Cosmetic Considerations in Dark-Skinned Patients.

For dermatologists, diversities of human races result in an opportunity to encounter patients with various skin types. Cosmetic procedures have gained more popularity and become more accessible over the past decades. Thus, the selection of appropriate treatment protocol for each patient becomes inevitable. This review will focus on basic knowledge and key points in performing safe cosmetic-related procedures in patients with dark-complexioned skin. In terms of structure and function of the skin, people of color have equal epidermal thickness, corneocyte size and melanocyte number. However, they have more stratum corneum compaction, melanosome dispersion and melanocyte activity than fair skin individuals. Data regarding drug penetration and cutaneous irritation showed conflicting results. Superficial chemical peels and microdermabrasion can be done safely in dark-skinned patients. Medium-depth peel should be used with extreme caution. While deep-depth peel should be avoided at all times due to pigmentary and textural complications. Prolonged treatment interval, use of priming agents and sun protection are recommended. Injectable materials including botulinum toxin and soft tissue augmentation by hyaluronic acid filler can be done harmlessly in dark-skinned patients. Lasers and energy-based devices should be done with caution. Higher melanin dispersion and melanocyte activity acts as competitive chromophore. Pigmentary or textural changes can occur after aggressive treatment protocol. High energy setting, pulse stacking, short wavelength lasers and short treatment interval should be avoided in dark-skinned patients.

Evaluation of an Acne Severity Grading Self-Assessment System Suitable for the Thai Population - A Pilot Study.

Background: Patient self-assessment is a potential tool in clinical practice to obtain subjective information of acne severity also in clinical trials to assess the general population in research and epidemiologic studies. The patient self-evaluation of acne severity has not yet been developed in Thailand. Objective: We aimed to validate an acne severity grading self-assessment suitable for the Thai population. Methods: A pilot study was conducted in 77 volunteers with acne lesions. We developed the Thai Global Evaluation Acne Scale (TGEA) and Thai Global Acne Grading System (TGAGS) by translating and adapting the original version. Patient self-assessment of acne severity was performed in two rounds. A training session about acne was provided to all participants lesions before starting the second round. Reliability between the self-assessment and clinician assessment of acne severity was statistically assessed. Results: For TGEA, 48.05% participants rated their acne severity corresponded with the clinicians (Cohen's kappa coefficient, kappa = 0.26). After receiving the training, 79.22% subjects responded their acne severity corresponded with the clinicians (kappa = 0.66). For TGAGS, 77.92% patients who answered their acne severity corresponded with the clinicians (kappa = 0.52). After receiving the training, 94.80% participants responded their acne severity corresponded with the clinicians (kappa = 0.89). For raw score of the TGAGS, the intraclass correlation coefficient (ICC) during the self-assessment of acne severity compared to the clinician assessments was 0.54 and it increased to 0.79 after the training. Conclusion: Due to the almost perfect reliability, we suggested that TGAGS is a reliable subjective self-assessment of acne severity suitable for the Thai population. The training is essential in enhancing the reliability of this instrument. Our study's findings can facilitate clinical practice and research studies.

Pretibial Pruritic Papular Dermatitis: A Case Report and Emphasis on Effective Treatment with Pentoxifylline.

Pretibial pruritic papular dermatitis (PPPD) is a distinctive skin disorder in response to persistent pretibial manipulation. Clinically, it manifests as multiple discrete, pruritic, flesh-colored-to-erythematous papules and plaques confined to the pretibial area. The histological hallmark of PPPD comprises irregular epidermal psoriasiform hyperplasia with parakeratosis and spongiosis, dermal fibrosis, and lymphohistiocytic infiltration. Due to its rarity and underrecognition, the prevalence and standard treatment of the disease have yet to be well elucidated. Here, we present a case of PPPD in a 60-year-old female presenting with numerous pruritic, erythematous-to-brownish papules and plaques on bilateral pretibial areas for 1.5 years. The lesions were significantly improved after 1 month of additional treatment with oral pentoxifylline. In this report, we aim to raise awareness in recognizing PPPD since it manifests unique clinical, dermoscopic, and histological features, representing pretibial skin's response to chronic rubbing. In addition, we proposed a novel effective therapy for the disease using pentoxifylline.

Incobotulinum Toxin Type A for Treatment of Ultraviolet-B-Induced Hyperpigmentation: A Prospective, Randomized, Controlled Trial.

