Acquired dermal melanocytosis: appearance during pregnancy.

We report the first case of acquired dermal melanocytosis (ADM) appearing during pregnancy. A 23-year-old Hispanic woman presented to the Dermatology Clinic of Columbia-Presbyterian Medical Center during the second trimester of pregnancy with a nonpalpable blue-gray patch with interspersed discrete brown macules on the right lower extremity. It had appeared during the first trimester of pregnancy. Cutaneous biopsy specimens revealed dermal melanocytes. A review of all reported cases of this rare dermatosis in the international literature is presented.

Dapsone and sulfones in dermatology: overview and update.

In their 60-year history, dapsone and the sulfones have been used as both antibacterial and anti-inflammatory agents. Dapsone has been used successfully to treat a range of dermatologic disorders, most successfully those characterized by abnormal neutrophil and eosinophil accumulation. This article reviews and updates the chemistry, pharmacokinetics, clinical application, mechanism of action, adverse effects, and drug interactions of dapsone and the sulfones in dermatology.

Lichenoid eruption following hepatitis B vaccination: first North American case report.

Lichen planus is often found in association with a variety of underlying conditions. In particular, liver diseases such as primary biliary cirrhosis, primary sclerosing cholangitis, hepatitis C, and hepatitis B have been implicated in cutaneous lichen planus. Of interest, there is mounting evidence that lichen planus-like eruptions can occur following administration of the hepatitis B vaccine, which has recently become a routine immunization in many parts of the world. We present what we believe to be the first North American case of lichenoid drug eruption associated with the hepatitis B vaccine and provide a brief review of other reported cases of lichenoid eruption seen following hepatitis B vaccination.

Preview of potential therapeutic applications of leukotriene B4 inhibitors in dermatology.

This article reviews the mechanisms and potential therapeutic uses of compounds with inhibitory effects on leukotriene B4 (LTB4) production or its activity, and focuses on compounds that have been shown in animal and/or human studies to have potential efficacy in treating dermatological disorders. These compounds, many of which are not familiar to many dermatologists, include inhibitors of 5-lipoxygenase such as ETH615, 15-hydroxyeicosatetraenoic acid, leflunomide, linetastine, lonapalene, MK886, R-68151 and zileuton, and antagonists of LTB4 such as SC53228, SC50605, SC51146 and VML295. The purpose of this paper is to introduce our colleagues to these potentially useful compounds currently in preclinical or early clinical testing.

Haptoglobin is a natural regulator of Langerhans cell function in the skin.

Langerhans cells (LC), the best-understood antigen presenting cells (APC) of the skin, are functionally plastic. Freshly obtained LC readily activate allogeneic T cells, but are incapable of activating autologous, naive T cells. When placed in culture in the presence of GM-CSF, LC up-regulate surface expression of class I and II MHC molecules along with co-stimulatory molecules, such as B7, CD40 and IL-12. This functional transformation enables the cells to activate naive, autologous T cells in vitro. It is paradoxical that intracutaneous administration of exogenous GM-CSF fails to induce intraepidermal LC to undergo functional transformation in situ. It has been reported that serum contains a factor that prevents fresh LC from undergoing functional transformation in culture, and the relevant serum factor has now been identified as haptoglobin (Hp), based on the following experimental results: (a) SDS-PAGE, amino acid sequencing, and mass spectrometric analyses of the inhibitory factor purified by high performance liquid chromatography (HPLC) from normal human serum revealed molecules completely homologous to Hp alpha-1 chain; (b) pure human Hp, but not serum depleted of Hp, inhibited fresh LC from acquiring the capacity to activate autologous T cells in vitro; (c) abundant Hp was detected in cytoplasmic compartments of fresh, but not cultured, LC. It was concluded that Hp, an acute phase protein, is a systemically-derived factor that prevents epidermal LC from spontaneously undergoing functional maturation in the skin. This novel property of Hp may be important in ameliorating or preventing certain T cell-dependent inflammatory skin diseases.

Eruptive paraneoplastic keloids.

We present a 66-year-old woman who developed eruptive keloids in association with endometrial carcinoma in the absence of trauma, surgery, inflammation, or other known preludes to keloid formation. Keloid formation and endometrial carcinoma are both associated with similar cytokine abnormalities and as such, we hypothesize that this is a previously unreported paraneoplastic phenomenon.

Reassessment of the suction blister model of wound healing: introduction of a new higher pressure device.

