Pseudo-Fringe sign in frontal fibrosing alopecia-like cutaneous lupus erythematosus.

BACKGROUND: Marginal alopecia presents itself frequently in dermatological practice. For patients who present peripheral scalp hair loss, cicatricial and non-cicatricial alopecia should be considered, such as ophiasis, traction alopecia and frontal fibrosing alopecia. In spite of the several types of hair loss that have been described in cutaneous lupus erythematosus, the 'pseudo-fringe sign' had never been observed in such patents. OBJECTIVE: This study aims at including the 'pseudo-fringe sign' as another possibility of clinical manifestation in patients with cutaneous lupus erythematosus. METHODS: A case report of a 67-year-old lady with the diagnosis of lupus erythematosus and peripheral hair loss is shown in this study; the respective differential diagnosis have also been discussed. RESULTS: The diagnosis of a scarring alopecia caused by lupus erythematosus was established with dermoscopy and histopathology. CONCLUSION: Cutaneous lupus erythematosus is another diagnostic possibility for patients who display the 'pseudo-fringe sign'.

European S1 guidelines on the management of lichen planus: a cooperation of the European Dermatology Forum with the European Academy of Dermatology and Venereology.

Lichen planus (LP) is a chronic inflammatory and immune-mediated disease that affects the skin, hair, nails and mucous membranes. Although there is a broad clinical spectrum of lichen planus manifestations, the skin and oral cavity remain the major sites of involvement. A group of European dermatologists with a long-standing interest and expertise in lichen planus has sought to define therapeutic guidelines for the management of patients with LP. The clinical features, diagnosis and possible medications that clinicians can use, in order to control the disease, will be reviewed in this manuscript. The revised final version of the lichen planus guideline was passed on to the European Dermatology Forum (EDF) for a final consensus with the European Academy of Dermatology and Venereology (EADV).

Erosive pustular dermatosis of the scalp: a multicentre study.

BACKGROUND: Erosive pustular dermatosis of the scalp (EPDS) is characterized by crusted erosions or superficial ulcerations that lead to scarring alopecia. OBJECTIVES AND METHODS: We performed a multicentre retrospective clinical study including 56 patients (29 females and 27 males, mean age 62.7) with a confirmed EPDS in order to describe epidemiology, clinical findings and therapeutic choices of this disease. RESULTS: Mechanical/chemical trauma was reported in 28.6%, a previous infection in 10.7%, a previous cryotherapy in 5.4% androgenetic alopecia in 48.2% and severe actinic damage in 25%. Trichoscopy showed absence of follicular ostia, tufted and broken hair, crusts, serous exudate, dilated vessels, pustules and hyperkeratosis. Histopathology revealed three different features, depending on the disease duration. The most prescribed therapy was topical steroids (62.5%), followed by the combination of topical steroids and topical tacrolimus (8.9%), systemic steroids (7.1%) and topical tacrolimus (5.4%). A reduction of inflammatory signs was observed in 28 patients (50%) treated with topical steroids and in all three patients treated with topical tacrolimus. CONCLUSION: The relatively high number of patients collected allowed us to identify a better diagnostic approach, using trichoscopy and a more effective therapeutic strategy, with high-potency steroids or tacrolimus, which should be considered as first-line treatment.

The impact of oxidative stress on hair.

Oxidative stress reflects an imbalance between the systemic manifestation of reactive oxygen species and a biological system's ability to detoxify the reactive intermediates or to repair the resulting damage. Reactive oxygen species or free radicals are highly reactive molecules that can directly damage lipids, proteins, and DNA. They are generated by a multitude of endogenous and environmental challenges, while the body possesses endogenous defense mechanisms. With age, production of free radicals increases, while the endogenous defense mechanisms decrease. This imbalance leads to progressive damage of cellular structures, presumably resulting in the aging phenotype. While the role of oxidative stress has been widely discussed in skin aging, little focus has been placed on its impact on hair condition. Moreover, most literature on age-related hair changes focuses on alopecia, but it is equally important that the hair fibers that emerge from the scalp exhibit significant age-related changes that have equal impact on the overall cosmetic properties of hair. Sources of oxidative stress with impact on the pre-emerging fiber include: oxidative metabolism, smoking, UVR, and inflammation from microbial, pollutant, or irritant origins. Sources of oxidative stress with impact on the post-emerging fiber include: UVR (enhanced by copper), chemical insults, and oxidized scalp lipids. The role of the dermatologist is recognition and treatment of pre- and post-emerging factors for lifetime scalp and hair health.

