Prevalence of hair shedding among women.

Hair shedding in female patients is a frequent complaint in dermatological, endocrinological, and gynecological consults. Previously, the Sinclair Hair Shedding Scale was developed to assess normal versus excessive hair shedding in female pattern hair loss (FPHL) subjects. However, the prevalence of hair shedding in females not suffering from FPHL is unknown. To gain better understanding of hair shedding in the general population, we recruited 300 subjects visiting a public hospital for conditions other than alopecia. Of the 300 subjects recruited, 263 did not suffer from FPHL. Among those subjects, approximately 40% reported experiencing excessive hair shedding (as defined by the Sinclair Hair Shedding Scale) on hair washing days. In comparison, in our subject population, approximately 60% of subjects with FPHL reported excessive hair shedding on hair washing days. To best of our knowledge, this is the first study to quantify the prevalence of hair shedding in women. While, no treatment currently exists for this condition, we hope that this study would encourage physicians and researchers to address this frequent concern.

Platelet-rich plasma as a novel treatment for lichen planopillaris.

Treatment of lichen planopillaris (LPP) remains a significant challenge due to the irreversible damage inflicted on hair follicles combined with the low efficacy of existing treatments. We hypothesized that growth factors released by the use of platelet-rich plasma (PRP) may arrest the development of LPP. To test our hypothesis, we treated an LPP patient that has failed previous treatments with a new PRP regimen. Following PRP treatment and six months follow-up, the patient experienced complete regression of itching and hair shedding. To the best of our knowledge, this is the first report of successful treatment of LPP with a PRP regimen.

Ten-year study on the correlation of clinical and pathohistological diagnosis of dysplastic nevi.

The aim of the study was to analyze the clinical prevalence and pathohistological correlation of dysplastic nevi. In the period between 2000 and 2009, in the Outpatient Clinic of Referral Centre for Melanoma of the Ministry of Health and Social Welfare of the Republic of Croatia, 12,344 patients were examined, and 35.07% of them were surgically removed in the same institution. Among the patients, 69.16% had clinically diagnosed melanocytic tumor. Out of them, 28.39% were dysplastic. Dysplastic nevus was pathohistologically diagnosed in 20.02% of pathohistologically diagnosed melanocytic tumors. There was women predominace among patients with clinically diagnosed dysplastic nevi (65.22%). The most frequent localization was the trunk in both sexes, women 78.18%, men 76.75%. The coincidence of clinical and pathohistological diagnosis of dysplastic nevus was 30.70%. The results of this study, based on a large number of patients could be a significant contribution in understanding characteristics of dysplastic nevus, its clinical and pathohistological complexity. We hope that the data will contribute to the creation of general accepted protocols in the diagnostics of dysplastic nevus.

Melasma--updated treatments.

Melasma is a common, acquired facial skin disorder, mostly involving sun-exposed areas like cheeks, forehead and upper lip. Melasma occurs in both sexes, although almost 90 percent of the affected are women. It is more common in darker skin types (Fitzpatrick skin types IV to VI) especially Hispanics/Latinos, Asians and African-Americans. The onset of the melasma is at puberty or later, with exception of darker skin types, who tend to develop this problem in the first decade of life. The etiology is still unknown, although there are a number of triggering factors related to the onset of melasma. The most important are sun-exposure and genetic factors in both sexes, while hormonal activity has more important role in females. In addition, stress and some cosmetic products and drugs containing phototoxic agents can cause outbreaks of this condition. Melasma should be treated using monotherapies or combination of therapy, mainly fixed triple or dual combinations containing hydroquinone, tretinoin, corticosteroids or azelaic acid. Modified Kligman's formula is also very effective. Above mentioned therapy regimens in combination with UVA and UVB blocking sunscreens are mostly effective in epidermal melasma. Discontinuation of the use of birth control pills, scented cosmetic products, and phototoxic drugs coupled with UV protection are also benefitial in clearing of melasma. Alternative treatment including chemical peels and glicolic acid, seem to have the best result as a second line treatment after bleaching creams. Laser treatments show limited efficacy and should rarely be used in the treatment of melasma. Combining topical agents like hydroquinone, tretinoin and a corticosteroid in addition to sun avoidance, regular use of sunscreen throughout the year and patient education is the best treatment in this difficult to treat condition.

Whole-Face Approach with Hyaluronic Acid Fillers.

