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November/December 2012 • Volume 10 • Issue 6

EDITORIAL Hair Then and Now Lavery and Parish

COMMENTARY Female Pattern Hair Loss Sharma, Dabaghian, and Lambert

Striae Distensae: The Fibrillin/Transforming Growth Factor b Signaling Puzzle Lacerda

ORIGINAL CONTRIBUTIONS Hair Care Practices in Diverse Populations: What Makes the Difference? Chappell, Armbrecht, and Jensen

Topical Acne Treatment With Acetylcysteine: Clinical and Experimental Effects Montes, Wilborn, and Montes

REVIEW Green Tea in Dermatology Pazyar, Feily, and Kazerouni

Topical Vitamin D Analogs Available to Treat Psoriasis Oquendo, Abramovits, and Morrell

CORE CURRICULUM Pathophysiology of Adverse Cutaneous Drug Reactions—Applied Perceptions: Part II Sehgal, Verma, and Bhattacharya

DEPARTMENTS PERILS OF DERMATOPATHOLOGY On Bossing: Taking Charge Without The Facts Wassef, Serna-Tamayo, McDonough, Tumer, and Lambert

HISTORY OF DERMATOLOGY SOCIETY NEWSLETTER Mosquito Wars: Malaria and Bioterrorism in Italy, 1943–1945 Snowden

CASE STUDIES Radiation Port Erythema Multiforme: Erythema Multiforme Localized to the Radiation Port in a Patient With Non–Small Cell Lung Cancer Chodkiewicz and Cohen

Cladosporium Scalp Infection Sosa, Cohen, and Tschen

Metastatic Melanoma From an Unknown Primary Site Presenting as Skin-Colored Nodules and Multiple Visceral Involvement Ghosh, Bandyopadhyay, Barma, Basu, and Roy

BOOK REVIEW ACS(I) Textbook on Cutaneous and Aesthetic Surgery Reviewed by Parish


Indicated for the topical treatment of plaque psoriasis in patients aged 18 years or older

My doctor has prescribed SORILUX Foam for my plaque psoriasis...

My Life. My Treatment.

The only vitamin D3 analog treatment in a topical foam formulation VersaFoam®-AEF: Aqueous-based Emulsion Formulation Free of ethanol, preservatives, parabens, and fragrance SORILUX Foam, with VersaFoam technology, penetrates the skin barrier to deliver the molecule into the epidermis and dermis1 The contribution to efficacy of individual components of the vehicle has not been established.

Important Safety Information for SORILUX Foam SORILUX Foam should not be used by patients with known hypercalcemia The propellant in SORILUX Foam is flammable. Instruct the patient to avoid fire, flame, and/or smoking during and immediately following application Transient, rapidly reversible elevation of serum calcium has occurred with use of calcipotriene. If elevation in serum calcium outside the normal range should occur, discontinue treatment until normal calcium levels are restored Instruct the patient to avoid excessive exposure of the treated areas to either natural or artificial sunlight, including tanning booths and sun lamps. Physicians may wish to limit or avoid use of phototherapy in patients who use SORILUX Foam SORILUX Foam has not been evaluated in patients with erythrodermic, exfoliative, or pustular psoriasis

Adverse events reported in greater than 1% of subjects and in a higher rate in subjects treated with SORILUX Foam compared with vehicle were limited to erythema SORILUX Foam should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus It is not known whether calcipotriene is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when SORILUX Foam is administered to a nursing woman Safety and effectiveness of SORILUX Foam in pediatric patients less than 18 years of age have not been established SORILUX Foam is not for oral, ophthalmic, or intravaginal use

Please see Brief Summary of Prescribing Information on the next page. Reference: 1. Data on file, Stiefel Laboratories, Inc. SORILUX is a trademark and VersaFoam is a registered trademark of Stiefel Laboratories, Inc. ©2012 Stiefel Laboratories, Inc. All rights reserved. Printed in USA. SLX001R0 March 2012


SORILUX

BRIEF SUMMARY The enlarged fontanelles are most likely due to calcipotriene’s (calcipotriene) Foam, 0.005% ribs. effect upon calcium metabolism. The maternal and fetal no-effect

The following is a brief summary only; see full prescribing information for complete product information.

exposures in the rat (43.2 mcg/m2/d) and rabbit (17.6 mcg/m2/d) studies are approximately equal to the expected human systemic exposure level (18.5 mcg/m2/d) from dermal application.

INDICATIONS AND USAGE

Nursing Mothers

SORILUX Foam is indicated for the topical treatment of plaque psoriasis in patients aged 18 years and older.

It is not known whether calcipotriene is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when SORILUX Foam is administered to a nursing woman.

CONTRAINDICATIONS

Pediatric Use

SORILUX Foam should not be used by patients with known hypercalcemia.

Safety and effectiveness of SORILUX Foam in pediatric patients less than 18 years of age have not been established.

WARNINGS AND PRECAUTIONS

Geriatric Use

Flammability The propellant in SORILUX is flammable. Instruct the patient to avoid fire, flame, and/or smoking during and immediately following application.

Effects on Calcium Metabolism Transient, rapidly reversible elevation of serum calcium has occurred with use of calcipotriene. If elevation in serum calcium outside the normal range should occur, discontinue treatment until normal calcium levels are restored.

Ultraviolet Light Exposure Instruct the patient to avoid excessive exposure of the treated areas to either natural or artificial sunlight, including tanning booths and sun lamps. Physicians may wish to limit or avoid use of phototherapy in patients who use SORILUX Foam. [See Nonclinical Toxicology (13.1).]

Unevaluated Uses SORILUX Foam has not been evaluated in patients with erythrodermic, exfoliative, or pustular psoriasis.

ADVERSE REACTIONS Clinical Trials Experience Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in clinical practice. SORILUX Foam was studied in 3-vehicle controlled trials. Seven hundred and thirty-one subjects with plaque psoriasis, including 473 exposed to SORILUX Foam were treated twice daily for 8 weeks. Adverse events reported in greater than 1% of subjects and in a higher rate in subjects treated with SORILUX Foam compared to vehicle were limited to erythema.

DRUG INTERACTIONS

No drug interaction studies were conducted with SORILUX Foam.

USE IN SPECIFIC POPULATIONS Pregnancy Teratogenic Effects, Pregnancy Category C: There are no adequate and well-controlled studies in pregnant women. Therefore, SORILUX Foam should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Studies of teratogenicity were done by the oral route where bioavailability is expected to be approximately 40–60% of the administered dose. Increased rabbit maternal and fetal toxicity was noted at 12 mcg/kg/d (132 mcg/m2/d). Rabbits administered 36 mcg/kg/d (396 mcg/m2/d) resulted in fetuses with a significant increase in the incidences of incomplete ossification of pubic bones and forelimb phalanges. In a rat study, doses of 54 mcg/kg/d (318 mcg/m2/d) resulted in a significantly higher incidence of skeletal abnormalities consisting primarily of enlarged fontanelles and extra

Clinical studies of SORILUX Foam did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients.

OVERDOSAGE

Topically applied calcipotriene can be absorbed in sufficient amounts to produce systemic effects. Elevated serum calcium has been observed with use of topical calcipotriene. [See Warnings and Precautions (5.2).]

NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Calcipotriene topically administered to mice for up to 24 months at dose levels of 3, 10, or 30 mcg /kg/d (corresponding to 9, 30, or 90 mcg /m2/d) showed no significant changes in tumor incidence when compared to controls. In a study in which albino hairless mice were exposed to both UVR and topically applied calcipotriene, a reduction in the time required for UVR to induce the formation of skin tumors was observed (statistically significant in males only), suggesting that calcipotriene may enhance the effect of UVR to induce skin tumors. [See Warnings and Precautions (5.3).] The genotoxic potential of calcipotriene was evaluated in an Ames assay, a mouse lymphoma TK locus assay, a human lymphocyte chromosome aberration assay, and a mouse micronucleus assay. All assay results were negative. Studies in rats at doses up to 54 mcg /kg/d (318 mcg /m2/d) of calcipotriene indicated no impairment of fertility or general reproductive performance.

PATIENT COUNSELING INFORMATION

[See FDA-approved Patient Labeling in full Prescribing Information]. The patient should be instructed as follows: t %o not place SORILUX Foam in the refrigerator or freezer. t "WPJd excessive exposure of the treated areas to either natural or artificial sunlight, including tanning beds and sun lamps. t *f SORILUX Foam gets in or near their eyes, to rinse thoroughly with water. t Talk to their doctor if their skin does not improve after treatmen with SORILUX Foam for 8 weeks. t Wash their hands after applying SORILUX Foam unless their hands are the affected site t "WPJd fire, flame, or smoking during and immediately following application since SORILUX Foam is flammable. SOR:4BRS

SORILUX is a trademark of Stiefel Laboratories, Inc. ©2011 Stiefel Laboratories, Inc. April 2011


University of Athens Medical School, Athens, Greece

WORLD CONGRESS

OF COSMETIC

DERMATOLOGY BY THE INTERNATIONAL ACADEMY OF COSMETIC DERMATOLOGY

ATHENS, GREECE JUNE 27-30, 2013 www.wcocd2013.com info@wcocd2013.com Congress Organising Bureau ERASMUS CONFERENCES TOURS & TRAVEL S.A. E-mail: info@wcocd2013.com Website: www.erasmus.gr


TABLE OF CONTENTS /PWFNCFS%FDFNCFSt7PMVNFt*TTVF

EDITORIAL Hair Then and Now...................................................................................................................................... 334 Michael Joseph Lavery, MB BCh BAO; Lawrence Charles Parish, MD, MD (Hon)

COMMENTARY Female Pattern Hair Loss ............................................................................................................................ 336 Amit Sharma, BA; Laurie Dabaghian, BA; W. Clark Lambert, MD, PhD

Striae Distensae: The Fibrillin/Transforming Growth Factor β Signaling Puzzle .............................................. 338 Davi de Lacerda, MD

ORIGINAL CONTRIBUTIONS Hair Care Practices in Diverse Populations: What Makes the Difference? ...................................................... 341 Jeaneen Chappell, MD; Eric Armbrecht, PhD; Sara Jensen, MD

Topical Acne Treatment With Acetylcysteine: Clinical and Experimental Effects ............................................. 348 Leopold F. Montes, MD, MS, FRCPC; Walter H. Wilborn, PhD, MS; Carolina M. Montes, MD

REVIEW Green Tea in Dermatology ........................................................................................................................... 352 Nader Pazyar, MD; Amir Feily, MD; Afshin Kazerouni, MD

Topical Vitamin D Analogs Available to Treat Psoriasis .................................................................................. 356 Marcial Oquendo, MD; William Abramovits, MD; Peter Morrell, DO

CORE CURRICULUM Virendra N. Sehgal, MD, Section Editor

Pathophysiology of Adverse Cutaneous Drug Reactions—Applied Perceptions: Part II.................................... 373 Virendra N. Sehgal, MD; Prashant Verma, MD; Sambit N. Bhattacharya, MD

DEPARTMENTS PERILS OF DERMATOPATHOLOGY W. Clark Lambert, MD, PhD, Section Editor On Bossing: Taking Charge Without The Facts .............................................................................................. 385 Cindy Wassef, BA; Cristian Serna-Tamayo, BS; Patrick McDonough, BA; Gizem Tumer, MD; W. Clark Lambert, MD, PhD

HISTORY OF DERMATOLOGY SOCIETY NEWSLETTER Eve J. Lowenstein, MD, PhD, Section Editor

Mosquito Wars: Malaria and Bioterrorism in Italy, 1943–1945 ...................................................................... 388 Frank M. Snowden, PhD

CASE STUDIES Vesna Petronic-Rosic, MD, MSc, Section Editor

Radiation Port Erythema Multiforme: Erythema Multiforme Localized to the Radiation Port in a Patient With Non–Small Cell Lung Cancer.............................................................................................. 390 Hubert M. Chodkiewicz, MD; Philip R. Cohen, MD

Cladosporium Scalp Infection ...................................................................................................................... 393 Erwin Eduardo Argueta Sosa, MD; Philip R. Cohen, MD; Jaime A. Tschen, MD

329


TABLE OF CONTENTS /PWFNCFS%FDFNCFSt7PMVNFt*TTVF Metastatic Melanoma From an Unknown Primary Site Presenting as Skin-Colored Nodules and Multiple Visceral Involvement ...................................................................................................................... 396 Sudip Kumar Ghosh, MD, DNB; Debabrata Bandyopadhyay, MD; Kuntal Deb Barma, MBBS; Swapnendu Basu, MD; Amit Roy, MS

BOOK REVIEW Jennifer L. Parish, MD, Section Editor

ACS(I) Textbook on Cutaneous and Aesthetic Surgery................................................................................... 401

ABOUT OUR JOURNAL SKINmed: Dermatology for the Clinician® QSJOU*44/ POMJOF *44/ JTQVCMJTIFECJNPOUIMZCZ1VMTF.BSLFUJOH$PNNVOJDBUJPOT --$ MPDBUFEBU1FOJOTVMB"WFOVF 4FB#SJHIU /+