[Cicatricial alopecias]. / Vernarbende Alopezien.

Cicatricial alopecias are a diagnostic and therapeutic challenge. The irreversibility and cosmetic sequelae of cicatricial alopecia demand special diagnostic attention. Loss of follicular orifices points to permanent hair loss, due to irreversible damage to essential parts of the follicle or destruction of the entire follicle. Where there is no obvious physical/chemical injury or acute infectious etiology, clinical differential diagnosis may be difficult. Clinical inspection is of limited usefulness. Accurate diagnosis based on a careful patient history, examination, microbiological studies, and scalp biopsy are prerequisite to therapy. On the basis of histology, a differentiation is made between primary cicatricial alopecias due to preferential destruction of the follicle, and secondary cicatricial alopecias resulting from events outside impinging upon and eradicating the follicle. The primary cicatricial alopecias include well-defined chronic inflammatory diseases differentiated depending on the type and pattern of inflammation. Although clinicopathologic features allow for diagnosis in most cases, therapeutic limits reflect the boundaries of our present understanding. With expanding technologies for dissecting the immunologic and molecular basis, there is hope for a deeper understanding of the underlying pathogenesis and novel therapeutic interventions.

Involvement of scalp and nails in lupus erythematosus.

Lupus erythematosus (LE) is a systemic autoimmune disorder associated with polyclonal B-cell activation resulting in diverse patterns of autoantibody production and a heterogeneous clinical expression constituting a spectrum extending from limited cutaneous disease to life-threatening systemic manifestations. For daily clinical practice, the characteristics of cutaneous lupus erythematosus (CLE) have been well defined in terms of morphology, and clinical and laboratory criteria are available for the classification as systemic lupus erythematosus (SLE). The many different types of skin lesions encountered in patients with LE have been classified into those that are histologically specific for LE and those that are not. While LE non-specific skin lesions on their own do not enable a diagnosis of LE, they can be important reflections of underlying SLE disease activity. This also applies to the involvement of the scalp and nails. Finally, it must be kept in mind that LE patients may also develop drug-related, or other unrelated common disorders of the hair and nails that do not reflect LE disease activity.

Chemotherapy-induced hair loss.

Chemotherapy-induced hair loss occurs with an estimated incidence of 65%. Forty-seven percent of female patients consider hair loss to be the most traumatic aspect of chemotherapy and 8% would decline chemotherapy due to fears of hair loss. At present, no approved pharmacologic intervention exists to circumvent this side-effect of anticancer treatment, though a number of agents have been investigated on the basis of the current understanding of the underlying pathobiology. Among the agents that have been evaluated, topical minoxidil was able to reduce the severity or shorten the duration, but it did not prevent hair loss. The major approach to minimize chemotherapy-induced hair loss is by scalp cooling, though most published data on this technique are of poor quality. Fortunately, the condition is usually reversible, and appropriate hair and scalp care along with temporarily wearing a wig may represent the most effective coping strategy. However, some patients may show changes in color and/or texture of regrown hair, and in limited cases the reduction in density may persist.

[Hormones and hair growth]. / Hormone und Haarwachstum.

With respect to the relationship between hormones and hair growth, the role of androgens for androgenetic alopecia (AGA) and hirsutism is best acknowledged. Accordingly, therapeutic strategies that intervene in androgen metabolism have been successfully developed for treatment of these conditions. Clinical observations of hair conditions involving hormones beyond the androgen horizon have determined their role in regulation of hair growth: estrogens, prolactin, thyroid hormone, cortisone, growth hormone (GH), and melatonin. Primary GH resistance is characterized by thin hair, while acromegaly may cause hypertrichosis. Hyperprolactinemia may cause hair loss and hirsutism. Partial synchronization of the hair cycle in anagen during late pregnancy points to an estrogen effect, while aromatase inhibitors cause hair loss. Hair loss in a causal relationship to thyroid disorders is well documented. In contrast to AGA, senescent alopecia affects the hair in a diffuse manner. The question arises, whether the hypothesis that a causal relationship exists between the age-related reduction of circulating hormones and organ function also applies to hair and the aging of hair.

Disseminated herpes zoster mimicking rheumatoid vasculitis in a rheumatoid arthritis patient on etanercept.