BACKGROUND: Negative pressure suction blisters have been used as a reproducible and minimally invasive in vivo model of wound healing in human subjects. Despite advantages over other available methods, this technology has not been employed widely in wound healing research. OBJECTIVE: To evaluate the efficacy of a higher pressure suction blister system as an in vivo human model for wound healing and to demonstrate the superiority of this method over previously used suction blister models of wound healing. METHODS: Four 5-mm-diameter suction blisters were induced on the medial upper arm of 18 healthy men and women using a negative pressure of 508 mmHg. Blister roofs were removed, exposing the underlying dermis. The time required for blister formation, the uniformity of wounds, and the degree of patient tolerance were assessed. The ability to monitor clinical re-epithelialization over 7 days was also evaluated by a team of investigators. RESULTS: Four partial-thickness wounds were produced on each subject in 25-45 min. Wound diameter and morphology were uniform in all subjects. Volunteers tolerated the procedure without complaints of pain or discomfort. Progressive, re-epithelialization was observed daily starting 24 h post-wounding. CONCLUSIONS: This higher pressure suction blister system is an effective model for wound healing. Compared to reported methods, it is a better tolerated, more reliable, and more efficient approach to studying in vivo wound repair in human subjects. It is especially well suited for screening the wound healing potential of new pharmacologic agents.

Pharmacokinetics of doxepin in subjects with pruritic atopic dermatitis.

BACKGROUND: Doxepin applied topically by itself or in combination with triamcinolone acetonide is a safe and effective treatment for atopic dermatitis. OBJECTIVE: We evaluated the pharmacokinetic profile of doxepin and desmethyldoxepin after topical application of doxepin hydrochloride 5% cream alone or in combination with 0.025% triamcinolone acetonide (doxepin/TAC). METHODS: Twenty-four subjects with atopic dermatitis received either doxepin or doxepin/TAC cream 4 times daily for 7 days in a randomized, double-blind, controlled trial. Serum samples were obtained and pharmacokinetic parameters estimated from the dose-normalized serum concentrations of doxepin and desmethyldoxepin. Efficacy and adverse experiences were determined by physician and subject evaluations. RESULTS: Pharmacokinetic parameters (K(e ), t(1/2 ) and AUC) calculated in 9 subjects (doxepin/TAC = 4 subjects, doxepin = 5 subjects) with detectable serum concentrations were similar for both groups. Pruritus relief and lessening of pruritus severity were significantly greater with doxepin/TAC than doxepin alone. CONCLUSION: Topically applied doxepin is safe and effective therapy for pruritus.

Effect of onychomycosis on quality of life.

BACKGROUND: Onychomycosis impairs normal nail functions, causes considerable pain, interferes with daily activities, and has negative psychosocial effects. OBJECTIVE: Our purpose was to determine patients' perception of onychomycosis on the quality of life. METHODS: A total of 258 patients with confirmed onychomycosis were surveyed by telephone at three centers. Responses to a standardized quality-of-life questionnaire were analyzed for patient demographics, physical and functional impact, psychosocial impact, and economic impact. RESULTS: Highest positive responses were nail-trimming problems (76%), embarrassment (74%), pain (48%), nail pressure (40%), and discomfort wearing shoes (38%). Ability to pick up small objects was impaired in 41% of subjects with fingernail involvement. More than 58 onychomycosis-related sick days and 468 medical visits (1.8 per subject) were reported during a 6-month period. CONCLUSION: Onychomycosis has significant social, psychologic, health, and occupational effects. Relevance of quality-of-life issues to overall health, earning potential, and social functioning should prompt reconsideration of the value of aggressive treatment of and financial coverage for onychomycosis.

Fluorescence photography in the evaluation of hyperpigmentation in photodamaged skin.

BACKGROUND: Treatment-related changes in hyperpigmentation are difficult to quantify with visible light photography, especially when the changes are subtle. OBJECTIVE: Our purpose was to determine the utility and reliability of fluorescence photography to measure changes in mottled and diffuse hyperpigmentation. METHODS: Thirty-two subjects, with mildly to moderately photodamaged skin, completed a 36-week, double-blind, vehicle-controlled study of tretinoin cream 0.025%. Clinical evaluation of hyperpigmentation as well as standard flash photographs and fluorescence photographs were obtained at baseline and week 36. RESULTS: The fluorescence photographs were evaluated blindly and yielded macule counts that decreased significantly from baseline in tretinoin-treated subjects compared with vehicle-treated subjects (31% vs 11% decrease; p = 0.02). Diffuse hyperpigmentation, as evaluated from the fluorescence photographs, decreased 16% from baseline for tretinoin-treated subjects and increased 5% for vehicle-treated subjects (p < 0.01). No significant differences in mottled or diffuse hyperpigmentation were observed between groups through clinical evaluation. CONCLUSION: Fluorescence photography is a noninvasive method that is sensitive in the evaluation and quantification of distribution and changes of mottled and diffuse hyperpigmentation.

Fluorescence photography in the evaluation of acne.

BACKGROUND: Quantification of acne remains a challenge. It may be difficult to identify lesions by standard flash photography. Previous studies have shown that foci of light in fluorescence photographs correspond to high protoporphyrin IX production by Propionibacterium acnes in open comedones, follicles, and inflammatory lesions. OBJECTIVE: Our purpose was to study the utility of fluorescence photography for evaluation of acne. METHODS: Forty subjects with mild to moderate acne vulgaris were randomly selected to apply either clindamycin 1% topical solution or vehicle twice daily. Counts of acne lesions and flash and fluorescence photographs were obtained at baseline, and at 4, 8, and 12 weeks. RESULTS: At 12 weeks, the treatment group had a larger percentage change in open comedones, less fluorescence in all areas assessed, and a larger percent decrease in fluorescence than the vehicle group. CONCLUSION: Fluorescence photography appears to be a useful tool to chart the course of acne treatment.