The use of hyaluronic acid fillers in aesthetic medicine has changed over the years and the procedure became one of the most common in the world. Understanding the ageing process of the face and the anatomical interrelationships in the face have dramatically influenced the use of the hyaluronic acid fillers and the assessment of the patient. It was supported by a new technology of products and by the delivery of tools (eg, blunt cannulas), face imaging, and innovative injection techniques. The whole-face approach challenges the practitioner to look at the face as a whole, and the patient to trust and rely on the treatment plan. Over the years, we have understood, that the most important outcome of aesthetic procedures is what does the whole face look like not static but in motion, and how do people read emotions from it. Nowadays, the result changes "the face information" and makes aesthetic procedures more satisfactory. In this manuscript, we reviewed essentials of the current treatment approach including patient's consultations, product selection and injection techniques used in different parts of the face. One size fits none; thus, we provided a general overview of hyaluronic acid fillers used in different indications and presented several treatment approaches to each region of the face.

Lentigo maligna melanoma--the review.

Lentigo maligna melanoma (LMM) is a slowly growing tumor of elderly white population. It typically develops on chronically sun-exposed skin of the head and neck area which indicates that the cumulative exposure to the UV radiation has crucial role in the development of LMM. Precursor lesion is lentigo maligna (LM) which commonly presents as an irregular brownish pigmented macular lesion persisting for years. Women are affected more often as men by LMM, with the average age of over 60 years. The age of onset has dropped over the past years and this tumour is nowadays also diagnosed in 40-year-old individuals. However, the incidence rate increases with age and peaks in the seventh and eighth decades of life. The prognosis for invasive lentigo maligna melanoma does not differ from that for other histogenetic types of melanoma after controlling for tumour thickness. The diagnosis and treatment of LMM remain challenging. In this presentation, we review the epidemiology, clinical presentation, histopathology, and treatment of LMM.

Senile lentigo--cosmetic or medical issue of the elderly population.

Senile lentigo or age spots are hyperpigmented macules of skin that occur in irregular shapes, appearing most commonly in the sun-exposed areas of the skin such as on the face and back of the hands. Senile lentigo is a common component of photoaged skin and is seen most commonly after the age of 50. There are many disscusions on whether senile lentigo represents a melanoma precursor, namely lentigo maligna melanoma and, if there is a need for a regular follow up in cases of multiple lesions. Clinical observations sometimes report that in the location of the newly diagnosed melanoma, such lesion preexsisted. On contrary, some authors believe that senile lentigo represents a precursor of seborrheic keratosis, which does not require a serious medical treatment. However, the observation of the possible association of senile lentigo with the melanoma development makes us cautious in the assessment of this lesion. Histologically, there are elongated rete ridges with increased melanin at the tips, and the number of melanocytes is not increased. The dermatoscopic features are also distinctive. If the lesion becomes inflammed it may evolve into benign lichenoid keratosis. Cryotherapy and laser treatment are common therapeutic approaches. Sun protection creams may be useful in early lesions.

Multiple primary melanoma: epidemiological and prognostic implications; analysis of 36 cases.

Patients who are already diagnosed with cutaneous melanoma are at increased risk of developing another primary melanoma. The occurrence of multiple primary melanoma is a rare phenomenon, varying in frequency, with an estimated incidence ranging from 0.2% to 8.6%. The authors are presenting data on the patients with multiple primary melanoma from the Croatian Referral Melanoma Centre. The clinical, histological and epidemiological characteristics of 36 (3.6%) patients, identified from 991 patients with histologically confirmed melanoma, are analyzed in this study. Twenty-eight of the patients (78%) had two primary melanomas, six had three melanomas (16.7%) and two (5,6%) had four melanomas. Diagnosis was established synchronously in 11 patients (30%) and, in the rest of the patients, time interval between the diagnosis of the first and second melanoma varied from 1 month to the longest interval of 16 years. However, the majority of subsequent melanomas were removed within 2 years of the initial operation. The mean Breslow's thickness of the first melanoma was significantly higher than the mean Breslow's thickness of the second primary melanoma. The proportion of in situ to invasive melanomas was greater for the second melanomas compared with the first melanomas. Therefore, we emphasize the importance of regular follow-up as well as the education in regular self--skin examinations in melanoma patients in order to detect subsequent primary melanomas in the early phase.

The role of UV radiation in the development of basal cell carcinoma.