Editorial MANAGING EDITOR %IBZBOJEIJ,BSVOBOJEIJ TLJONFE!EJBDSJUFDIDPN

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November/December 2012

EDITORIAL BOARD

EDITOR IN CHIEF

Lawrence Charles Parish, MD, MD (Hon) Philadelphia, PA

DEPUTY EDITORS William Abramovits, MD Dallas, TX

W. Clark Lambert, MD, PhD Newark, NJ

Larry E. Millikan, MD Meridian, MS

Vesna Petronic-Rosic, MD, MSc Chicago, IL

Marcia Ramos-e-Silva, MD, PhD Rio de Janeiro, Brazil

Jennifer L. Parish, MD Philadelphia, PA

EDITORIAL BOARD Mohamed Amer, MD Cairo, Egypt

Howard A. Epstein, PhD Philadelphia, PA

Jasna Lipozencic, MD, PhD Zagreb, Croatia

Noah S. Scheinfeld, MD, JD New York, NY

Robert L. Baran, MD Cannes, France

Ibrahim Hassan Galadari, MD, PhD, FRCP Dubai, United Arab Emirates

Eve J. Lowenstein, MD, PhD New York, NY

Virendra N. Sehgal, MD Delhi, India

Anthony V. Benedetto, DO Philadelphia, PA

Anthony A. Gaspari, MD Baltimore, MD

George M. Martin, MD Kihei, HI

Riccarda Serri, MD Milan, Italy

Brian Berman, MD, PhD Miami, FL

Michael Geiges, MD Zurich, Switzerland

Marc S. Micozzi, MD, PhD Rockport, MA

Charles Steffen, MD Oceanside, CA

Jack M. Bernstein, MD Dayton, OH

Michael H. Gold, MD Nashville, TN

George F. Murphy, MD Boston, MA

Alexander J. Stratigos, MD Athens, Greece

Sarah Brenner, MD Tel Aviv, Israel

Lowell A. Goldsmith, MD, MPH Chapel Hill, NC

Oumeish Youssef Oumeish, MD, FRCP Amman, Jordan

James S. Studdiford III, MD Philadelphia, PA

Joaquin Calap Calatayud, MD Cadiz, Spain

Aditya K. Gupta, MD, PhD, FRCP(C) London, Ontario, Canada

Joseph L. Pace, MD, FRCP Naxxar, Malta

Robert J. Thomsen, MD Los Alamos, NM

Henry H.L. Chan, MB, MD, PhD, FRCP Hong Kong, China

Seung-Kyung Hann, MD, PhD Seoul, Korea

Art Papier, MD Rochester, NY

Julian Trevino, MD Dayton, OH

Noah Craft, MD, PhD, DTMH Torrance, CA

Roderick J. Hay, BCh, DM, FRCP, FRCPath London, UK

Johannes Ring, MD, DPhil Munich, Germany

Snejina Vassileva, MD, PhD Sofia, Bulgaria

Ncoza C. Dlova, MBChB, FCDerm Durban, South Africa

Tanya R. Humphreys, MD Philadelphia, PA

Roy S. Rogers III, MD Rochester, MN

Daniel Wallach, MD Paris, France

Richard L. Dobson, MD Mt Pleasant, SC

Camila K. Janniger, MD Englewood, NJ

Donald Rudikoff, MD New York, NY

Michael A. Waugh, MB, FRCP Leeds, UK

William H. Eaglstein, MD Palo Alto, CA

Abdul-Ghani Kibbi, MD Beirut, Lebanon

Robert I. Rudolph, MD Wyomissing, PA

Wm. Philip Werschler, MD Spokane, WA

Boni E. Elewski, MD Birmingham, AL

Andrew P. Lazar, MD Livermore, California

Vincenzo Ruocco, MD Naples, Italy

Joseph A. Witkowski, MD Philadelphia, PA

Charles N. Ellis, MD Ann Arbor, MI

Ronni Wolf, MD Rechovot, Israel

332


7PMVNFt*TTVF

November/December 2012

EDITORIAL

Hair Then and Now Michael Joseph Lavery, MB BCh BAO;1 Lawrence Charles Parish, MD, MD (Hon)2 You can’t part the skin of a sausage, Or a dad from his fond son and heir. And you can’t part the hair on a bald-headed man, For there’ll be no parting there1

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From the Department of Medicine, Mater Infirmorum Hospital, Belfast, Northern Ireland;1 and Department of Dermatology and Cutaneous Biology and the Jefferson Center for International Dermatology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA2 Address for Correspondence: Lawrence Charles Parish, MD, MD (Hon), 1760 Market Street, Suite 301, Philadelphia, PA 19103 tE-mail: larryderm@yahoo.com

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*OEFFE UIF8FTU&OEBOE#SPBEXBZIBWFTFFONBOZQSPEVDREFERENCES UJPOT SFWPMWJOH BSPVOE IBJS 3PEHFS BOE )BNNFSTUFJOT South 1 McDonald P. Oxford dictionary of medical quotations. Oxford, England; PaciďŹ cJODMVEFTBTPOHBCPVUBHJSMXBOUJOHUPiXBTIUIBUNBO Oxford University Press. 2004:10. SJHIU PVUUB NZ IBJSw .PSF DPOUSPWFSTJBMMZ  UIF NVTJDBM Hair 2 Cox JS. The construction of an Ancient Egyptian wig (c. 1400 B.C.) in the DPNFT UP NJOE BT B QSPUFTU BHBJOTU BVUIPSJUZ *O NPSF SFDFOU British Museum. J Egyptian Archaeol. 1977;63:67–70. 3 Twain M. A Connecticut Yankee in King Arthur’s Court. 1889. UJNFT UIFBEWFOUPGIBJSUSBOTQMBOUTBOEUIFVTFPGUPQJDBMNJONew  York, NY. http://www.twainquotes.com/Redheads.html Accessed PYJEBMBOEPSBMmOBTUFSJEFIBWFBEESFTTFEUIFDPODFSOTPGSFDFESeptember 23, 2012. JOHIBJSMJOFT 4 Olson K. Dress and the Roman Women: Self-Presentation and Society. London, England: Routledge; 2008:71.

I’m not really bald, I’m a hair donor.9 I bought a book on hair loss and the pages kept falling out.10 8IJMFUIF"NFSJDBOXSJUFS4BN&XJOHDPNNFOUFE Ination is when you pay ďŹ fteen dollars for the ten-dollar haircut you used to get for ďŹ ve dollars when you had hair.11 CONCLUSIONS 4FBO $POOFSZ BQQBSFOUMZ CFHBO MPTJOH IJT IBJS XIFO BHFE  BOE XPSF XJHT GPS FBDI PG UIF +BNFT #POE NPWJFT IPXFWFS  IFXBTDPOUFOUXJUIIJTJNBHF)FXBTFWFOTFFOQSJWBUFMZBOE JONPTUPUIFSmMNTHPJOHCBME"TXFDPNFUPUIFFOEPGUIJT

5

Olson K. Dress and the Roman Women: Self-Presentation and Society. London, England: Routledge; 2008:74.

6

Sherrow V. Encyclopedia of Hair: A Cultural History. Greenwood Press: Westport, CT; 2006:320.

7

Corson R. Fashions in Hair: The First Five Thousand Years. 8th ed. London, England: Peter Owen Limited; 2001:21.

8

Latham R, Matthews WG. The Diary of Samuel Pepys: Volume X - Companion. London, England: Harper Collins; 2010:10–100.

9

Byrne R. The 2,548 Wittiest Things Anybody Ever Said. New York, NY: Simon & Schuster; 2012: Quote 978.

10 Byrne R. The 2,548 Wittiest Things Anybody Ever Said. New York, NY: Simon & Schuster; 2012: Quote 984. 11 Twibell D. Protecting your portfolio against rising inflation. Denver Business Journal. 2012. Accessed 09/23/2012. http://www.bizjournals. com/denver/print-edition/2012/08/03/protecting-your-portfolioagainst.html.

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Volume 10 • Issue 6

COMMENTARY

Female Pattern Hair Loss Amit Sharma, BA; Laurie Dabaghian, BA; W. Clark Lambert, MD, PhD

T

he accompanying article1 comprehensively reviews the important topic of androgenic alopecia in the female population. Female pattern hair loss affects millions of individuals worldwide and has significant psychosocial consequences. Although there has been considerable investigation into the development of male pattern hair loss, it is only recently that there has been a growing interest in understanding female pattern hair loss and its similarities and differences to its male counterpart.

The authors accurately describe the normal physiology of hair growth and cycle and relate how disruption leads to androgenetic alopecia. The authors mention a possible genetic involvement in pattern hair loss. It is noteworthy that in addition to the cited studies concerning the mutations in the metabolism gene CYP 17 and 17-alpha-hydroxylase, there has been ongoing investigation into the polymorphism of the androgen receptor (AR), especially in regards to the trinucleotide repeat found in the gene. The AR gene is on the X chromosome and has an amino terminus with CAG repeats. The number of CAG repeats differs from individual to individual. It is thought that the more CAG repeats in the AR gene, the less the gene is expressed. Moreover, the expansion of this trinucleotide repeat has been found to be present in patients with polycystic ovarian syndrome, hirsuitism, and acne.2,3 An initial study concluded that there is an inverse relationship between the number of repeats and androgen levels. Moreover, a reduced triplet length was found to be prevalent among balding men.4 The authors thoroughly discuss the diagnostic methods for pattern hair loss. Although diagnosis of androgenic alopecia is mostly clinical, there has been a surge in newer technologies, such as dermoscopy, that aid in characterizing the condition. With the recent findings concerning the CAG triplet repeats in the androgen receptor gene, tests are becoming available that assess the risk of developing pattern hair loss based on triplet length. It is reported that 97.3% of women with a CAG length of ≤15 develop either Ludwig II or III grade hair loss.5 A current Hair Genetic Test examines 8 variants of the AR gene. One important variant is known as rs6152.

The positive and negative predictive values for the test detecting this variant are both 70%.5 The changes associated with the development and progression of androgenetic alopecia are complex. Histological examination provides apparent changes associated with the development of pattern hair loss but is limited by the small sample size examined on a punch biopsy. This may prove amenable to special types of histological investigation, such as creation of histological images using ultrasound, perhaps incorporating new developments such as recently developed high frequency sonography,6 which could potentially provide diagnostic images of large areas without removal of tissue. An additional exciting prospect would be to investigate the chemical changes that occur with hair growth, aging, and disease. Raman spectroscopy is an innovative optical technology that provides a rapid chemical analysis of tissue in vivo. By measuring the inelastic interactions of light with matter, Raman spectroscopy can accurately determine the chemical composition of a sample. Polarized Raman microspectroscopy has been applied to study the composition of human hair shafts, characterizing the structural variations of keratin.7 Raman spectra of bleached hair, when compared with normal hair, confirm changes in keratotic disulfide bonds.8,9 Moreover, the technology has been applied to study diagnostic changes in trichothiodystrophy. Using biochemical and electron microscopy techniques, it has been demonstrated that trichothiodystrophic hair has reduced cysteine content compared with normal hair.10 Raman spectra of trichothiodystrophic hair evidences alteration of molecular structure of the sulfur-rich proteins, leading to fragility and brittleness.11 It would be of value to investigate biochemical changes that occur with androgenic alopecia. Such chemical characterization of disease may help in screening, diagnosing, and selecting therapy. CONCLUSIONS Pattern hair loss is a stressful condition that the physician must recognize and treat appropriately. The authors of this paper systematically discuss the intricacies of normal and abnormal hair development. In recent years, much has been revealed regarding

From the Department of Dermatology, New Jersey Medical School, Newark, NJ Address for Correspondence: W. Clark Lambert, MD, PhD, Room H576 Medical Science Building, UMDNJ-New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07103 • E-mail: lamberwc@umdnj.edu

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the pathogenesis of androgenetic alopecia at the molecular level; yet, the disruption of the hair cycle and aberrations in signaling events that lead to the development and progression of pattern hair loss are not fully understood. With future investigations into the development and diagnosis of androgenic alopecia, it should be possible to design more specific therapies and drug regimens.

5

Schweiger E, Boychenko O, Bernstein R. Update on the pathogenesis, genetics and medical treatment of patterned hair loss. J Drugs Dermatol. 2010;9:1412.

6

Hayashi K, Koga H, Uhara H, Saida T. High-frequency 30-MHz sonography in preoperative assessment of tumor thickness of primary melanoma: usefulness in determination of surgical margin and indication for sentinel lymph node biopsy. Int J Clin Oncol. 2009;14: 426–430.

7

Ackermann K, Koster J, Schlücker S. Polarized Raman microspectroscopy on intact human hair. J Biophotonics. 2008;1:419–424.

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8

Gniadecka M, Nielsen O, Christensen D, Wulf H. Structure of water, proteins, and lipids in intact human skin, hair, and nail. J Invest Dermatol. 1998;110:393–398.

9

Akhtar W, Edwards H, Farwell D, Nutbrown M. Fourier-transform Raman spectroscopic study of human hair. Spectrochim Acta A Mol Biomol Spectrosc. 1997;53:1021–1031.