Topical 8% glycolic acid and 8% L-lactic acid creams for the treatment of photodamaged skin. A double-blind vehicle-controlled clinical trial.

OBJECTIVE: To evaluate the efficacy and tolerability of 2 widely used topical alpha-hydroxy acids at low concentrations, 8% glycolic acid and 8% lactic (L-isoform) acid creams, in the treatment of photodamaged skin. DESIGN: A single-center, 22-week, double-blind, vehicle-controlled, randomized clinical trial assessed the overall severity of photodamage on the faces and forearms of volunteers, based on 7 individual clinical components of cutaneous photodamage. SETTING: The study was performed in an outpatient clinical research unit at the Massachusetts General Hospital, Boston. PATIENTS: Seventy-four women, aged 40 to 70 years, with moderately severe photodamaged facial skin were enrolled in the study. One subject withdrew from the study early because of skin irritation, and 6 subjects withdrew from the study for personal reasons. INTERVENTIONS: Glycolic acid, L-lactic acid, or vehicle creams were applied twice daily to the face and outer aspect of the forearms. MAIN OUTCOME MEASURES: Improvement in alpha-hydroxy acid-treated photodamaged skin as determined by patient self-assessments and physician evaluations of efficacy and irritancy. RESULTS: The percentage of patients using either 8% glycolic acid or 8% L-lactic acid creams on the face achieving at least 1 grade of improvement (using a scale from 0 through 9) in overall severity of photodamage was significantly greater than with the vehicle cream (76% glycolic acid, 71% lactic acid, and 40% vehicle; P < .05). On the forearms, after 22 weeks, treatment with glycolic acid cream was superior to the vehicle in improving the overall severity of photodamage and sallowness (P < .05). L-Lactic acid cream was significantly superior to the vehicle in reducing the overall severity of photodamage (P < .05), mottled hyperpigmentation (P < .05), sallowness (P < .05), and roughness on the forearms (P < .05) at week 22. CONCLUSIONS: Topical 8% glycolic acid and 8% L-lactic acid creams are modestly useful in ameliorating some of the signs of chronic cutaneous photodamage. These agents are well tolerated and available without prescription.

Physical enhancement of dermatologic drug delivery: iontophoresis and phonophoresis.

Iontophoresis and phonophoresis are emerging technologies capable of enhancing drug penetration through the stratum corneum, the principal barrier to percutaneous absorption. With utilization of applied electric current or ultrasonic waves, respectively, iontophoresis and phonophoresis have shown efficacy in an increasing number of clinical applications. This article reviews the underlying principles, current status, and potential of iontophoresis and phonophoresis in dermatologic therapy.

Polarized light photography in the evaluation of photoaging.

BACKGROUND: The clinical characteristics of photodamaged skin, such as coarse and fine wrinkling, sallowness, hyperpigmentation, tactile roughness, laxity, and erythema, are not accurately evaluable from photographic records. OBJECTIVE: The purpose of this study was to develop accurate and reproducible photographic techniques that generate an evaluable record of the characteristics of photodamaged skin. METHODS: The method used involved illumination and photography through polarizing filters (polarized light photography). RESULTS: Polarized light photography generates images that selectively enhance either the surface features or the subsurface features of the skin, providing an accurate and evaluable record for evaluation of photodamaged skin. CONCLUSION: Polarized light photography, when coupled with precise framing and mapping, yields an accurate and evaluable record of photodamaged skin.

Better dermatologic office photography: taking the photograph.

In a previous article we reviewed the questions every medical photographer must ask when looking through the viewfinder, as well as the difference between plastic surgical and dermatologic photography. We conclude by offering a mnemonic for the three views necessary in dermatologic photography: Location, Scan, and Detail, and by suggesting a technique for preadjusting the camera, lens setting, and flash that will guarantee consistent, high-quality clinical photos.

Better dermatologic office photography: getting started.

In an earlier paper, we defined a medical photograph as one that accurately maximizes clinical information while minimizing irrelevant data. This paper expands on this concept, providing specific hints to assist the practitioner in obtaining consistent high-quality clinical photos. We review the important question every medical photographer must ask when looking through the viewfinder as well as the difference between photography for practitioners of plastic surgery and dermatology.

Confluent and reticulated papillomatosis: response to high-dose oral isotretinoin therapy and reassessment of epidemiologic data.

Confluent and reticulated papillomatosis is most probably a disorder of keratinization rather than a fungal infection. We describe an 18-year-old man who was effectively treated with high-dose oral isotretinoin. Our review of the literature on confluent and reticulated papillomatosis refutes previously accepted epidemiologic data.