Central scalp alopecia photographic scale in African American women.

Central centrifugal cicatricial alopecia (CCCA) is a common but poorly understood cause of hair loss in African American women. A photographic scale was developed that captures the pattern and severity of the central hair loss seen with CCCA in order to help identify this problem in the general community and to potentially correlate clinical data with hair loss. The utility and reproducibility of this photographic scale was determined in a group of 150 African American women gathered for a health and beauty day who were evaluated by both four investigators experienced in the diagnosis of hair disorders and by the subjects themselves.

Fungal infections in HIV-infected patients.

Opportunistic fungal infections are commonly encountered in the acquired immunodeficiency syndrome (AIDS) patient population. Fungal infections in the patient infected with the human immunodeficiency virus (HIV) are a major cause of morbidity and mortality. The yeasts Candida and Cryptococcus neoformans, the dimorphic fungi Histoplasma capsulatum and Sporothrix schenckii, and the dermatophyte fungi are the most common pathogenic fungi in patients infected with HIV. The characteristics of these and other relevant mycotic pathogens, and their clinical presentation are discussed. Mycoses in the patient infected with HIV are often atypical, and can be masked by other infections. Cutaneous manifestations may provide valuable diagnostic clues. The clinician must maintain a high index of suspicion to establish an early diagnosis and rapidly institute therapy. Treatment may suppress rather than cure the mycosis, because host immunity in conjunction with antifungal agents is necessary to eliminate infection.

Fat necrosis with features of erythema nodosum in a patient with metastatic pancreatic carcinoma.

A 59-year-old man presented with painful subcutaneous nodules on the anterior surfaces of the legs. He had received oral antibiotics and supportive care for presumed cellulitis and thrombophlebitis, but had minimal improvement. Five months earlier, he had undergone pancreaticoduodenectomy for acinar pancreatic carcinoma; at that time, the serum level of amylase had been normal, but the level of lipase was elevated. The patient denied fever, rigors, arthritis/arthralgia, or pleuritic pain. His medications included aspirin, furosemide, ranitidine, and nortriptyline. He denied any allergies. Physical examination revealed numerous firm, tender, erythematous and violaceous, subcutaneous nodules on the lower extremities, with marked bilateral pitting edema (Fig. 1). Skin biopsy of a representative lesion revealed septal panniculitis, consistent with erythema nodosum (Fig. 2). None of the characteristic changes of pancreatic fat necrosis was present. The patient was treated with aspirin, 650 mg orally, q 6 h, and indomethacin, 50 mg orally, q 12 h, but he continued to develop new nodules; prednisone, 60 mg orally was begun. Although he reported improvement in symptoms, the nodules failed to respond clinically and older nodules ulcerated along the medical aspect of the right leg (Fig. 3). The complete blood count was normal, except for hemoglobin, 10.9 mg per dL. Routine serum biochemical studies were also normal, except for albumin, 3.1 mg per dL, LDH, 312 U per L, and SGOT, 51 U per L. Serum amylase was 14 U per L (normal per 30 to 115 U per L) and serum lipase was 54,160 U per L (normal 0 to 200 U per L). Chest roentgenogram and tuberculin skin test were negative. A CT scan of the abdomen revealed extensive liver metastases. A second biopsy of the skin and subcutis of a necrotic nodule revealed lobular panniculitis with the characteristic picture seen in pancreatic fat necrosis (Fig. 4). The patient was presumed to have metastatic pancreatic carcinoma and pancreatic fat necrosis. Nodules subsequently developed on the thighs, arms, hands, wrists, and fingers. He developed arthritis and arthralgias of the ankles, wrists, and hands, bilaterally, and the right knee. Aspiration of a right knee effusion revealed numerous neutrophils, but no evidence of infection. Treatment was begun with the somatostatin analog, octreotide, in increasing doses. During this therapy, the lesions did not progress and new lesions did not appear. There was no change in the lipase level. Inadvertently, octreotide was omitted at discharge, but reintroduction of octreotide was associated with lack of further progression of the nodules, according to the patient's spouse; however the patient became progressively debilitated and his abdominal pain worsened, requiring continuous sedation. His condition deteriorated and he died several weeks after hospital discharge.