1

Sehgal VN, Srivastava G, Aggarwal AK, Midha R. Hair biology and its comprehensive sequence in female pattern baldness: diagnosis and treatment modalities—part I. SKINmed. 2012.

2

Pugeat M, Nicolas MH, Craves JC, et al. Androgens in polycystic ovarian syndrome. Ann NY Acad Sci. 1993;687:124–135.

3

Futterweit W. Polycystic ovary syndrome: clinical perspectives and management. Obstet Gynecol. 1999;54:403.

10 Itin P, Sarasin A, Pittelkow M. Trichothiodystrophy: update on the sulfur-deficient brittle hair syndromes. J Am Acad Dermatol. 2001; 44:891–920.

4

Ellis JA, Stebbing M, Harrap SB. Polymorphism of the androgen receptor gene is associated with male pattern baldness. J Invest Dermatol. 2001;116:452–455.

11 Liang C, Morris A, Schlücker S, et al. Structural and molecular hair abnormalities in trichothiodystrophy. J Invest Dermatol. 2006;126: 2210–2216.

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COMMENTARY

Striae Distensae: The Fibrillin/Transforming Growth Factor β Signaling Puzzle Davi de Lacerda, MD

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From Clin. Med. Dr. Davi de Lacerda, Av. Angélica, 2530 Cj 46, São Paulo, Brazil Address for Correspondence: Davi de Lacerda, MD, Clin. Med. Dr. Davi de Lacerda, Av. Angélica, 2530 Cj 46, São Paulo – SP 01228-200 #SB[JMt&NBJMEMBDFSEB!VTQCS

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Figure 1. Typical red striae distensae that appeared during pregnancy.

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diagnostic value of striae. J Am Acad Dermatol. 201;64: 290–295.

Figure 3. )JTUPMPHZ IFNBUPYZMJOBOEFPTJO PSJHJOBMNBHOJĂĽDBUJPO x20) of striae distensae demonstrating fragmented collagen from the same patient as that shown in Figure 2.

REFERENCES 1

7JFOOFU$ #SJEF+ "SNCSVTUFS7 FUBM$POUSBDUJMFGPSDFTHFOFSBUFECZTUSJBFEJTUFOTBFüCSPCMBTUTFNCFEEFEJODPMMBHFOMBUtices. Arch Dermatol Res. 2005;297:10–17.

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Agache P. Mechanical factors in striae distensae. In: Morettig ( 3FCPSB" FETStria Distensae. Milan, Italy: Brocades; 1976: 87–96.

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Ledoux M, Beauchet A, Fermanian C, et al. A case-control study of cutaneous signs in adult patients with Marfan disease:

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3PCFSUTPO* +FOTFO4 )BOEGPSE15#EPNBJOQSPUFJOTFWPMVUJPOBSZJOTJHIUTJOUPUIFNVMUJGBDFUFESPMFTPGüCSJMMJOTBOE-5#1T Biochem J. 2010;433:263–276.

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3BHIVOBUI. 6OTÚME$ ,VCJUTDIFDL65IFDVUBOFPVTNJDSPüCSJMMBSBQQBSBUVTDPOUBJOTMBUFOUUSBOTGPSNJOHHSPXUIGBDUPSCFUB CJOEJOH QSPUFJO -5#1  BOE JT B SFQPTJUPSZ GPS MBUFOU 5(' CFUBJ Invest Dermatol. 1998;111:559–564.

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0MJWJFSJ+ 4NBMEPOF4 3BNJSF[''JCSJMMJOBTTFNCMJFTFYUSBDFMMVMBSEFUFSNJOBOUTPGUJTTVFGPSNBUJPOBOEüCSPTJTFibrogenesis Tissue Repair. 2010;3:24–31.

9

Leivo T, Arjomaa P, Oivula J, et al. Differential modulation of transGPSNJOHHSPXUIGBDUPSCFUBCZCFUBNFUIBTPOFWBMFSBUFBOE isotretinoin: corticosteroid decreases and isotretinoin increases UIF MFWFM PG USBOTGPSNJOH HSPXUI GBDUPSCFUB JO TVDUJPO CMJTUFS fluid. Skin Pharmacol Appl Skin Physiol. 2000;13:150–156.

10 #BSOFUU$1 $IJUBZBU% #SBEMFZ5+ 8BOH: )JOFL"%FYBNFUIBTPOFOPSNBMJ[FTBCFSSBOUFMBTUJDüCFSQSPEVDUJPOBOEDPMMBHFO  TFDSFUJPO CZ -PFZT%JFU[ TZOESPNF üCSPCMBTUT B QPTTJCMF treatment? Eur J Hum Genet. 2011;19:624–633. 11 8BUTPO3& $SBWFO/. ,BOH4 FUBM"TIPSUUFSNTDSFFOJOH QSPUPDPM VTJOHüCSJMMJOBTBSFQPSUFSNPMFDVMF GPSQIPUPBHJOH repair agents. J Invest Dermatol. 2001;116:672–678. 12 ,JTTJO&: -FNBJSF3 ,PSO+) -BGZBUJT35SBOTGPSNJOHHSPXUI factor β JOEVDFT üCSPCMBTU üCSJMJO NBUSJY GPSNBUJPO Arthritis Rheum. 2002;46:3000-3009. 13 )JSBJ .  )PSJHVDIJ .  0ICBZBTIJ 5  FU BM -BUFOU 5('βCJEJOH QSPUFJO  CJOET UP %"/$&üCVMJO BOE SFHVMBUFT FMBTUJD üCFS BTTFNCMZEMBO J. 2007;26:3283–3295. 14 /BLBNVSB 5  -P[BOP 13  *LFEB :  FU BM 'JCVMJO%"/$& JT essential for elastogenesis in vivo. Nature. 2002;417:171–175. 15 :BOBHJTBXB) %BWJT&$ 4UBSDIFS#$ FUBM'JCVMJOJTBOFMBTUJOCJEJOHQSPUFJOFTTFOUJBMGPSFMBTUJDüCSFEFWFMPQNFOUJOWJWP Nature. 2002;415:168–171.

VINTAGE LABEL

$PVSUFTZPG#VZ&OMBSHF 1IJMBEFMQIJB 1" SKINmed. 2012;10:338–340

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ORIGINAL CONTRIBUTION

Hair Care Practices in Diverse Populations: What Makes the Difference? Jeaneen Chappell, MD; Eric Armbrecht, PhD; Sara Jensen, MD ABSTRACT ɨJTTUVEZFYBNJOFTXIFUIFSTPDJPEFNPHSBQIJDGBDUPSTBOEPSIBJSBUUSJCVUFTBSFCFUUFSQSFEJDUPSTPGIBJSXBTIGSFRVFODZ"UPUBMPG QBUJFOUTXFSFSFDSVJUFEGSPNUIFHFOFSBMEFSNBUPMPHZPVUQBUJFOUDMJOJDUPDPNQMFUFBOJUFNRVFTUJPOOBJSFCZTFMGSFQPSUɨSFFMJOFBS SFHSFTTJPONPEFMTXFSFDPOTUSVDUFEBOEDPNQBSFEUPEFUFSNJOFXIFUIFSTPDJPEFNPHSBQIJDGBDUPST IBJSXBTIGSFRVFODZ PSBDPNCJOBUJPO PGUIFUXPXPVMECFTUQSFEJDUXBTIGSFRVFODZ3FTVMUTTIPXFEUIBUTPDJPEFNPHSBQIJDGBDUPST TQFDJmDBMMZSBDF TFY BOEBHFHSPVQ BSFBMM CFUUFSQSFEJDUPSTPGIBJSXBTIGSFRVFODZUIBOIBJSBUUSJCVUFTTVDIBTIBJSUZQF UFYUVSF MFOHUI BOETDBMQUZQF BEKVTUFER 2WT  SFTQFDUJWFMZ  SKINmed.o

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From the Department of Dermatology, Saint Louis University School of Medicine, Saint Louis, MO Address for Correspoindence: Jeaneen Chappell, MD, Saint Louis University School of Medicine, Department of Dermatology, 1402 South (SBOE#PVMFWBSE 4U-PVJT .0t&NBJMKDIBQQF!TMVFEV

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Department of Dermatology

Hair Care Survey 1. What is your age?

__________

2. What is your gender?

Male________

Female________

3. What is your ethnicity? Non-Hispanic________

Hispanic________

4. What is your race? Black________

White________

Hispanic_________

Native American________

Asian________

Other (please explain) _____________________________

5. What is your natural hair color? Brown________

Black________

Blonde________

Red________

Gray________

6. What is your hair texture? Fine________

Coarse________

7. Is your hair either? (check all that apply) Straight________

Curly________

Wavy________

Oily________

Neither________

Thin________

Normal________

8. Is your hair usually? Dry________

Combination________

9. Is your hair? Thick________

10. What is your hair length? Short________

Medium________

Long________

11. What is your average styling time after washing your hair? £5 min_______ 6–10 min________ 11–20 min________ 21–30 min________ >30 min________ 12. Do you oil your scalp? (If yes include what product you are currently using) Yes_________________________________

No________

13. How often do you wash your hair? (please enter a number in appropriate spot) _______ times/week

_______ times/month

Other________________________________________ 14. Who washes your hair? Yourself________

Hairdresser________

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November/December 2012 15. Do you currently color your hair? Yes________

No________

16. Do you currently have any of the following? Perm________

Relaxer________

Braids________ None________

Texturizer________

Jheri curl________

S curl________

Other_____________________________

17. Do you have dandruff/ямВaky scalp? (If yes, continue to questions below) Yes________

No________

18. Are you currently being treated for seborrheic dermatitis (i.e. dandruff) by a doctor? (If yes include the most recent treatment) Yes________

No________

Medication: ________________________________

Strength___________

Medication: ________________________________

Strength___________

Frequency of use______________________________ 19. If you are currently being treated for seborrheic dermatitis, how satisямБed are you with your current treatment? Very much________

Very________

Somewhat________

A little________

Not at all_________ 20. If you are currently being treated for seborrheic dermatitis, were you ever asked about your hair care practices by your physician? Yes________

No________

Figure 1. 4BNQMFPGUIFJUFNIBJSDBSFTVSWFZ

WBSJBCMFT SBDF P TFY P BOEBHFHSPVQ P   SFTVMUFEJOTUBUJTUJDBMTJHOJmDBODF╔иFTUBOEBSEJ[FEbDPF─ЛDJFOU XFSF o BOEGPSSBDF BHF BOETFY SFTQFDUJWFMZ "TPCTFSWFEJOUIF4%'POMZNPEFM SBDFDPOUSJCVUFEBMNPTU UJNFTUIFBNPVOUPGBOZPUIFSWBSJBCMFJOUIF)" 4%'NPEFM /POFPGUIF)"TXFSFTUBUJTUJDBMMZTJHOJmDBOUQSFEJDUPSTPGXBTI GSFRVFODZJOUIF)" 4%'NPEFM

RESULTS

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343

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November/December 2012

Table. Demographic Characteristics and Hair Attributes of Study Participants (N=96)

7

AFRICAN CAUCASIAN AMERICAN

Actual Wash Hair Times Per Week

6

n=59

P VALUE

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DEMOGRAPHIC CHARACTERISTICS 4

3

HAIR ATTRIBUTES

2

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0 0.0

1.0

2.0

3.0 4.0 Predicted Value

5.0

6.0

7.0

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Figure 2. Sociodemographic factor linear regression model (95% confidence interval, lines; R2=0.59)



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7

6 Actual Wash Hair Times Per Week

n=37

5

5



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4

3



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2

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3.0 4.0 Predicted Value

5.0

6.0



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7.0

Figure 3. Hair attributes plus sociodemographic factors linear regression model (95% confidence interval, lines; R2=0.59)

$IFNJDBM1SPDFTT 3FMBYFS



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344

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November/December 2012

$IFNJDBMSFMBYFST BTUSBJHIUFOJOHUFDIOJRVFDPNNPOBNPOH "GSJDBO "NFSJDBOT BT ZPVOH BT  UP  ZFBST  VTF TPEJVN  QPUBTTJVN MJUIJVN PSHVBOJEJOFIZESPYJEFTUPDMFBWFDZTUFJOFEJTVMmEFCPOETJOUIFIBJST XIJDISFTVMUTJOBTPGUFSDVSM QBUUFSO"MUIPVHIUIFJSVTFXBTSFQPSUFECZPG"GSJDBO "NFSJDBO SFTQPOEFOUT  JU XBT OPU BTTPDJBUFE XJUI BO FĊFDU PO 8' *OUFSFTUJOHMZ  BMUIPVHI DVSMZ IBJS UZQF XBT UIF CFTU QSFEJDUPS PG 8' BNPOH UIF )"T UFTUFE  UIFTF BUUSJCVUFT JO HFOFSBM XFSF UIF QPPSFTU QSFEJDUPST PG 8' BOE ZJFMEFE UIF MPXFTUBEKVTUFER2PGBMMUIFNPEFMTUFTUFE WT )" BMTP EJE OPU DPOUSJCVUF BOZ TUBUJTUJDBMMZ TJHOJmDBOU WBSJBCMFT UPUIF)" 4%'NPEFMɨJTTVHHFTUTUIBU8' BOEQPTTJCMZ PUIFSIBJSDBSFQSBDUJDFT XFSFNPSFEFQFOEFOUPOFUIOJDJUZ  TFY BOETPDJBMPSDVMUVSBMOPSNTSBUIFSUIBOUIFBUUSJCVUFTPG UIFIBJSJUTFMG