Incobotulinum toxin A (IncoBoNT-A) is effective in preventing ultraviolet B (UVB)-induced hyperpigmentation. This prospective, randomized, controlled study aimed to evaluate the effect of IncoBoNT-A on the treatment of UVB-induced hyperpigmentation in 15 volunteers. Five hyperpigmentation squares (2 × 2 cm) were induced by local UVB on the abdomen at baseline. At Day 7, each site was randomized to receive no treatment (control), normal saline, or intradermal IncoBoNT-A injection with 1:2.5, 1:5, and 1:7.5 dilutions (12, 6, and 4 units, respectively). The mean lightness index (L*), hyperpigmentation improvement score evaluated by blinded dermatologists, and participant satisfaction scores were obtained at Days 21, 28, and 35. At Day 21, improvements in mean L* of 1:2.5, 1:5, and 1:7.5 IncoBoNT-A-treated, saline-treated, and control sites were 14.30%, 12.28%, 6.62%, 0.32%, and 4.98%, respectively (p = 0.86). At Day 28, the improvement in mean L* in IncoBoNT-A-treated groups was superior to that in the other groups. In terms of the hyperpigmentation improvement score, 12 participants (80%) experienced better outcomes with the IncoBoNT-A-injected site compared with the other sites. IncoBoNT-A, especially at higher concentrations, showed some positive effects on the treatment of UVB-induced hyperpigmentation. This may serve as an adjuvant treatment for hyperpigmentary conditions that are aggravated by UVB.

Comparison of the efficacy and safety of using 0.01% versus 0.03% bimatoprost for the treatment of eyebrow hypotrichosis: A randomized, double-blind, split-face, comparative study.

BACKGROUND: Previous studies have proven the efficacy and safety of 0.01% and 0.03% bimatoprost for the treatment of eyebrow hypotrichosis; however, there is no comparison study between both concentrations. AIMS: To compare the efficacy and safety between 0.01% and 0.03% bimatoprost for the treatment of eyebrow hypotrichosis. PATIENTS/METHODS: This prospective, randomized, double-blind, split-face clinical study was conducted in 30 patients with eyebrow hypotrichosis. Each side of eyebrow of individual patients was randomly assigned for 0.01% and 0.03% bimatoprost, applied on each eyebrow once daily. Eyebrow density, diameter, the Global Eyebrow Assessment scale, 7-point rating scale, and patient satisfaction were evaluated. Side effects were also recorded. RESULTS: Both 0.01% and 0.03% bimatoprost significantly improved eyebrow density and diameter (P < .05), although there were no statistically significant differences in changes in eyebrow density and diameter from baseline between both concentrations (P = .96 and .84, respectively). Additionally, patients significantly preferred 0.03% bimatoprost in terms of clinical improvement and satisfaction (P = .04 and .003, respectively). CONCLUSIONS: Both 0.01% and 0.03% bimatoprost are effective and safe for the treatment of eyebrow hypotrichosis. Bimatoprost 0.03% is superior to its 0.01% counterpart, albeit without statistical significance.

Ashy Dermatosis and Lichen Planus Pigmentosus: The Histopathological Differences.

BACKGROUND: Ashy dermatosis (AD) and lichen planus pigmentosus (LPP) are both acquired macular pigmentation of uncertain aetiology. Despite the controversy surrounding their entities, recent global consensus has concluded that they are 2 different diseases with distinct clinical presentations. Nevertheless, there are limited data on their histopathological comparisons. OBJECTIVE: To evaluate the differences in histopathological findings between AD and LPP. METHODS: Electronic records and photographs of patients with the diagnosis of AD or LPP from January 2008 to December 2018 were retrospectively reviewed by a dermatologist. Patients were then classified into groups with AD and LPP, based on the clinical descriptions from the recent consensus. Those with history/clinical presentations suggestive of other causes of macular pigmentation were excluded. The histopathological diagnosis of AD and LPP was then reevaluated by a blinded dermatopathologist. RESULTS: One hundred and twenty-four patients with acquired macular pigmentation were identified; 24 were excluded due to clinical history or photographs being inconsistent with AD or LPP. Of the remaining 100 patients, 71 had clinical findings consistent with LPP while 29 had AD. The prevalence of epidermal hyperkeratosis was significantly higher in LPP when compared to AD (33.8% vs. 0%, p < 0.001), as well as epidermal hypergranulosis (35.2% vs. 0%, p < 0.001), lichenoid dermatitis (49.3% vs. 7.1%, p < 0.001), perifollicular infiltration (47.9% vs.10.3%, p < 0.001), and perifollicular fibrosis (35.2% vs. 10.3%, p=0.01). In addition, the degree of pigmentary incontinence was more severe in LPP (21.1% vs. 3.5%, p=0.015). For AD, vacuolization of the epidermal basal cell layer was more common (96.4% vs. 77.5%, p=0.02). CONCLUSIONS: Although most cases of AD and LPP can be diagnosed clinically, in doubtful cases, histopathological findings of lichenoid dermatitis, epidermal hyperkeratosis/hypergranulosis, and moderate to severe pigmentary incontinence can help distinguish LPP from AD.