Basal cell carcinoma (basalioma, BCC) is undoubtedly the most common malignant skin cancer and the most common human malignancy in general, with the continuous increase in its incidence. BCC is generally a disorder of white individuals, especially those with fair skin. UV radiation is the most important risk factor in the development of BCC. Short-wavelength UVB radiation (290-320 nm, sunburn rays) is believed to play a greater role in BCC formation than long-wavelength UVA radiation (320-400 nm, tanning rays). A latency period of 20-50 years is typical between the time of UV damage and the clinical onset of BCC. Therefore, in most cases BCC develops on chronically sun-exposed skin in elderly people, most commonly in the area of head and neck. UVB radiation damages DNA and its repair system and alters the immune system resulting in a progressive genetic alterations and formation of neoplasm. UV-induced mutations in the TP53 tumor-suppressor gene have been found in about 50% of BCC cases. The mutations that activate the Hedgehog intercellular signaling pathway genes, including PTCH, Sonic hedgehog (Shh) and Smoothened (Smo) play a significant role in cutaneous carcinogenesis. Epidemiologic studies demonstrate the higher incidence of the BCC in more equatorial latitudes than in polar latitudes. Other risk factors for the development of BCC include sun bed use, family history of skin cancers, skin type 1 and 2, immunosuppression, previous radiotherapy, and chronic exposure to toxic substances such as inorganic arsenic. Although rarely metastatic, its malignant nature is sometimes emphasized by the local tissue destruction, disfigurement, and even death if left untreated. Due to extremely high incidence of BCC medical professionals should be aware of the importance of the public education on the etiology of this tumor and the importance of the UV protection.

Trends, habits and attitudes towards suntanning.

Epidemiological studies suggest a relationship between suntanning habits and high risk of malignant melanoma (MM). The incidence of MM is increased during the last 40 years. Sun exposure is highly prevalent in all age groups, especially among young and it is influenced by certain believes and attitudes towards suntanning and stimulated by peer pressure and aesthetic references. What is the cause of higher incidence of MM? Is it only trend and attitudes towards suntanning? A prototype of a young female of 21st century is attractive, slim, with bronze complexion, dresses in the bathing suit, whereas the lady of the 19th is pale, dressed in white dress and with hat or sunshade that protects face and hair from the sun. When did social mores and medical knowledge about sun exposure change? A critical interplay occurred between the end of 19th century and the start of the 20th century with significant success of phototherapy and the growing popularity of sunbathing which reflected number of social changes. During the same time of invigoration of sun exposure, appeared the first reports about correlation between sunlight and skin cancer, but without significant repercussion on medical profession and therefore without knowledge of the public. The 1920s and 1930s were highlighted with the great discovery that ultraviolet wavelengths less than 313 nm played the role in vitamin D synthesis which prevents rickets. Numerous other medical benefits were soon attributed to the sunlight. Finally, the cancerogenity of UV light came to attention when scientist succeeded in induction of skin cancer in rodents after UV light exposure. The etiology of sunlight in development of skin cancer was mentioned in scientific articles and public magazines in 1940s and 1950s. Over the decades the message that sunlight exposure leads to increased risk of skin cancer, reach the public. But despite the knowledge, even at present people believe that tan person looks healthier. Additional and continuous educational campaigns are needed for changing people's behavior.

Nevus Spitz--everlasting diagnostic difficulties--the review.

In 1910, Darier and Civatte described in details an unusual melanocytic tumor characterized by rapid growth on the nose of a young child. They could not state whether the tumor was benign or malignant. In 1947, Sophie Spitz described the same lesion as juvenile melanoma in which prognosis was frequently excellent. Later, the study was revised and it was concluded that juvenile melanoma was a benign tumor and can affect adults. Although, the prognosis was mostly excellent, Spitz reported in one of 13 cases fatal metastases from nevus Spitz. In 1999, Barnhill et al described one fatal case of the patient for whom it was thought to have typical Spitz nevus. Nowadays, there is still a lack of consensus about histopathology and also a terminology of the tumors that are neither typical nevus Spitz, neither malignant melanoma. All histopathological, clinical and ancillary criteria must be weighed in the final interpretation of epitheloid/spindle cell lesion. At the present, the final diagnosis remains pathohistological, with important emphasis given to clinical impression. Persistently changing lesion indicates malignancy potential of the lesion. Barnhill recommends that all Spitz tumors are completely excised. Atypical tumors should be excised with wider margins up to 1 cm. Patient should be carefully monitored by regular examinations for recurrence and metastasis.

Chloasma--the mask of pregnancy.