7

Actual Wash Hair Times Per Week

6

5

4

3

2

1

0

"T QBUJFOU QPQVMBUJPOT CFDPNF JODSFBTJOHMZ NVMUJDVMUVSBM BOE QIFOPUZQFT CFDPNF MFTT TUFSFPUZQJDBM  JU XJMM CF JNQPSUBOU GPS QIZTJDJBOT UP CF FUIOJDBMMZ DPOTDJPVT TJODF IBJS DBSF QSBDUJDFT Figure 4. Hair attributes linear regression model (95% NBZ CF EJDUBUFE NPSF CZ B QBUJFOUT DVMUVSBM CBDLHSPVOE PS confidence interval, lines; R2=0.27) EFNPHSBQIJD BUUSJCVUFT UIBO UIF QIFOPUZQJD BUUSJCVUFT PG UIF IBJS JUTFMG8IFO FWBMVBUJOH QBUJFOUT JO UPUP  TJNVMBUFE CZ UIF ɨJTMFBETUPQIZTJDJBOTBQQMZJOHCSPBEHFOFSBMJ[BUJPOTSFHBSEJOH )" 4%'NPEFM POMZ4%' SBDF TFY BOEBHF BSFSFMJBCMFQSFIBJSDBSFQSBDUJDFTBDSPTTIFUFSPHFOFPVTFUIOJDHSPVQTUIBUNBZ EJDUPSTPG8'4%'BSFUIFSFGPSFUIFNPTUIFMQGVMGBDUPSTUPUBLF OPUOFDFTTBSJMZBQQMZUPJUTNFNCFST0OFPGUIFNPTUDPNNPO JOUP DPOTJEFSBUJPO XIFO TFMFDUJOH B NFEJDBUJPO XIPTF FċDBDZ SBUFMJNJUJOHIBJSDBSFQSBDUJDFTBNPOHEJĊFSFOUDVMUVSFTJT8'4– SFMJFTPO8' #BTFEPOBOUISPQPMPHJDTUVEJFT JUJTXFMMLOPXOUIBUWBSJBCJMJUZ FYJTUTCFUXFFOIBJSTIBQFTBNPOHFUIOJDHSPVQT4PNFBVUIPST LIMITATIONS CSPBEMZEJWJEFUIFTFHSPVQTCBTFEPOFUIOJDPSJHJOSFTVMUJOHJO 3FTVMUTXFSFMJNJUFECZQBUJFOUSFDBMMPG8' GBJMVSFUPNFBTVSFPUIFS UISFFNBJODMBTTJmDBUJPOT"GSJDBO "TJBO BOE$BVDBTJBO0UIFS GBDUPSTUIBUNBZJOnVFODF8' BOEGBJMVSFUPJODMVEFSBDFPUIFSUIBO BVUIPSTSFMZPOTIBQFQBUUFSOEFTDSJQUPSTTVDIBTXBWZ DVSMZ BOE $BVDBTJBOBOE"GSJDBO"NFSJDBOɨJTQBUJFOUTBNQMFESBXOGSPN TUSBJHIUXIJMFPUIFSTVTFBNPSFTDJFOUJmDNFUIPEPGDMBTTJGZJOH BVOJWFSTJUZCBTFEDMJOJDNBZOPUCFSFQSFTFOUBUJWFPGUIFHFOFSBM IBJSUZQFTCBTFEPOGBDUPSTTVDIBTUIFDVSWFEJBNFUFS DVSMJOEFY  QPQVMBUJPO BOE SFTVMUT TIPVME CF HFOFSBMJ[FE XJUI DBVUJPO &WFO BOEOVNCFSPGXBWFTBOEUXJTUT–8"MUIPVHIJUJTJNQPSUBOUUP XJUI JUT MJNJUBUJPOT  UIJT TUVEZ ESBXT BUUFOUJPO UP B DMJOJDBM OFFE HFOFSBUFBSFQSPEVDJCMFNFUIPEPGEJTUJOHVJTIJOHEJĊFSFOUIBJS BNPOHEFSNBUPMPHJTUTUPBTTFTTEFNPHSBQIJDGBDUPSTJOBDVMUVSBMMZ UZQFT GFXTUVEJFTTDJFOUJmDBMMZBEESFTTXIFUIFSUIFTFEJĊFSFODFT TFOTJUJWFBOESFTQFDUGVMNBOOFS JNQBDU8' 0.0

1.0

2.0

3.0 4.0 Predicted value

5.0

6.0

7.0

*O UIJT TUVEZ  "GSJDBO "NFSJDBO XPNFO PMEFS UIBO  XFSF GPVOEUPXBTIUIFJSIBJSUIFMFBTUXIJMF$BVDBTJBONFOCFUXFFO UIFBHFTPGBOEZFBSTXBTIFENPTUPGUFO6TJOHUIF4%' POMZNPEFMUPDPNQBSFUIFTBNFTFYBOEBHFHSPVQBMTPTIPXT BRVBOUJUBUJWFEJĊFSFODFJO8'"GSJDBO"NFSJDBOXPNFOPMEFS UIBOBSFQSFEJDUFEUPXBTIUIFJSIBJSMFTTUIBOPODFBXFFL ZXBTIFTQFSXFFL XIJMF$BVDBTJBOXPNFOPMEFSUIBO ZFBSTBSFQSFEJDUFEUPXBTIUIFJSIBJSBMNPTUUJNFTQFSXFFL Z   XBTIFT QFS XFFL  %FDSFBTFE 8' JT OPU FYDMVTJWF UP UIF BEVMU "GSJDBO "NFSJDBO QPQVMBUJPO *U JT BMTP QSBDUJDFE CZ "GSJDBO"NFSJDBOHJSMT XJUIPGSFTQPOEFOUTJOPOFTUVEZ SFQPSUJOHB8'PGPODFFWFSZUPXFFLT SKINmed. o

CONCLUSIONS )BJSRVBMJUJFT TVDIBTUFYUVSFBOEDVSMJOFTT XFSFPCUBJOFECZ TFMGSFQPSUWJBTVSWFZ*UJTQPTTJCMFUIBUUIFSFJTBDVMUVSBMCJBT JO SFTQPOTFT CFUXFFO $BVDBTJBOT BOE "GSJDBO "NFSJDBOT  CVU UIFSF JT OP FWJEFODF JO UIF SFWJFXFE MJUFSBUVSF PS UIF DMJOJDBM BOESFTFBSDIFYQFSJFODFPGUIFBVUIPSTUIBUBSFTQPOEFOUTDVMUVSFXPVMEBĊFDUSFTQPOTFTSFHBSEJOHIBJSRVBMJUJFT8FCFMJFWF UIFSJTLPGQPTTJCMFDPOGPVOEJOH BUUSJCVUBCMFUPDVMUVSBMCJBT JT TNBMM0VSTUVEZEJEOPUJODPSQPSBUFBOZTQFDJBMNFDIBOJTNUP DPOUSPMPSBTTFTTUIJTCJBTJGQSFTFOU'VUVSFSFTFBSDIJTOFFEFEUP BTTFTTDVMUVSBMCJBTCFUXFFO$BVDBTJBOTBOE"GSJDBO"NFSJDBOT JOTFMGBTTFTTNFOUPGQIZTJDBMBUUSJCVUFTPGIBJS



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November/December 2012 5

REFERENCES 1

#BJMFZ 1  "SSPXTNJUI $  %BSMJOH ,  FU BM " EPVCMFCMJOE SBOEPNJ[FE WFIJDMFDPOUSPMMFEDMJOJDBMUSJBMJOWFTUJHBUJOHUIFFGGFDUPG;O150EPTFPO the scalp vs. antidandruff efficacy and antimycotic activity. Int J Cosmet Sci. 2003;25:183–188.

2

)PVTNBO54 .FMMFO#( 3BQQ43 'MFJTDIFS"#+S 'FMENBO431BUJFOUT with psoriasis prefer solution and foam vehicles: a quantitative assess ment of vehicle preference. Cutis. 2002;70:327–332.

3

(SJNBMU3"QSBDUJDBMHVJEFUPTDBMQEJTPSEFSTJ Investig Dermatol Symp Proc. 2007;12:10–14.

4

McMichael AJ. Hair and scalp disorders in ethnic populations. Dermatol Clin. 2003;2:629–644.

6

7 8

9

2VJOO$3 2VJOO5. ,FMMZ"1)BJSDBSFQSBDUJDFTJO"GSJDBO"NFSJDBO women. Cutis. 2003;72:280–282, 285–289. %FMB.FUUSJF3 4BJOU-�HFS% -PVTTPVBSO( FUBM4IBQFWBSJBCJMJUZBOE classification of human hair: a worldwide approach. Hum Biol. 2007;79:265–281. -PVTTPVBSO( (BSDFM"- -P[BOP* FUBM8PSMEXJEFEJWFSTJUZPGIBJSDVSMJ ness: a new method of assessment. Int J Dermatol. 2007;46 suppl 1:2–6. ,BKJVSB :  8BUBOBCF 4  *UPV 5  FU BM 4USVDUVSBM BOBMZTJT PG IVNBO hair single fibres by scanning microbeam SAXS. J Struct Biol. 2006; 155:438–444. 3VDLFS8SJHIU% (BUIFST3 ,BQLF" +PIOTPO% +PTFQI$-)BJSDBSF practices and their association with scalp and hair disorders in African American girls. J Am Acad Dermatol. 2011;64:253–262.

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Courtesy of BuyEnlarge, Philadelphia, PA SKINmed. o



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ORIGINAL CONTRIBUTION

Topical Acne Treatment With Acetylcysteine: Clinical and Experimental Effects Leopold F. Montes, MD, MS, FRCPC;1,2 Walter H. Wilborn, PhD, MS;2 Carolina M. Montes, MD3 ABSTRACT "NPOH UIF MBSHF WBSJFUZ PG FĊFDUT PG BDFUZMDZTUFJOF  TFWFSBM PG UIFN SFMBUF UP DVUBOFPVT GVODUJPO JO HFOFSBM BOE UP TFCBDFPVTBDUJWJUZJOQBSUJDVMBS%VFUPUIFMBUUFS BTUVEZXBTVOEFSUBLFOUPJOWFTUJHBUFBQPTTJCMFFĊFDUPGUIJTTVCTUBODF JO HSBEF * BDOF "O BOBMZTJT PG UIF EBUB GSPN  QBUJFOUT JO B EPVCMFCMJOE TUVEZ EFNPOTUSBUFE UIBU  BDFUZMDZTUFJOF UPQJDBMHFMJTTJHOJmDBOUMZTVQFSJPSUPQMBDFCP P JOSFEVDJOHDPNFEPDPVOUT$PNQBSBCMFSFTVMUTXFSFPCUBJOFEJOCPUI TFYFTɨJTTUVEZJOEJDBUFTUIBUBDFUZMDZTUFJOFJTBOFĊFDUJWFUIFSBQFVUJDPQUJPOGPSUIFUSFBUNFOUPGNJMEUPNPEFSBUFBDOF SKINmed.o

A

DFUZMDZTUFJOF  PS $5H9NO34   JT UIF NBDF UZMDZTUFJOF EFSJWBUJWF PG -DZTUFJOF  BO BNJOP BDJE UIBUPDDVSTJONBOZQSPUFJOTBOEGSPNXIJDINBZCF PCUBJOFECZIZESPMZTJT"DFUZMBUJPOPGDZTUFJOFQSPEVDFTBDFUZM DZTUFJOF 1BTVCTUBODFXJUIBWBSJFUZPGFĊFDUT2–23 5BCMF* 4PNF PG UIFTF BDUJPOT BSF FJUIFS DVUBOFPVTSFMBUFE12 14–20 PS MJOLFE UP TFCVNGVODUJPO7 8 21

1SFWFOUJPOPGDPOUSBTUNFEJVNoJOEVDFEOFQISPQBUIZ11

ɨVT JUPDDVSSFEUPVTUIBUBTUVEZEJSFDUFEBUFYQMPSJOHBQPT TJCMFFĊFDUPGUPQJDBMBDFUZMDZTUFJOFJOQBUJFOUTXJUIBDOFXPVME CFXPSUIXIJMFɨJTSFQPSUTVNNBSJ[FTUIFSFTVMUTPGTVDIB USJBMQFSGPSNFEPOBEPVCMFCMJOECBTJT

.FMBOPDZUFTIJFMEGSPNPYJEBUJWFEBNBHFBOEEFMBZPGPOTFUPG NFMBOPNB17

1SFWFOUJPOPGDZDMPQIPTQIBNJEFDZUBSBCJOFJOEVDFEBMPQFDJB12 5SFBUNFOUPGBVUJTUJDTQFDUSVNEJTPSEFST13 1SFWFOUJPOPG67MJHIUoJOEVDFEQIPUPBHJOHPGIVNBOTLJOJOWJWP14 1SPUFDUJPOGSPN67#oQSPEVDFETZTUFNJDJNNVOPTVQQSFTTJPO15 1SPUFDUJPOJOIBQUFOJOEVDFEJSSJUBOUBOEDPOUBDUIZQFSTFOTJUJWJUZ SFBDUJPOT