The validation of smartphone applications for heart rate measurement.

BACKGROUND: The smartphone apps provide a user-friendly option for measurement of heart rate (HR) by detecting pulsatile photoplethysmographic signals with built-in cameras from the fingertips, however, the validation study is limited. METHODS: We compared HR detected by the smartphone apps (App1 = Instant HR, App2 = Cardiio: HR Monitor and App3 = Runtastic HR Monitor) with simultaneous standard ECG monitoring in the adult patients at the critical care unit. RESULTS: HR measurements were obtained from 140 patients with mean age 67.6 ± 15.3 years. Mean baseline HR was 89.1 ± 19.1 bpm (range, 32-136 bpm). Sinus rhythm was presented in 111 patients (79.3%), atrial fibrillation in 25 patients (17.9%), pacemaker rhythm in 3 patients (2.1%), and high-grade AV block in 1 patient (0.7%). The ECG-derived HR correlated well with App1 (r = 0.98), App2 (r = 0.97), and App3 (r = 0.92). In patients with regular rhythm, mean absolute deviation was 0.8 ± 1, 0.7 ± 0.9, 1.0 ± 1.3 bpm on App1, App2 and App3, respectively. In the patients with irregular rhythm, median absolute deviation (IQR) was 3 (2-5.5), 4 (1.5-11.5), and 6 (2-13) bpm. Skin colour did not affect with the HR measurement. CONCLUSIONS: HR measurements from all applications were correlated well with ECG monitoring. However, it was less accurate in case of irregular rhythm such as atrial fibrillation. Key messages Several reports on inaccuracy of mobile health apps have been published. We conducted the validation study in the real patients by using popular mobile apps. Heart rate measurements from mobile apps were correlated well with standard ECG. The accuracy of HR from apps was worse at irregular rate and tachycardia.

Non-invasive high-intensity focused ultrasound for UV-induced hyperpigmentation in Fitzpatrick skin types III and IV: a prospective, randomized, controlled, evaluator-blinded trial.

Skin hyperpigmentation is a frequently encountered problem, particularly in darker skin types. Unfortunately, standard treatments for this condition have shown disappointing results. High-intensity focused ultrasound (HIFU) is commonly indicated for skin laxity, but recently was used to treat UV-induced hyperpigmentation in animal models. This study is aimed to evaluate the efficacy and safety of high-intensity focused ultrasound for UVB-induced hyperpigmentation in human subjects. A randomized, evaluator-blinded pilot study was conducted on 20 subjects. Each subject was induced three hyperpigmentary spots by local broadband UVB. After 2 weeks, each spot was randomly allocated to control, low-energy, and high-energy HIFU. Subjects were instructed to follow up weekly for a duration of 1 month. Lightness index measurements, mean improvement scores, subjects' satisfaction, pain scores, and side effects were evaluated. All 20 subjects completed the study. Fourteen subjects had Fitzpatrick (FPT) skin type III and six subjects had FPT skin type IV. Twelve subjects showed greater improvement at control sites while eight subjects showed greater improvement at HIFU-treated sites. In FPT skin type III, HIFU appeared to be inferior to control in both lightness index and mean improvement scores, but in FPT skin type IV, HIFU had greater lightness index improvement and higher improvement scores than control. Side effects were more frequent in high-energy-treated areas. Focused ultrasound may be offered in some patients with hyperpigmentary conditions. More research is needed to determine proper energy settings for optimal outcome.

Prevalence and Clinical Characteristics of Itch in Vitiligo and Its Clinical Significance.