Tumor necrosis factor-alpha (TNFalpha)-blocking agents are immunomodulating agents introduced for treatment of a variety of chronic inflammatory disease conditions. Adverse effects include an increased incidence of infections. Clinically, these infections often have atypical presentations that may hamper prompt diagnosis. In our report of a patient on etanercept therapy for rheumatoid arthritis, the correct diagnosis was delayed because disseminated herpes zoster was clinically mimicking vasculitis. Initially assuming rheumatoid vasculitis, immunosuppression was increased, resulting in worsening of skin lesions. Only an extended work-up, including a skin biopsy and viral cultures, established the correct diagnosis. Management of varicella zoster virus (VZV) infection primarily focuses on early initiation of antiviral therapy to control VZV replication. Therapy with intravenous acyclovir followed by oral valacyclovir allowed complete resolution of acute skin changes. In immunosuppressed patients, the possibility of infection with atypical presentation must always be kept in mind, and that this might mimic other disease conditions. Broad differential diagnosis and an extended diagnostic workup help in establishing the correct diagnosis.

Incidence of bullous pemphigoid and pemphigus in Switzerland: a 2-year prospective study.

BACKGROUND: Bullous pemphigoid (BP), pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are autoimmune bullous diseases characterized by the presence of tissue-bound and circulating autoantibodies directed against disease-specific target antigens of the skin. Although rare, these diseases run a chronic course and are associated with significant morbidity and mortality. There are few prospective data on gender- and age-specific incidence of these disorders. OBJECTIVES: Our aims were: (i) to evaluate the incidence of BP and PV/PF in Swiss patients, as the primary endpoint; and (ii) to assess the profile of the patients, particularly for comorbidities and medications, as the secondary endpoint. METHODS: The protocol of the study was distributed to all dermatology clinics, immunopathology laboratories and practising dermatologists in Switzerland. All newly diagnosed cases of BP and pemphigus occurring between 1 January 2001 and 31 December 2002 were collected. In total, 168 patients (73 men and 95 women) with these autoimmune bullous diseases, with a diagnosis based on clinical, histological and immunopathological criteria, were finally included. RESULTS: BP showed a mean incidence of 12.1 new cases per million people per year. Its incidence increased significantly after the age of 70 years, with a maximal value after the age of 90 years. The female/male ratio was 1.3. The age-standardized incidence of BP using the European population as reference was, however, lower, with 6.8 new cases per million people per year, reflecting the ageing of the Swiss population. In contrast, both PV and PF were less frequent. Their combined mean incidence was 0.6 new cases per million people per year. CONCLUSIONS; This is the first comprehensive prospective study analysing the incidence of autoimmune bullous diseases in an entire country. Our patient cohort is large enough to establish BP as the most frequent autoimmune bullous disease. Its incidence rate appears higher compared with other previous studies, most likely because of the demographic characteristics of the Swiss population. Nevertheless, based on its potentially misleading presentations, it is possible that the real incidence rate of BP is still underestimated. Based on its significant incidence in the elderly population, BP should deserve more public health concern.

Scalp psoriasis: European consensus on grading and treatment algorithm.

The scalp is a common site of involvement of psoriasis and, for many patients, is a challenging aspect of their disease. This can be attributed not only to the scaling, itching and cosmetic embarrassment that go with scalp psoriasis, but also to the fact that the scalp skin is relatively inaccessible, making topical therapies difficult to apply. The proximity of sensitive facial skin can also limit the use of potentially irritating topical treatments. Nevertheless, the specific challenges of scalp psoriasis are often neglected by treatment guidelines. This paper summarizes the discussions that took place at an international conference of experts convened in Geneva, Switzerland, in March 2008. The objective of the meeting was to review the available treatments for scalp psoriasis in terms of efficacy, safety, convenience, and the implications for patient compliance with treatment. In addition, definitions of mild, moderate and severe scalp psoriasis were agreed. This paper presents a treatment algorithm that includes recommendations for patients in all three categories. It considers the role of potent topical corticosteroids, vitamin D3 derivatives, salicylic acid preparations, and photo- and radiotherapy, as well as systemic therapies, including newer biological agents, for patients with widespread psoriasis with scalp involvement. Data from clinical trials indicate that a potent topical corticosteroid in a short-contact formulation is the most appropriate treatment for most patients with scalp psoriasis.