.PEVMBUJPOPGQSPPODPHFOJDPYJEBUJWFTUSFTTJOOFWJ18 *NQSPWFNFOUPGOFPOBUBMJDIUIZPTJT19 5SFBUNFOUPGUSJDIPUJMMPNBOJB20

Table I. Clinical and Experimental Effects of Acetylcysteine

ɨFSBQFVUJDFĊFDUPOUIFTLJOPGTFCPSSIFJDSBUT21 *OIJCJUJPOPGGVOHBMHSPXUI22

.VDPMZTJTUISPVHICSFBLJOHEJTVMmEFCPOETJONVDVT1

&OIBODFNFOUPGXPVOEIFBMJOHUISPVHIQSPNPUJPOPGBOHJPHFOFTJT23

5SFBUNFOUPGQBSBDFUBNPMPWFSEPTFCZJODSFBTJOHHMVUBUIJPOF SFTFSWFT2 5SFBUNFOUPGDISPOJDPCTUSVDUJWFQVMNPOBSZEJTFBTF3

MATERIAL AND METHODS

1SFWFOUJPOPGTDMFSPTJTJONZSJOHPUPNJ[FEUZNQBOJDNFNCSBOF4 3FMJFGJODISPOJDTVQQVSBUJWFPUJUJTNFEJB5 

$IFNPQSPUFDUJPOJOMVOHDBODFSBOEPUIFSGPSNTPGDBODFS *NQSPWFNFOUPG.FJCPNJBNHMBOEGVODUJPO7 5SFBUNFOUPGDISPOJDCMFQIBSJUJT8 5SFBUNFOUPGESZFZFJO4KPHSFOTZOESPNF9 .PEVMBUJPOPGJOnBNNBUJPOJODZTUJDmCSPTJT10

ACETYLCYSTEINE ɨF UPQJDBM QSFQBSBUJPO TUVEJFE XBT B  BDFUZMDZTUFJOF HFM &BDI HSBN PG UIJT DMFBS IZESPQIJMJD HFM DPOUBJOFE BDFUZMDZTUF JOFNHBOEUIFQSFTFSWBUJWFT NFUIZMQBSBCFONHQSPQZM QBSBCFONHBOEEJTPEJVNFEFUBUFNH JOBDMFBSBRVFPVT HFMPGDBSCPYZWJOZMQPMZNFS HMZDFSJOF BOEXBUFSɨFHFMXBT BEKVTUFEUPBQ)PGXJUITPEJVNIZESPYJEF

From the Vitiligo Unit, Buenos Aires, Argentina;1 the Department of Dermatology Research, Structural Research Center, Mobile, AL;2 and Trumbull Laboratories, Germantown, TN3 Address for Correspondence: Leopold F. Montes, MD, MS, FRCPC, Paraguay 2302 (9-A), C1121ABL Buenos Aires, Argentina t&NBJMMFPQPMEPNPOUFT!IPUNBJMDPN

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Table II. General Population Characterization

ACETYLCYSTEINE

PLACEBO

PATIENTS, NO.

PERCENTAGES

PATIENTS, NO.

PERCENTAGES

<13–18





31



19–21

3



3



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17



15





PATIENTS

STATISTICAL METHOD

" UPUBM PG  QBUJFOUT TFFLJOH USFBUNFOU GPS HSBEF * BDOF FOUFSFE UIF TUVEZ 4JYUZmWF QBUJFOUT XFSF USFBUFE XJUI   BDFUZMDZTUFJOFHFM XIJMFQBUJFOUTXFSFUSFBUFEXJUIQMBDFCP UIF WFIJDMF BMPOF XJUIPVU BDFUZMDZTUFJOF  ɨSFF QBUJFOUT JO UIF BDFUZMDZTUFJOFUSFBUFE HSPVQ WPMVOUBSJMZ ESPQQFE PVU PG UIF TUVEZ CFGPSF DPNQMFUJPO ɨF QBUJFOUT EFSNBUPMPHJD BOE HFOFSBMIFBMUIIJTUPSZXBTSFDPSEFEPOBENJTTJPOUPUIFTUVEZ ɨF DIBSBDUFSJTUJDT PG UIF HFOFSBM QPQVMBUJPO BSF TVNNBSJ[FE JO5BCMF**

ɨFMFTJPOEBUBXFSFUSBOTGPSNFEUPMPHBSJUIN CBTF PGUIF DPNFEP DPVOUT BOE FBDI QBUJFOUT SFTQPOTF UP USFBUNFOU XBT EFUFSNJOFEBTUIFSBUFPGDIBOHFJOUIFMPHBSJUINPGUIFDPNFEP DPVOUPWFSUIFUJNFDPVSTFPGUSFBUNFOUɨFDBMDVMBUFEDPFċ DJFOUTXFSFCBTFEPOUIFBDUVBMOVNCFSPGEBZTFMBQTFECFUXFFO UIFTUBSUPGUSFBUNFOUBOEBOZHJWFOPCTFSWBUJPOɨFEBUBXFSF FWBMVBUFE CZ BO BOBMZTJT PG B ¨ UBCMF XJUI VOFRVBM BOE EJT QSPQPSUJPOBUFTVCDMBTTOVNCFST5SFBUNFOUBOETFYFĊFDUTXFSF DBMDVMBUFE BOE UIFJS TJHOJmDBODF EFUFSNJOFE CZ VTJOH UIF 4UV EFOUtTUBUJTUJD

'BDJBMDPNFEPDPVOUTXFSFNBEFQSJPSUPFOUFSJOHUIFTUVEZBOE FWFSZXFFLTGPSXFFLT'PMMPXJOHBQSFUSFBUNFOUEFSNBUP MPHJD FYBNJOBUJPO  QBUJFOUT XFSF BTTJHOFE UP B DPEFE QSPEVDU ɨFBTTJHONFOUTUPUSFBUNFOUXFSFSBOEPNJ[FE CVUTPPSEFSFE UIBUBQQSPYJNBUFMZUXPUIJSETPGUIFQBUJFOUTSFDFJWFEBDFU ZMDZTUFJOFHFMBOEUIFSFNBJOJOHQBUJFOUTUIFWFIJDMFBMPOFɨF EPVCMFCMJOETUVEZXBTDPOEVDUFEXJUIUIFQSPEVDUDPEFCFJOH VOLOPXOUPCPUIUIFQBUJFOUBOEUIFJOWFTUJHBUPS

RESULTS

ɨFSBUFPGSFEVDUJPOJODPNFEPDPVOUTXBTTJHOJmDBOUMZ P  HSFBUFS GPS QBUJFOUT USFBUFE XJUI BDFUZMDZTUFJOF HFM XIFO DPN QBSFEXJUIUIPTFUSFBUFEXJUIQMBDFCP"OFTUJNBUFPGUIFQFS DFOUSFEVDUJPOPGDPNFEPDPVOUTBGUFSXFFLTPGUSFBUNFOUXBT DBMDVMBUFEUPCFGPSNFOUBLJOHBDFUZMDZTUFJOFUIFSBQZ BOE  GPS NFO UBLJOH QMBDFCP ɨF QFSDFOU SFEVDUJPO TREATMENT XBT  GPS XPNFO UBLJOH BDFUZMDZTUFJOF BOE  GPS &BDIQBUJFOUXBTJOTUSVDUFEUPBQQMZUIFQSFQBSBUJPOCZSVCCJOH XPNFOUBLJOHQMBDFCP 5BCMF***  JUUIPSPVHIMZPOUIFFOUJSFGBDFUXJDFEBJMZVOUJMDPNQMFUFQFO FUSBUJPO XBT BDIJFWFE $PODPNJUBOU MPDBM PS TZTUFNJD UIFSBQZ /JOF QFSDFOU PG UIF BDFUZMDZTUFJOFUSFBUFE QBUJFOUT BOE  PG UIF QMBDFCPUSFBUFE QBUJFOUT SFQPSUFE NJME JSSJUBUJPO  QFFMJOH  XBTFYDMVEFE"OPONFEJDBUFETPBQXBTVTFEFYDMVTJWFMZ

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Table III. Comparison of 5% Acetylcysteine Gel vs Placebo for the Treatment of Acnea

MEN

WOMEN

37

28

o

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5% ACETYLCYSTEINE GEL  1BUJFOUT /P  .FBOSBUFPGDIBOHF  3FEVDUJPOBUXFFLT 

PLACEBO  1BUJFOUT /P  .FBOSBUFPGDIBOHF  3FEVDUJPOBUXFFLT 

18



o

o





B

ɨFNFBOEBJMZSBUFPGDIBOHFJODPNFEPDPVOUT MPHDPVOUT BOEBO FTUJNBUFPGUIFQFSDFOUSFEVDUJPOJODPNFEPDPVOUTBUUIFUIXFFL PGUSFBUNFOUBSFDMBTTJmFEBTUPUSFBUNFOUBOETFYPGQBUJFOU8FJHIUFE TFYEJÄ&#x160;FSFODF NBMFoGFNBMF o P 8FJHIUFE USFBUNFOUEJÄ&#x160;FSFODF ESVHoQMBDFCP o P 

ɨF QSFDJTF NFDIBOJTN PG BDUJPO PG UPQJDBM BDFUZMDZTUFJOF JO BDOFSFNBJOTUPCFJOWFTUJHBUFEɨFQPTTJCJMJUZPGBOFÄ&#x160;FDUPO T FCBDFPVT HMBOE TFDSFUJPO XPVME OPU TFFN VOMJLFMZ CFDBVTF  BNPOH UIF WBSJPVT FÄ&#x160;FDUT PG BDFUZMDZTUFJOF 5BCMF *  BO PVU TUBOEJOH PVUDPNF JT UIF JNQSPWFNFOU PG EZTGVODUJPO PG UIF .FJCPNJBNHMBOE 7UIFTFCBDFPVTHMBOEPGUIFFZFMJE3FMBUFE UP UIJT FÄ&#x160;FDU JT UIF FÄ&#x160;FDUJWFOFTT PG BDFUZMDZTUFJOF JO DISPOJD CMFQIBSJUJT8ɨFTUVEZPGBQPTTJCMFFÄ&#x160;FDUPGBDFUZMDZTUFJOFPO UIFTFCBDFPVTHMBOETXPVME UIFSFGPSF CFUIFOFYUMPHJDBMTUFQ *OBEEJUJPO CFDBVTFPGUIFQSFTFODFXJUIJODPNFEPOFTPGDFMMT PG Pityrosporum ovale 24 33 B QPUFOUJBMMZ DPNFEPHFOJD PSHBO JTN 33UIFBOUJGVOHBMBDUJPOPGBDFUZMDZTUFJOF22NBZMJLFXJTFCF QMBZJOHBSPMF CONCLUSIONS

