, and excellent posttreatment cosmesis.

[Palmoplantar lichen nitidus: a rare cause of palmoplantar hyperkeratosis]. / Lichen nitidus palmoplantaire. Une cause rare de kératodermie palmoplantaire.

BACKGROUND: Lichen nitidus is a rare condition, which may be a cause of palmoplantar hyperkeratosis. We report two cases. CASE REPORTS: A 53 year-old woman presented with a dry and fissured palmoplantar hyperkeratosis. Histological examination of a biopsy showed the typical features of lichen nitidus. Significant improvement was obtained with acitretin. A few months later, multiple lichen nitidus papules appeared on the limbs and the abdomen. A 67 year-old woman was referred to us for a fissured, disabling palmoplantar hyperkeratosis refractory to topical steroids. Histological examination led to the diagnosis of lichen nitidus. Local PUVA therapy resulted in the cleaning of her lesions. Later, typical papules of lichen nitidus appeared on her elbows. DISCUSSION: Nineteen cases of palmoplantar localization of lichen nitidus have been described. The features are usually tiny yellow papules but sometimes a non-specific keratoderma resembling chronic eczema. Palmoplantar involvement of lichen nitidus may be isolated or associated with cutaneous lesions on unusual sites. Oral retinoids and local PUVA are effective treatments.

[Grover's disease following hemodialysis in a patient with renal failure]. / Morbus Grover unter Hämodialy--setherapie bei Niereninsuffizienz.

A 54-year-old woman with polycystic renal disease and renal failure developed Grover's disease while undergoing renal dialysis. Grover's disease or transitory acantholytic dermatosis is characterized by intensely pruritic, hyperkeratotic, succulent papules and plaques located on the trunk. The pathogenesis is unknown; genetic factors and actinic damage have been implicated. Medications, heat or immunosuppression can worsen the disease. Associations with atopic dermatitis, contact dermatitis and asteatotic dermatitis have also been described. Differential diagnostic considerations include folliculitis, scabies and dermatitis herpetiformis. Therapeutic options include moisturizing agents and phototherapy, as well as topical and systemic retinoids. There are only few case reports in the literature describing Grover's disease occurring during hemodialysis treatment. All such previous patients have been men; ours is the first woman.

Laser-mediated photodynamic therapy of actinic keratoses.

OBJECTIVE: To assess the safety and efficacy of the long-pulsed pulsed dye laser (LP PDL) (595 nm) with photodynamic therapy (PDT) for treatment of actinic keratoses (AKs). DESIGN: Prospective, controlled study with 10-day and 2-, 4-,6-, and 8-month follow-ups. SETTING: Clinical research center. PATIENTS Volunteer sample of 41 patients (age range, 35-91 years; skin types I-III) with AKs. INTERVENTION: Single treatment with application of topical 20% 5-aminolevulinic acid for 3 hours or 14 to 18 hours, followed by LP PDL irradiation at 595 nm. Controls received LP PDL irradiation alone. MAIN OUTCOME MEASURES: Safety assessments, treatment and recovery times, and efficacy assessments, including patient mean percentage of lesions cleared and distribution of patients by percentage of lesions cleared for different anatomic sites. RESULTS: We observed no to slight pain; slight to moderate erythema; no purpura, crusting, or scarring; treatment time of 1 lesion per second; and resolution of erythema by 7 to 14 days. The patient mean (95% confidence interval) percentage of head lesions (2620 lesions) cleared after 1 treatment was 99.47% (99.44%-99.50%) at 10 days, 98.19% (98.15%-98.23%) at 2 months, 92.94% (92.73%-93.14%) at 4 months, 91.65% (91.15%-92.15%) at 6 months, and 90.32% (78.10%-100%) at 8 months. For extremities (949 lesions), these were 83.1% (81.4%-84.9%) at 10 days, 75.5% (73.4-77.6) at 2 months, 70.9% (68.9%-72.8%) at 4 months, 92.0% (84.0%-100%) at 6 months, and 100% at 8 months. For trunk (53 lesions), these were 85% (74%-100%) at 10 days, 85% (74%-100%), and 65% (50%-80%) at 4 months. No difference in safety or efficacy was found between the 3-hour and 14- to 18-hour incubation times. In the laser-only control group, no decrease in lesions was observed. Among 31 patients with head lesions, 28 (90%) at 10 days, 19 (70%) at 2 months, 9 (47%) at 4 months, 5 (42%) at 6 months, and 5 (56%) at 8 months were completely (100%) clear following a single treatment. Skin biopsy specimens of nonresponding lesions demonstrated a high rate of squamous cell carcinoma and other non-AK neoplasms. CONCLUSIONS: Treatment of AKs using LP PDL (595 nm) at nonpurpuric parameters following topical application of 5-aminolevulinic acid is safe and effective. The advantages may include minimal discomfort, rapid incubation treatment and recovery times, excellent posttreatment cosmesis, high efficacy rates with respect to head lesions, and practical applicability to large body surface areas.