OBJECTIVE: Vitiligo usually presented as asymptomatic depigmented macules and patches. Little is known regarding itch in vitiligo. This study aimed to evaluate the prevalence and characteristics of itch in vitiligo patients. PATIENTS AND METHODS: A cross-sectional study was conducted on vitiligo patients. Itch character and intensity were determined through questionnaires. Evaluation was also made by dermatologists to define vitiligo subtype, body surface area, Koebner phenomenon (KP), and so on. Data were assessed by computer software. Results were considered statistically significant if p < 0.05. RESULTS: Among 402 patients, itch on vitiliginous lesion presented in 20.2%. Prevalence of itch was most common in focal vitiligo (29.4%), followed by segmental vitiligo (20.3%) and nonsegmental vitiligo (19.6%), respectively. Tingling sensation was the most common itch-related symptom (82.7%). The median itch intensity is 5 by 10-point visual analog scale. Daily activity and sleep disturbance were observed in 60.5% and 39.5% of patients who experience itch. Itch occurred approximately 3 days prior to the development of lesions in 48.1% of patients. Thirty-two patients (78.1%) with both itch and KP type IIb had active disease. CONCLUSIONS: Itch in vitiligo is not uncommon. The presence of itch with KP type IIb may warrant the active vitiligo.

PPAR-γ Agonists and Their Role in Primary Cicatricial Alopecia.

Peroxisome proliferator-activated receptor γ (PPAR-γ) is a ligand-activated nuclear receptor that regulates the transcription of various genes. PPAR-γ plays roles in lipid homeostasis, sebocyte maturation, and peroxisome biogenesis and has shown anti-inflammatory effects. PPAR-γ is highly expressed in human sebaceous glands. Disruption of PPAR-γ is believed to be one of the mechanisms of primary cicatricial alopecia (PCA) pathogenesis, causing pilosebaceous dysfunction leading to follicular inflammation. In this review article, we discuss the pathogenesis of PCA with a focus on PPAR-γ involvement in pathogenesis of lichen planopilaris (LPP), the most common lymphocytic form of PCA. We also discuss clinical trials utilizing PPAR-agonists in PCA treatment.

Prevalence of Thyroid Abnormalities in Thai Patients with Vitiligo.

BACKGROUND: Vitiligo is an acquired hypopigmentary disorder. The prevalence of vitiligo is 0.1-2% worldwide. Numerous autoimmune diseases are associated with vitiligo, including autoimmune thyroid diseases. The prevalence of thyroid abnormalities is up to 34% in vitiligo patients depending on ethnicities. OBJECTIVE: This study aims to investigate thyroid abnormalities in Thai patients with vitiligo. METHODS: Medical records of vitiligo patients attending outpatient dermatology clinic at a university-based hospital from 2012 to 2016 were retrospectively reviewed. Data regarding vitiligo, clinical features, and autoimmune thyroid laboratory results were retrieved and analyzed. RESULTS: Among 325 vitiligo patients identified, anti-thyroid peroxidase and anti-thyroglobulin were positive in 90 (27.7%) and 63 patients (19.4%), respectively. Positive thyroid antibody was associated with female gender (p < 0.001) and vitiliginous hand lesions (p < 0.02). Out of 197 patients with complete thyroid function test, the prevalence of autoimmune thyroid diseases (AITD) is 12.7%. Female, nonsegmental type, higher affected area, and the presence of leukotrichia are significantly associated with AITD in vitiligo patients. CONCLUSIONS: Prevalence of positive thyroid antibodies and AITD in Thai patients with vitiligo is compatible with previous studies around the world. Screening for AITD with thyroid antibodies and serum TSH is essential for vitiligo patients.

Epithelial inflammation resulting from an inherited loss-of-function mutation in EGFR.

Epidermal growth factor receptor (EGFR) signaling is fundamentally important for tissue homeostasis through EGFR/ligand interactions that stimulate numerous signal transduction pathways. Aberrant EGFR signaling has been reported in inflammatory and malignant diseases, but thus far no primary inherited defects in EGFR have been recorded. Using whole-exome sequencing, we identified a homozygous loss-of-function missense mutation in EGFR (c.1283 G>A; p.Gly428Asp) in a male infant with lifelong inflammation affecting the skin, bowel, and lungs. During the first year of life, his skin showed erosions, dry scale, and alopecia. Subsequently, there were numerous papules and pustules--similar to the rash seen in patients receiving EGFR inhibitor drugs. Skin biopsy demonstrated an altered cellular distribution of EGFR in the epidermis with reduced cell membrane labeling, and in vitro analysis of the mutant receptor revealed abrogated EGFR phosphorylation and EGF-stimulated downstream signaling. Microarray analysis on the patient's skin highlighted disturbed differentiation/premature terminal differentiation of keratinocytes and upregulation of several inflammatory/innate immune response networks. The boy died at the age of 2.5 years from extensive skin and chest infections as well as electrolyte imbalance. This case highlights the major mechanism of epithelial dysfunction following EGFR signaling ablation and illustrates the broader impact of EGFR inhibition on other tissues.