"TUIFTQFDUSVNPGFÄ&#x160;FDUTBOEVTBHFPGBDFUZMDZTUFJOFDPOUJOVF UPFYQBOE BOPUIFSPVUDPNFJTJUTBCJMJUZUPSFEVDFUIFOVNCFS PGDPNFEPOFTJONJMEUPNPEFSBUFBDOF XJUIPVUUIFJSSJUBUJPO PS TMJHIU FYBDFSCBUJPO PG BDOF IPXFWFS  OPOF PG UIF QBUJFOUT QSPEVDFECZPUIFSBDOFUSFBUNFOUTɨJTFYDFMMFOUUPMFSBODFTVH EJTDPOUJOVFEUSFBUNFOUCFDBVTFPGUIFTFSFBDUJPOT HFTUT UIBU BDFUZMDZTUFJOF EFTFSWFT UP BMTP CF UFTUFE JO UIF NPSF TFWFSFGPSNTPGBDOF DISCUSSION $PNFEPOFTBSFUIFFBSMJFTU OPOJOGMBNNBUPSZ MFTJPOTPGBDOF Acknowledgment: Harold W. Hermann, MD, contributed to the 5XP GPSNT PG DPNFEPOFT24 25 BSF SFDPHOJ[FE UIF DMPTFE DPN preparation of this presentation. FEPBOEUIFPQFODPNFEPɨFDMPTFEDPNFEPJTFOUJSFMZDPW FSFECZBOBMNPTUJOUBDUFQJUIFMJBMMBZFSBOEIBTBNJDSPTDPQJD REFERENCES QPSFɨFPQFODPNFEPEJTQMBZTBEJTDPOUJOVPVTFQJUIFMJBMMBZFS 1 Acetylcysteine. In: Osol A, Pratt R, eds. The United States DisJOUFSSVQUFECZBEJMBUFEPQFOJOHɨFTUVEZPGNBOZDPNFEPOFT pensatory. Philadelphia: JB Lippincott Company; 1973:10. CZUSBOTNJTTJPOBOETDBOOJOHFMFDUSPONJDSPTDPQZSFWFBMFEUIBU 2 Kanter MZ. Comparison of oral and IV acetylcysteine in the treatUIFDPOUFOUPGDPNFEPOFTJTNBEFVQPGTFCVN LFSBUJOJ[FEDFMMT  ment of acetaminophen poisoning. Am J Health System Pharm. IBJST DFMMTPGPropionibacterium acnes BOEZFBTUT24â&#x20AC;&#x201C;298IJMFCBD 2006;6:1821. UFSJBQSPMJGFSBUFNPTUMZJOUIFEFFQFSMBZFSTPGDPNFEPOFT ZFBTUT 3 (SBOEKFBO& #FSUIFU1 3VGGNBO3 FUBM&GĂĽDBDZPGMPOHUFSN acetylcysteine in chronic bronchopulmonary disease: a metaJOIBCJU NBJOMZ UIF TVQFSmDJBM MBZFST30 $MPTFE DPNFEPOFT NBZ analysis of published double-blind, placebo-controlled clinical FJUIFS SFTPMWF PS USBOTGPSN UIFNTFMWFT JOUP PQFO DPNFEPOFT  trials. Clin Therapeut. 2000;22:209â&#x20AC;&#x201C;221. QVTUVMFT PSQBQVMFTɨFTFFWFOUTNBZUBLFQMBDFTQPOUBOFPVTMZ 4 Ozcan C, Gorur K, Cinel L, et al. The inhibitory effect of topical 31 32 PSBTBSFTVMUPGUSFBUNFOUTTVDIBTUPQJDBMUSFUJOPJO $PN N-acetylcysteine application on myringosclerosis in perforated rat FEPOFTIBWFBMTPCFFOFNQMPZFEGPSJOWJUSPBTTBZPGUPQJDBMBDOF tympanic membrane. Int J Ped Otorhinoar. 2002;63:179â&#x20AC;&#x201C;184. USFBUNFOUT27 28 5 0WFTFO 5  'FMEJOH +6  5PNNFSVQ #  FU BM &GGFDU PG N-acetyl*OUIJTTUVEZPGNJMEHSBEF*BDOF POMZDPNFEPOFTXFSFVTFE GPSMFTJPODPVOUT0UIFSMFTJPOTTVDIBTQBQVMFTPSQVTUVMFT JG QSFTFOU  XFSF UPP GFX UP KVTUJGZ DPVOUJOH 8IJMF PVS QBUJFOUT TIPXFESFTPMVUJPOPSPQFOJOHPGDMPTFEDPNFEPOFT BOPUFXPS UIZUSBOTGPSNBUJPOPGDPNFEPOFTJOUPQVTUVMFTPSQBQVMFTXBT OPUPCTFSWFE ɨJTEPVCMFCMJOEDPNQBSJTPOPGBUPQJDBMBDFUZMDZTUFJOFHFM WTUIFWFIJDMFBMPOFSFWFBMFEBTUBUJTUJDBMMZTJHOJmDBOUTVQFSJPSJUZ PGUIFBDUJWFQSFQBSBUJPOPWFSUIFWFIJDMFJOSFEVDJOHUIFOVNCFS PGDPNFEPOFTJOQBUJFOUTXJUIHSBEF*BDOF SKINmed. 2012;10:348â&#x20AC;&#x201C;351

350

cysteine on the incidence and recurrence of otitis media with effusion and re-insertion of ventilation tubes. Acta Otolaryngol Suppl. 2000;543:79â&#x20AC;&#x201C;81. 6

van Zandwijk N. N-acetylcysteine for lung cancer prevention. Chest. 1995;107:1437â&#x20AC;&#x201C;1441.

7

"LZZPM4BMNBO *  "[J[J 4  .VNDV 6  FU BM &GĂĽDBDZ PG UPQJDBM N-acetylcysteine in the treatment of Meibomiam gland dysfunction. J Ocul Pharm Therapeut. 2010;26:329â&#x20AC;&#x201C;333.

8

:BMDJO &  "MUJO '  $JOIVTFZJOPHMVF '  FU BM N-acetylcysteine in chronic blepharitis. Cornea. 2002;21:164â&#x20AC;&#x201C;168.

9

Williamson J, Doig WM, Forrester JV, et al. Management of the dry eye in Sjogrenâ&#x20AC;&#x2122;s syndrome. Brit J Ophthal. 1974;58:798.

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November/December 2012 10 Tirouvanziam R, Conrad CK, Bottiglieri T, et al. High-dose oral N-acetylcysteine, a glutathione prodrug, modulates inflammation JODZTUJDĂĽCSPTJTProc Nat Acad Sc. 2006;103:4628â&#x20AC;&#x201C;4633. 11 .BSFO[J (  "TTBOFMMJ &  .BSBOB *  FU BM N-acetylcysteine and contrast-induced nephropathy in primary angioplasty. N Engl J Med. 2006;354:2773â&#x20AC;&#x201C;2782. 12 Jimenez JJ, Huang HS, Yunis AA. Treatment with ImuVert/N-acetylcysteine protects rats from cyclophosphamide/cytarabineinduced alopecia. Cancer Invest. 1992;10:271â&#x20AC;&#x201C;276. 13 Bradstreet J, Geier DA, Kartzinel JJ. A case-control study of mercury burden in children with autistic spectrum disorders. J Am Phys Surg. 2003;8:76â&#x20AC;&#x201C;79. 14 Kang S, Chung JH, Fisher GT, et al. Topical N-acetylcysteine and genistein prevent ultraviolet light-induced signaling that leads to photoaging in human skin in vitro. J Invest Dermat. 2003;120:835â&#x20AC;&#x201C;841. 15 den Broeke, Gerard MJ. Topically applied N-acetylcysteine as a protector against UVB-induced immunosuppression. J Photochem Photobiol. 1995;27:61â&#x20AC;&#x201C;66. 16 Senaldi G, Pointaire P, Piguet PF, et al. Protective effect of N-acetylcysteine in hapten-induced irritant and contact hypersensitive reactions. J Invest Dermat. 1994;102:934â&#x20AC;&#x201C;937. 17 Cotter MA, Thomas J, Cassidy P. et al. N-acetylcysteine protects melanocytes against oxidative/stress damage and delays onset in ultraviolet-induced melanoma in mice. Clin Cancer Res. 2007;13:5952â&#x20AC;&#x201C;5958. 18 Goodson AG, Cotter MA, Cassidy P, et al. Use of oral acetylcysteine for protection of melanocytic nevi against UV-induced oxidative stress: towards a paradigma for melanoma prevention. Clin Cancer Res. 2009;15:7434â&#x20AC;&#x201C;7440. 19 Sarici SĂ&#x153;, Sahin M, YurdakĂśk M. Topical N-acetylcysteine treatment of neonatal ichthyosis. Turk J Pediatr. 2003;45:245â&#x20AC;&#x201C;247. 20 (SBOU +&  0EMBVH #-  ,JN 48 N-acetylcysteine, a glutamate modulator in the treatment of trichotillomania: a double-blind, placebo controlled study. Arch Gen Psychiatr. 2009;66:756â&#x20AC;&#x201C;763.

21 Laporte G. New anti-seborrheic substances. Am Perfum Cosmetic. 1970;85:47â&#x20AC;&#x201C;51. 22 De Lucca AJ, Walsh TJ, Daigle DJ. N-acetylcysteine inhibits germination of conidia and growth of Aspergillus spp. and Fusarium spp. Antimicrob Agents Chemother. 1996;40: 1274â&#x20AC;&#x201C;1276. 23 "LUVOD &  0[BDNBL 7)  0[BDNBD )4  FU BM N-acetylcysteine promotes angiogenesis and clearance of free oxygen radicals, thus improving wound healing in an alloxan-induced diabetic mouse model of incisional wound. Clin Exp Dermatol. 2010; 35:902â&#x20AC;&#x201C;909. 24 Plewig G, Kligman AM. Acneâ&#x20AC;&#x201C;Morphogenesis and Treatment. Berlin-Heidelberg: Springer Verlag; 1975. 25 Wilborn WH, Hyde BM, Montes LF. Scanning Electron Microscopy of Normal and Abnormal Skin%FFSĂĽFME#FBDI '-7$) Publishers; 1985:127â&#x20AC;&#x201C;135. 26 Wilborn WH, Montes LF. Scanning electron microscopy of comedones. Scan Electron Microsc. 1978;2:253â&#x20AC;&#x201C;258. 27 .POUFT-' 8JMCPSO8) 'MBOBHBO"%&MFDUSPONJDSPTDPQJDBTsay of a topical acne treatment. Benzoyl peroxide acetone gel. Scan Electron Microsc. 1979;3:185â&#x20AC;&#x201C;188. 28 8JMCPSO8) .POUFT-' -ZPOT3& FUBM6MUSBTUSVDUVSBMCBTJTGPS the assay of topical acne treatments. Transmission and scanning electron microscopy of untreated comedones. J Cutan Pathol. 1978;5:165â&#x20AC;&#x201C;183. 29 Montes LF, Wilborn WH. Fine structure of Corynebacterium acnes. J Invest Dermat. 1970;54:338â&#x20AC;&#x201C;345. 30 Montes LF. Acne J C Pathol. 1974;1:230. 31 ,MJHNBO". 'VMUPO+& 1MFXJH(5PQJDBMWJUBNJO"BDJEJOBDOF vulgaris. Arch Dermat. 1969;99:469â&#x20AC;&#x201C;476. 32 Bradford LG, Montes LF. Topical application of vitamin A acid in acne vulgaris. South Med J. 1974;67:683â&#x20AC;&#x201C;687. 33 Weary P. Comedogenic potential of the lipid extract of Pityrosporum ovale. Arch Dermat. 1970;102:84â&#x20AC;&#x201C;91.

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REVIEW

Green Tea in Dermatology Nader Pazyar, MD; Amir Feily, MD; Afshin Kazerouni, MD

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FB JT POF PG UIF NPTU QPQVMBS CFWFSBHFT BSPVOE UIF XPSME ɨF BWFSBHF  DVQT PG UFB DPOTVNFE QFS QFSTPO BOOVBMMZ TIPXT UIBU UFB JT B SBQJEMZ HSPXJOH EJFUBSZTVQQMFNFOUJOUIF6OJUFE4UBUFT5FBDPNFTGSPNUIF QMBOU camellia sinensis  XIPTF DPNQPVOET BSF QPMZQIFOPMT  QPMZTBDDIBSJEFT BNJOPBDJET BOEWJUBNJOT XIJDINBZQSFWFOU NBOZ EJTFBTFT *U JT BWBJMBCMF JO UISFF GPSNT HSFFO  CMBDL  BOE PPMPOH USBEJUJPOBM $IJOFTF UFB 1 2 (SFFO UFB 'JHVSF  IBT CFFO TIPXO UP IBWF BOUJPYJEBOU  BOUJJOnBNNBUPSZ  BOE BOUJDBSDJOPHFOJDBDUJWJUZBOEQPTTFTTFTDBSEJPOFVSPQSPUFDUJWF BDUJWJUZBOEXFJHIUMPTTFĊFDU3

UIJPMT BU IJHI DPODFOUSBUJPOT20 ɨF NBKPS HSFFO UFB DBUFDIJOT JODMVEF o oFQJDBUFDIJO &$  o oFQJDBUFDIJO HBMMBUF &$H  o oFQJHBMMPDBUFDIJO &($  BOE o oFQJHBMMPDBUFDIJO HBMMBUF &($H 21&QJDBUFDIJOHBMMBUF &$( BOEFQJHBMMPDBUFDIJOHBM MBUF &($( BSFUIFNPTUBCVOEBOUDPOTUJVFOUTJOHSFFOUFB22 /PUBCMZ &($(JTUIFNBJOQPMZQIFOPMQSFTFOUJOHSFFOUFBBOE UIFCFTUTUVEJFEDBUFDIJO23ɨFDIFNJDBMGPSNVMBFPGHSFFOUFB DPNQPVOETBSFMJTUFEJOUIF5BCMF246OGPSUVOBUFMZ UIFDMJOJDBM VTFPGHSFFOUFBJTTVQQPSUFENPTUMZCZBOFDEPUBMEBUB"MUIPVHI UIFTF SFQPSUT BSF JOUFSFTUJOH  DPOUSPMMFE USJBMT BSF OFFEFE GPS DPOmSNJOHJUTWBSJPVTDMBJNT

(SFFOUFBFYUSBDUJTNBEFCZMJHIUMZTUFBNJOHBOEESZJOHMFBWFT PG camellia sinensis4 0G OPUF  JO B IJHIUFNQFSBUVSF FOWJSPO NFOU HSFFOUFBJTOPUTUBCMFBOEUIFDIBOHJOHPGJUTJOHSFEJFOUT JTMJLFMZUPPDDVS5 GENERAL USAGE