Chloasma is a required hypermelanosis of sun-exposed areas occurred during pregnancy and it can affect 50-70% of pregnant women. It presents as symmetric hyperpigmented macules, which can confluent or punctuate. The most common locations are the cheeks, the upper lip, the chin and the forehead. The exact mechanism by which pregnancy affects the process of melanogenesis is unknown. Estrogen, progesterone, and melanocyte-stimulating hormone (MSH) levels are normally increased during the third trimester of pregnancy. However, nulliparous patients with chloasma have no increased levels of estrogen or MSH. In addition, the occurrence of melasma with estrogen- and progesterone-containing oral contraceptive pills has been reported. The observation that postmenopausal woman who are given progesterone develop melasma, while those who are given only estrogen do not, implicates progesterone as playing a critical role in the development of melasma. UV-B, UV-A, and visible light are all capable of stimulating melanogenesis. The condition is self-limited; however spontaneous resolution is time-consuming and may take months to resolve normal pigmentation. Therefore, it is worthwhile to prevent the onset of chloasma, by strict photoprotection. Prudent measures to avoid sun exposure include hats and other forms of shade combined with the application of a broad-spectrum sunscreen at least daily. Sunscreens containing physical blockers, such as titanium dioxide and zinc oxide, are preferred over chemical blockers because of their broader protection. Chloasma can be difficult to treat. Quick fixes with destructive modalities (eg, cryotherapy, medium-depth chemical peels, lasers) yield unpredictable results and are associated with a number of potential adverse effects. The mainstay of treatment remains topical depigmenting agents. Hydroquinone (HQ) is most commonly used.

ORAL LICHEN PLANUS AND ORAL LICHENOID REACTION--AN UPDATE.

Oral lichen planus (OLP) and oral lichenoid reaction (OLR) are clinically and histopathologically similar diseases. Whereas OLP is a consequence of T cell mediated autoinflammatory process to a still unknown antigen, OLR might be caused by drugs, dental restorative materials and dental plaque. Pubmed was searched and 24 publications published over the last three years regarding etiology, diagnosis and malignant alteration were included in this study. Patients with OLR who have amalgam fillings near lesions should have them replaced, i.e. when possible they should be referred to patch test, as well as when drug-induced OLR are suspected. OLR lesions induced by drugs should disappear when the offending drug has been discontinued. Histology finding in OLR consists of more eosinophils, plasma cells and granulocytes in comparison to OLP lesions. Furthermore, OLP lesions showed more p53, bcl-2 and COX-2 positivity when compared to OLR. OLP is characterized by infiltration, atrophic epithelium, rete pegs and Max Joseph spaces, while deep infiltration into connective tissue and hyperkeratosis were the criteria for making the diagnosis of OLR. The number of degranulated mastocytes in the reticular layer, as well as the number of capillaries was higher in OLR in comparison to OLP. It seems that OLR are more prone to malignant alteration in comparison to OLP.

Chemical peelings--when and why?

Chemical peels are growing in popularity with new agents, formulas and methods giving them greater reliability and safety. Although the operative procedure may seem relatively simple, proper knowledge and skills of the physician and education of the patient is crucial. It is very important for the physician to know chemical structure of the peels, level of necrosis they make in the skin, indications, absolute and relative contraindications, side effects and complications. It is also very important to evaluate the patients, their needs and their expectations, and to present them objective possibilities of the procedure. In chemical peels and their efficacy, preoperative and postoperative care plays an important role, which is out of the reach of the physician and therefore should be emphasized in consultation with the patient.

Multiple angiokeratomas of the vulva: case report and literature review.

Angiokeratomas of the vulva are relatively rare finding and a limited number of cases have been reported in the literature. Clinically, angiokeratomas of the vulva are benign vascular lesions usually occurring in middle-aged or older women. Microscopically these lesions are characterized by epidermal hyperkeratosis, papillomatosis, acanthosis, and marked dilatation of the papillary dermal vessels. In most patients, genital lesions are asymptomatic; however, bleeding, dyspareunia and other symptoms have been described. We report a case of a 45-year-old woman with numerous blue-to-red, scaly papules that spread over the entire area of both labia majora. The patient reported occasional pruritus and burning sensations, discomfort during the intercourse, and significant psychological burden. Histopathologic analysis of the lesion confirmed the diagnosis of angiokeratoma, and all lesions were electrocauterized under local anesthesia. The results of the treatment were very satisfactory, with no side effects or complications. During one-year follow-up, no relapses were noted and the patient remained asymptomatic. Therefore, dermatovenereologists should be aware of angiokeratomas and respective therapeutic options when examining a patient with pruritic, painful, or bleeding lesions in the genital region.