Expression of class II major histocompatibility antigens by keratinocytes in cutaneous T cell lymphoma.

BACKGROUND: Expression of various class II MHC antigens by lesional keratinocytes may play an important role in the pathophysiology of a wide variety of human dermatoses including cutaneous T cell lymphoma (CTCL). Nevertheless, there is relatively little information available concerning the concurrent expression of HLA-DR, -DP, and -DQ class II MHC antigens in CTCL. Therefore, our aim in this study was to determine the prevalence, localization, extent, temporal sequence, and consistency of class II MHC antigen expression by lesional keratinocytes in CTCL. METHODS: We used a semiquantitative immunohistologic analysis to analyze HLA-DR, -DP, and -DQ expression by lesional keratinocytes in 66 skin biopsies obtained from 39 patients with CTCL. RESULTS: Class II MHC antigen expression by keratinocytes was observed in 77% of cases. Expression was detected on the cytoplasmic membrane and within the cytoplasm. It varied among cases from focal to confluent. There was a hierarchy of antigen expression in terms of both extent and time course. HLA-DR was expressed first and most extensively, followed by HLA-DP and then HLA-DQ. Comparative studies of multiple serial or concurrent active lesions from 13 cases indicated that the overall pattern and extent of antigen expression was relatively constant within individual patients. CONCLUSIONS: There was no apparent correlation between class II MHC antigen expression and the clinical stage of disease, the type of CTCL skin lesion, or the overall density of the lesional T cell infiltrate. The hierarchy of keratinocyte class II MHC antigen expression observed in this study paralleled that noted in earlier studies of cultured keratinocytes exposed to recombinant interferon-gamma in vitro. This suggests that lesional cytokine levels may be the critical factor governing class II MHC antigen expression by lesional keratinocytes in CTCL.

Cutaneous involvement with Cryptococcus neoformans in AIDS.

Patients infected with HIV are susceptible to many opportunistic fungal infections. Cryptococcus neoformans infection is particularly common in patients with AIDS. We describe a patient with disseminated cryptococcosis resembling molluscum contagiosum and review the typical cutaneous manifestations of disseminated cryptococcosis. A synopsis of case reports in the English literature is also presented.

Isolation, detection, and amplification of intact mRNA from dermatome strips, epidermal sheets, and sorted epidermal cells.

Three different strategies for isolating RNA from epidermal cells were compared. Starting with dermatome sections frozen or disaggregated epidermal cells purified by fluorescence activated cell sorting (FACS), RNA was isolated with a guanidinium thiocyanate technique. Specific mRNA were detected by Northern blot analysis (involucrin, keratin 5, actin), or by reverse transcription and amplification with the polymerase chain reaction (PCR), using primers specific for keratinocyte products (keratins 1 and 14) and Langerhans cells (CD1a). Messenger RNA's characteristic of Langerhans cells and of keratinocytes at different stages of differentiation were detected in dermatome and epidermal sheet preparations as well as in FACS-separated cells. The use of snap-frozen dermatome sections allows the isolation of RNA from epidermis that has undergone minimal trauma and is very close to its in vivo state, but that includes RNA from some dermal cells. Extraction of RNA from Dispase-separated sheets involves slightly more manipulation of the epidermis but provides a sample free from dermal contaminants. PCR analysis of sorted epidermal cells is both sensitive and specific, but involves still greater manipulation. This final technique, however, allows the investigation of mRNA produced by small groups of epidermal cells that are still much closer to their in vivo state than if they had been cultured. By combining these techniques it is possible to determine the baseline production of specific mRNA in the skin in vivo and to assign their production to specific groups of cells with a sensitivity and specificity greater than any approach previously described.