Table. Chemical Formulae of Green Tea Compounds

COMPOUND

CHEMICAL FORMULA

&$ FQJDBUFDIJO

$)0 

&($ FQJHBMMPDBUFDIJO

$)0 

&$( FQJDBUFDIJOHBMMBUF

$)0M 

(SFFOUFBJTVTFEJODPTNFUJDTBOEJTTVHHFTUFEGPSTMPXJOHPG &($( FQJHBMMPDBUFDIJOHBMMBUF $)0M 

UIFBHJOHQSPDFTTFT 7QSFWFOUJPOPGBWBSJFUZPGNBMJHOBODJFT 8–14 IZQFSUFOTJPO 15 PCFTJUZ  QVMNPOBSZ EJTFBTFT 17–19 BOE NBOZ PUIFS EJTFBTFT 4DJFOUJmD TUVEJFT JOWFTUJHBUJOH UIFTF DMBJNT BSF DERMATOLOGIC APPLICATIONS OF ORAL GREEN TEA GFX BOEUIFNBKPSJUZIBWFOPUCFFOBQQSPWFE ɨFSFIBWFCFFOTPNFBOFDEPUBMSFQPSUTPOUIFVTFPGPSBMHSFFO INGREDIENTS AND MOLECULAR UFBJOUIFUSFBUNFOUPGTZTUFNJDEJTFBTFTVDIBTFTPQIBHFBMTRVB PHARMACOLOGY NPVTDFMMDBSDJOPNB DPMPSFDUBMDBODFS 9 11DFSWJDBMDBSDJOPNB 13 $BUFDIJOT QPMZQIFOPMTEFSJWBUJWFGSPNHSFFOUFBMFBWFT IBWFB QVMNPOBSZ mCSPTJT 17 QVMNPOBSZ UVCFSDVMPTJT 18 DBSEJPWBTDV XJEFSBOHFPGCJPMPHJDBMBDUJWJUJFT BMUIPVHIUIFTQFDJmDNPMFDV MBSEBNBHF 15BOEPUIFSEJTFBTFT CVUXFXFSFPOMZBCMFUPmOE MBSNFDIBOJTNTSFTQPOTJCMFBSFOPULOPXO1PMZQIFOPMTCJOEUP UIF GPMMPXJOH  JO WJWP TUVEJFT GPS UIF TZTUFNJD BQQMJDBUJPO PG NFNCSBOFQIPTQIPMJQJEBOEBSFFBTJMZBVUPPYJEJ[FEUPHFOFSBUF HSFFOUFBJOEFSNBUPMPHJDEJTFBTFT/PLOPXODMJOJDBMUSJBMPGUIF TVQFSPYJEFBOJPOBOETFNJRVJOPOFTɨFZDBOBEEVDUUPQSPUFJO TZTUFNJDBQQMJDBUJPOPGHSFFOUFBXBTGPVOE From the Department of Dermatology, Jahrom University of Medical Sciences, Jahrom, Iran Address for Correspondence: Amir Feily, MD, Motahari Street, Honari Clinic, Department of Dermatology, Jahrom, Iran t&NBJMESGFJMZ!ZBIPPDPN

SKINmed. 2012;10:352–355

352

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ANDROGENETIC ALOPECIA

4UBQIZMPDPDDBM TVQFSBOUJHFOT 4T"HT  IBWF HBJOFE BUUFOUJPO BT POF PG UIF FYBDFSCBUJOH GBDUPST PG BUPQJD EFSNBUJUJT "%  " TUVEZPONJDFEFNPOTUSBUFEUIFJOIJCJUPSZFĊFDUPGUIFHSFFO UFBDBUFDIJOFYUSBDU QPMZQIFOPO BOE&($(POTUBQIZMPDPDDBM FOUFSPUPYJO # 4&#  &($( JOIJCJUT 4&#JOEVDFE JOnBNNB UPSZDZUPLJOFT*OIJCJUJPOPG4T"HJOEVDFE5DFMMBDUJWBUJPOCZ DBUFDIJOJTPCTFSWFEJOCPUIJOWJWPBOEJOWJUSPTUVEJFT TVHHFTU JOHUIBUDBUFDIJONBZCFVTFGVMJOUIFUSFBUNFOUPG"%28

&($(NBZCFVTFGVMJOUIFQSFWFOUJPOPSUSFBUNFOUPGBOESP HFOFUJD BMPQFDJB CZ TFMFDUJWFMZ JOIJCJUJOH αSFEVDUBTF BDUJWJ UJFT&($(QSPNPUFTIBJSHSPXUIJOTDBMQIBJSGPMMJDMFTFYWJWP BOEBDDFMFSBUFTUIFQSPMJGFSBUJPOPGUIFDVMUVSFEIVNBOEFSNBM QBQJMMBDFMMTJOWJWPBOEJOWJUSP34

DERMATOLOGIC APPLICATIONS OF TOPICAL GREEN TEA EXTRACT

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ACNE VULGARIS

&($(IBTNVMUJGBDUPSJBMCFOFmUTBHBJOTUTFCVNQSPEVDUJPO*U PROTECTION AGAINST PUVA JTBTFMFDUJWFJOJCJUPSPGαSFEVDUBTFUZQF*BOEJUSFEVDFTNJDSP " TUVEZ SFWFBMFE UIBU QSFUSFBUNFOU PG IVNBO TLJO XJUI UPQJ DPNFEPOFTJ[FJONJDSPDPNFEPOBMBDOF4JHOJmDBOUSFTVMUTXFSF DBMBQQMJDBUJPOPGNHTUBOEBSEJ[FEHSFFOUFBFYUSBDUQFSDN2 SKINmed. 2012;10:352–355

353

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354

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November/December 2012 21 /BSVLBXB .  /PHB $  6FOP :  FU BM &WBMVBUJPO PG UIF CJUUFSOFTT PG HSFFOùUFBDBUFDIJOTCZBDFMMCBTFEBTTBZXJUIUIFIVNBOCJUUFSUBTUF SFDFQUPS I5"43 Biochem Biophys Res Commun  o 22 -JBOH( 5BOH" -JO9 FUBM(SFFOUFBDBUFDIJOTBVHNFOUUIFBOUJUVNPS BDUJWJUZPGEPYPSVCJDJOJOBOJOWJWPNPVTFNPEFMGPSDIFNPSFTJTUBOUMJWFS DBODFSInt J Oncolo 23 ,àSCJU[ $  )FJTF %  3FENFS 5  FU BM &QJDBUFDIJO HBMMBUF BOE DBUFDIJO HBMMBUF BSF TVQFSJPS UP FQJHBMMPDBUFDIJO HBMMBUF JO HSPXUI TVQQSFTTJPO BOE BOUJJOýBNNBUPSZ BDUJWJUJFT JO QBODSFBUJD UVNPS DFMMT Cancer Sci o 24 .FEJO4*OWFTUJHBUJOHUIFEFHSBEBUJPOSBUFPGFQJDBUFDIJODPNQPVOETJO HSFFOUFBEVSJOHMPOHUFSNTUPSBHFIUUQXXXVXTUPVUFEVDPOUFOU MJCUIFTJTNFEJOTQEG"DDFTTFE+VOF  25 &TGBOEJBSJ" ,FMMZ"15IFFGGFDUTPGUFBQPMZQIFOPMJDDPNQPVOETPOIBJS MPTTBNPOHSPEFOUTJ Natl Med Assoco 26 3VUUFS ,  4FMM %3  'SBTFS /  FU BM (SFFO UFB FYUSBDU TVQQSFTTFT UIF BHFSFMBUFEJODSFBTFJODPMMBHFODSPTTMJOLJOHBOEýVPSFTDFOUQSPEVDUTJO $#-NJDFInt J Vitam Nutr Reso 27 $PPQFS 3  .PSSÏ %+  .PSSÏ %. .FEJDJOBM CFOFåUT PG HSFFO UFB QBSU ** 3FWJFX PG BOUJDBODFS QSPQFSUJFT J Altern Complement Med o 28 )JTBOP .  :BNBHVDIJ ,  *OPVF :  FU BM *OIJCJUPSZ FGGFDU PG DBUFDIJO BHBJOTU UIF TVQFSBOUJHFO TUBQIZMPDPDDBM FOUFSPUPYJO # 4&#  Arch Dermatol Reso 29 .BINPPE5 "LIUBS/ ,IBO#" ,IBO). 4BFFE50VUDPNFTPG HSFFOUFBFNVMTJPOPOTLJOTFCVNQSPEVDUJPOJONBMFWPMVOUFFSTBosn J Basic Med Scio

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VINTAGE LABEL

$PVSUFTZPG#VZ&OMBSHF 1IJMBEFMQIJB 1" SKINmed. 2012;10:352–355

355

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7PMVNFt*TTVF

November/December 2012

REVIEW

Topical Vitamin D Analogs Available to Treat Psoriasis Marcial Oquendo, MD;1 William Abramovits, MD;1,2,3 Peter Morrell, DO4 ABSTRACT 1TPSJBTJTJTBDISPOJDBOEDVSSFOUMZJODVSBCMFJOnBNNBUPSZTLJOEJTFBTF BĊFDUJOHUPPGUIF64QPQVMBUJPOɨFDPTUPGDBSFJO UIF6OJUFE4UBUFTGPSIPTQJUBMJ[BUJPOT PVUQBUJFOUQIZTJDJBOWJTJUT QIPUPUIFSBQZ QSFTDSJQUJPOUIFSBQJFT BOEPWFSUIFDPVOUFSNFEJDBUJPOT JTFTUJNBUFEUPCFNPSFUIBONJMMJPOQFSZFBS(VJEFMJOFTEFWFMPQFECZUIF"NFSJDBO"DBEFNZPG%FSNBUPMPHZJOTUBUFUIBU BQQSPYJNBUFMZPGUIFTFQBUJFOUTXJUIQTPSJBTJTIBWFNJMEUPNPEFSBUFEJTFBTFUIBUDBOCFNBOBHFEXJUIUPQJDBMBHFOUT JODMVEJOHDPSUJDPTUFSPJETBOEWJUBNJO%BOBMPHT5PQJDBMWJUBNJO%BOBMPHTQSPWJEFiTUFSPJETQBSJOHwFĊFDUTBOEBGBWPSBCMFTBGFUZQSPmMF.BOZFYQFSUT  JODMVEJOHBSFDFOUDPOTFOTVTDPOGFSFODF DMBTTJGZUPQJDBMWJUBNJO%BHFOUTBTmSTUMJOFUIFSBQZGPSQTPSJBTJTFJUIFSBTNPOPUIFSBQZPSJO DPNCJOBUJPOXJUIUPQJDBMTUFSPJETEVFUPBTZOFSHJTUJD DPNQMFNFOUBSZFĊFDUJWFOFTT7JUBNJO%BOBMPHTBSFBOJOEJTQFOTBCMFDPNQPOFOU PGUIFDVSSFOUQIZTJDJBOTBSNBNFOUBSJVNGPSQTPSJBTJTUSFBUNFOUɨJTSFWJFX UIFSFGPSF JTPSJFOUFEUPHJWFBDPNQSFIFOTJWFVOEFSTUBOEJOH PGUIJTHSPVQPGESVHTBOEEJTQMBZUIFBWBJMBCMFDMJOJDBMEBUBGPSFBDIGPSNVMBUJPO SKINmedo

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"MUIPVHIUIFFYBDUNFDIBOJTNPGBDUJPOPGWJUBNJO%BOBMPHT JT OPU XFMM VOEFSTUPPE  TUVEJFT EFNPOTUSBUF UIBU UIFJS UPQJDBM BQQMJDBUJPOQSPEVDFTTUBCJMJ[BUJPOPGFQJEFSNBMLFSBUJOPDZUFTCZ CJOEJOHUIFMJHBOEBDUJWBUFEUSBOTDSJQUJPOGBDUPSGPSWJUBNJO%  BDUJWBUJOHUIFUSBOTDSJQUJPOPGHFOFTUIBUJOIJCJUJOUFSMFVLJO *-   *- BOEJOUFSGFSPOHBNNBQSPEVDUJPO *'/γ CZ5DFMMT  BOE SFHVMBUF UIFJS QSPMJGFSBUJPO BOE EJĊFSFOUJBUJPO 5PQJDBM WJUBNJO % XBT TIPXO UP EFDSFBTF UIF OVNCFS PG FQJEFSNBM 5DFMMT OFVUSPQIJMT BOEEFOESJUJD-BOHFSIBOTDFMMTJOQTPSJBUJD (VJEFMJOFTEFWFMPQFECZUIF"NFSJDBO"DBEFNZPG%FSNBUPMPHZ QMBRVFT  ""%  JO  TUBUF UIBU BQQSPYJNBUFMZ  PG QBUJFOUT XJUI QTPSJBTJTIBWFNJMEUPNPEFSBUFEJTFBTFUIBUDBOCFNBOBHFEXJUI CLASS GENERALITIES UPQJDBMBHFOUT3"NPOHUIPTF WJUBNJO%BOBMPHTBOEDPSUJDPTUFPHARMACOLOGY SPJETIBWFUIFNPTUSBOEPNJ[FEDMJOJDBMUSJBMTUPQSPWFFċDBDZ4 7JUBNJO % JT NBEF JO UIF TLJO XIFO EFIZESPDIPMFTUFSPM 7JUBNJO%XBTmSTUVTFEGPSQTPSJBTJTJOPSBMGPSNEVSJOHUIF SFBDUTXJUI67#JOUIFCBTBMDFMMMBZFSBOETUSBUVNTQJOPTVN  T5 ɨF 64 'PPE BOE %SVH "ENJOJTUSBUJPO IBT BQQSPWFE QIPUPDIFNJDBMMZ QSPEVDJOH DIPMFDBMDJGFSPM 8IFUIFS NBEF JO From the Dermatology Treatment & Research Center, Dallas, TX1; Department of Medicine, Baylor University Medical Center, Dallas, TX2; the Departments of Dermatology & Family Practice, University of Texas Southwestern Medical School, Dallas, TX3; and the Dermatology Institute, Duncanville, TX4 Address for Correspondence: Marcial Oquendo, MD, Dermatology Treatment and Research Center. 5310 Harvest Hill Road, Suite 160, %BMMBT 59t&NBJMESPRVFOEP!HNBJMDPN