A randomized controlled trial to assess sunscreen application and beta carotene supplementation in the prevention of solar keratoses.

BACKGROUND: Solar keratoses (SKs) are among the strongest determinants of skin cancer, but little is known about the success of measures to control these common skin tumors. OBJECTIVE: To determine whether daily sunscreen application and/or beta carotene supplementation retards the rate of occurrence of SKs in adults in the medium term. DESIGN: Randomized controlled trial conducted between February 1992 and August 1996. SETTING: General community of the subtropical township of Nambour, Australia (latitude, 26 degrees south). PARTICIPANTS: A total of 1621 adults aged 25 to 74 years. Interventions Participants were randomized to daily use of sunscreen (application of a high-protection sunscreen to their head, neck, arms, and hands every morning) or application of sunscreen at their usual discretionary rate. They were also randomly assigned to take either one 30-mg tablet of beta carotene or one placebo tablet each day. MAIN OUTCOME MEASURE: Change in the prevalent number of SKs in the intervention group relative to change in the control group. RESULTS: The ratio of SK counts in 1994 relative to 1992 was lower in people randomized to daily sunscreen use (1.20; 95% confidence interval, 1.04-1.39) than in those randomized to discretionary sunscreen use (1.57; 95% confidence interval, 1.35-1.84). This 24% reduction is equivalent to the prevention of an average of 1 additional SK per person over that time. A reduction in the rate of change of SK prevalence was also seen in the sunscreen intervention group relative to the discretionary sunscreen group between 1994 and 1996, but it was not significant. No effect on the rate of change of prevalent SK counts was seen among those taking beta carotene supplements relative to those taking placebo tablets. CONCLUSIONS: Daily application of sunscreen retarded the rate of SK acquisition among adults in a subtropical environment, while a beta carotene supplementation of 30 mg/d had no influence on the occurrence of SKs.

Arsenic toxicity from homeopathic treatment.

UNLABELLED: Homeopathic medicine is commonly believed to be relatively harmless. However, treatment with improperly used homeopathic preparations may be dangerous. CASE REPORTS: Case 1 presented with melanosis and keratosis following short-term use of Arsenic Bromide 1-X followed by long-term use of other arsenic-containing homeopathic preparations. Case 2 developed melanotic arsenical skin lesions after taking Arsenicum Sulfuratum Flavum-1-X (Arsenic S.F. 1-X) in an effort to treat his white skin patches. Case 3 consumed Arsenic Bromide 1-X for 6 days in an effort to treat his diabetes and developed an acute gastrointestinal illness followed by leukopenia, thrombocytopenia, and diffuse dermal melanosis with patchy desquamation. Within approximately 2 weeks, he developed a toxic polyneuropathy resulting in quadriparesis. Arsenic concentrations in all three patients were significantly elevated in integument tissue samples. In all three cases, arsenic concentrations in drinking water were normal but arsenic concentrations in samples of the homeopathic medications were elevated. CONCLUSION: Arsenic used therapeutically in homeopathic medicines can cause clinical toxicity if the medications are improperly used.

Managing solar keratoses.

Solar keratoses (actinic keratoses) are common, often multiple, epidermal lesions found mainly on the sun-exposed skin of fair-skinned middle-aged and older people. They may transform into non-melanoma skin cancers, particularly squamous cell carcinoma. Here, we review the prevention and treatment of solar keratoses.