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3&7*&8

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SUSPENSIONS 4VTQFOTJPOT BSF IFUFSPHFOFPVT NJYUVSFT XJUI VOEJTTPMWFE QBSUJDMFT*OHFOFSBM UIFZTFQBSBUFPOTUBOEJOH"DPNCJOBUJPOPG DBMDJQPUSJFOFCFUBNFUIBTPOFJTBWBJMBCMFJOUIJTQSFTFOUBUJPOBTB DPMPSMFTTUPTMJHIUMZPĊXIJUF BMNPTUDMFBS MJQPQIJMJDTVTQFOTJPO ɨFDBMDJQPUSJFOFDPNQPOFOUJTEJTTPMWFEJOQPMZPYZQSPQZMFOF TUFBSZMFUIFSXIJMFUIFNJDSPOJ[FECFUBNFUIBTPOFJTQBSUMZ TPMWBUFEBOEQBSUMZTVTQFOEFEJOBMJRVJEQBSBċOCBTFUIFSFGPSF  JUNVTUCFTIBLFOCFGPSFVTF

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CONTRAINDICATIONS/WARNINGS

7JUBNJO % BOE JUT BOBMPHT GPS UPQJDBM VTF TIPVME OPU CF VTFE JO QBUJFOUT XJUI LOPXO PS TVTQFDUFE EJTPSEFST PG DBMDJVN NFUBCPMJTN PS IZQFSDBMDFNJB PS FWJEFODF PG WJUBNJO % UPYJDJUZ 1IPUPTFOTJUJWJUZ DBO PDDVS XJUI BMM UIFTF QSPEVDUT "MTP  ɨF VTF PG FBDI NFEJDBUJPO JO UIJT HSPVQ WBSJFT BDDPSEJOH UP QIPUPUIFSBQZJOUIFTFQBUJFOUTTIPVMECFQSBDUJDFEXJUIDBVUJPO UIFWFIJDMFJOXIJDIJUJTQSFTFOUFEɨFDIPJDFPGGPSNVMBUJPO EVFUPJODSFBTFESJTLPGTLJOUVNPSTTFFOJOQSFDMJOJDBMUSJBMTJO DSFBN PJOUNFOU TPMVUJPO TVTQFOTJPO PSGPBN NBZEFQFOEPO NJDF10 11 14 MFTJPOMPDBUJPO1TPSJBTJTPGUFOJOWPMWFTNVMUJQMFCPEZBSFBT IBJS BOEOPOoIBJSCFBSJOH BOENVMUJQMFGPSNVMBUJPOTBSFDPNNPOMZ TOPICAL VITAMIN D ANALOGS QSFTDSJCFEUPBEESFTTTQFDJmDBSFBTɨJTNVMUJQMFWFIJDMFTDFOBSJP #SBOEFE QSFTFOUBUJPOT BWBJMBCMF JO UIF 6OJUFE 4UBUFT JODMVEF NBZMFBEUPEFDSFBTFEDPNQMJBODFBOEJODSFBTFEDPTU12 EPWPOFYDSFBN 4PSJMVYGPBN$BMDJUSJFOF 7FDUJDBM BOE5BDMPOFY PJOUNFOUT%PWPOFYTPMVUJPOBOE5BDMPOFY4DBMQTVTQFOTJPO

OINTMENTS

0JOUNFOUTBSFVTVBMMZPJMCBTFEBOEPODFUIPVHIUUPCFUIFNPTU FĊFDUJWFWFIJDMFGPSQTPSJBTJTCFDBVTFPGJUTPDDMVTJWFOBUVSFBOE NPJTUVSJ[JOHBCJMJUZ0JOUNFOUTTVQFSJPSFĊFDUJWFOFTTIBTCFFO QSPWFO 13 BMUIPVHI OFXFS  NPSF FċDJFOU EFMJWFSZ TZTUFNT BSF OPX BWBJMBCMF 1BUJFOU QSFGFSFODF GPS PJOUNFOU JT UZQJDBMMZ MPX TJODFJUJTHSFBTJFSBOENFTTJFSUIBOPUIFSDIPJDFT$BMDJQPUSJFOF BOE DBMDJUSJPM BOE B DPNCJOBUJPO DBMDJQPUSJFOFCFUBNFUIBTPOF EJQSPQJPOBUFBSFBWBJMBCMFJOUIJTQSFTFOUBUJPO

(FOFSJDWFSTJPOTFYJTUGPSTPNFPGUIFTFGPSNVMBUJPOT

CALCIPOTRIENE

$BMDJQPUSJFOF BT NPOPUIFSBQZ IBT CFFO TIPXO UP JNQSPWF TJHOTBOETZNQUPNTJOBQQSPYJNBUFMZUPPGQBUJFOUT XJUI DISPOJD QMBRVF QTPSJBTJT CFHJOOJOH BGUFS  XFFLT PG UIFSBQZ 10 21 22XJUINBYJNVNFċDBDZBUXFFLTUPQFSCPUI TIPSU BOE MPOHUFSN EBUB " NFUBBOBMZTJT TIPXFE DBMDJQPUSJFOFUPCFBTFĊFDUJWFJOQTPSJBTJTBTCFUBNFUIBTPOFWBMFSBUFBOE CREAMS NPSF FĊFDUJWF UIBO EJUISBOPM  DPBM UBS  BOE UBDBMDJUPM15o "MTP $SFBNTBSFHFOFSBMMZPJMJOXBUFSFNVMTJPOTBOEUFOEUPCFMFTT XIFODPNQBSFEXJUIBOUISBMJO JUGBSFECFUUFSJOUFSNTPGDMJOJHSFBTZ UIBO PJOUNFOUT BOE NPSF BQQFBMJOH DPTNFUJDBMMZ  BMCFJU DBMFċDBDZBOEXBTQSFGFSSFECZQBUJFOUTCFDBVTFJUEJEOPUTUBJO PGUFOMFTTFĊFDUJWF$BMDJQPUSJFOFJTBWBJMBCMFJOUIJTQSFTFOUBUJPO BOEXBTMFTTJSSJUBUJOH1"ESBXCBDLPGDBMDJQPUSJFOFBOEPUIFS SKINmed. o



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3&7*&8

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CALCITRIOL *OTFWFSBMUSJBMT DBMDJUSJPMXBTFĊFDUJWFJOJNQSPWJOHTZNQUPNT PG EJTFBTF JO QBUJFOUT XJUI NJME UP NPEFSBUF QMBRVF QTPSJBTJT 5BCMF* BDIJFWJOHBSFTQPOTFJOBQQSPYJNBUFMZPGQBUJFOUT BOE iDMFBS PS NJOJNBMw JO BQQSPYJNBUFMZ  PG QBUJFOUT23 24 "MUIPVHIIFBEUPIFBEDPNQBSJTPOTPGDBMDJQPUSJFOFBSFTDBSDF  TPNF TUVEJFT TIPX TMJHIUMZ JODSFBTFE FċDBDZ GSPN DBMDJQPUSJFOF 30 BOE PUIFST TIPX DBMDJUSJPM BENJOJTUFSFE UXJDF EBJMZ PWFS BXFFLUSFBUNFOUQFSJPEIBWJOHTJNJMBSFċDBDZUPDBMDJQPUSJFOF EJĊFSFODFXBTOPUTUBUJTUJDBMMZTJHOJmDBOU IPXFWFS XJUIB CFUUFSTBGFUZQSPmMF23

CALCIPOTRIENE/BETAMETHASONE ɨF DPNCJOBUJPO DBMDJQPUSJFOFCFUBNFUIBTPOF IBT CFFO XJEFMZ TUVEJFE JO TFWFSBM MBSHF TUVEJFT  EFNPOTUSBUJOH UIBU UIF

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Table I. Clinical Studies for Calcitriol

STUDY

METHODS

RESULTS/OBSERVATION

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Table II. Clinical Studies for Calcipotriene/Betamethasone

STUDY

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REFERENCES 1

Grace K. Kim, DO. The rationale behind topical vitamin D analogs in the treatment of psoriasis. J Clin Aesthet Dermatol. 2010;3:46â&#x20AC;&#x201C;53.

2

Murphy G, Reich K. In touch with psoriasis: topical treatments and cur rent guidelines. J Eur Acad Dermatol Venereol. 2011;25(suppl 4):3â&#x20AC;&#x201C;8.

3

.FOUFS" ,PSNBO/+ &MNFUT$" FUBM(VJEFMJOFTPGDBSFGPSUIFNBO agement of psoriasis and psoriatic arthritis: Section 3. Guidelines of care for the management and treatment of psoriasis with topical thera pies. J Am Acad Dermatol. 2009;60:643â&#x20AC;&#x201C;659.

4

Murphy G, Reich K. In touch with psoriasis: topical treatments and cur rent guidelines. J Eur Acad Dermatol Venereol. 2011;5(suppl 4):3â&#x20AC;&#x201C;8.

5

Nagpal S, Lu J, Boehm MF. Vitamin D analogs: mechanism of action and therapeutic applications. Curr Med Chem. 2001;8:1661â&#x20AC;&#x201C;1679.

6

Guilhou JJ. The therapeutic effects of vitamin D3 and its analogues in psoriasis. Expert Opin Investig Drugs. 1998;7:77â&#x20AC;&#x201C;84.

7

Segaert S, Duvold LB. Calcipotriol cream: a review of its use in the man agement of psoriasis. J Dermatolog Treat. 2006;17:327â&#x20AC;&#x201C;337.

8

Scott LJ, Dunn CJ, Goa KL. Calcipotriol ointment. A review of its use in the management of psoriasis. Am J Clin Dermatol. 2001;2:95â&#x20AC;&#x201C;120.

9

Dam TN, Moller B, Hindkjaer J, Kragballe K. The vitamin D3 analog DBMDJQPUSJPM TVQQSFTTFT UIF OVNCFS BOE BOUJHFOQSFTFOUJOH GVODUJPO PG Langerhans cells in normal human skin. J Investig Dermatol Symp Proc. 1996;1:72â&#x20AC;&#x201C;77.

12 #POJ&&MFXTLJ.% 8JMMJBN"CSBNPWJUT.% FUBM"OPWFMGPBNGPSNVMB tion of ketoconazole, 2%, for the treatment of seborrheic dermatitis on multiple body regions. J Drugs Dermatol. 2007;6:1001â&#x20AC;&#x201C;1008. 13 %VXFC( "MEFCBOJ4 &M[PSHIBOZ" #FOHIB[JM. "MIBEEBS+$BMDJQPUSJPM ointment versus cream in psoriasis vulgaris. Int J Clin Pharmacol Res. 2003;23:47â&#x20AC;&#x201C;51. 14 Sorilux foam [package insert]. San Antonio, TX: Stiefel Laboratories, Inc; 2011. 15 Molin L, Cutler TP, Helander I, Nyfors B, Downes N. Comparative efficacy PGDBMDJQPUSJPM .$ DSFBNBOECFUBNFUIBTPOFWBMFSBUFDSFBNJO UIFUSFBUNFOUPGDISPOJDQMBRVFQTPSJBTJT"SBOEPNJ[FE EPVCMFCMJOE  parallel group multicentre study. Calcipotriol Study Group. Br J Dermatol. 1997;136:89â&#x20AC;&#x201C;93. 16 Mason J, Mason AR, Cork MJ. Topical preparations for the treatment of psoriasis: a systematic review. Br J Dermatol. 2002;146:351â&#x20AC;&#x201C;364. 17 #FSUI+POFT +  $IV "$  %PEE 8"  FU BM " NVMUJDFOUSF  QBSBMMFMHSPVQ DPNQBSJTPOPGDBMDJQPUSJPMPJOUNFOUBOETIPSUDPOUBDUEJUISBOPMUIFSBQZ in chronic plaque psoriasis. Br J Dermatol. 1992;127:266â&#x20AC;&#x201C;271. 18 Pinheiro N. Comparative effects of calcipotriol ointment (50 μg/g) and 5% coal tar/2% allantoin/0.5% hydrocortisone cream in treating plaque psoriasis. Br J Clin Pract. 1997;51:16â&#x20AC;&#x201C;19. 19 7FJFO/, #KFSLF+3 3PTTNBO3JOHEBIM* +BLPCTFO)#0ODFEBJMZUSFBU ment of psoriasis with tacalcitol compared with twice daily treatment XJUIDBMDJQPUSJPM"EPVCMFCMJOEUSJBMBr J Dermatol. 1997;137:581â&#x20AC;&#x201C;586.

10 %PWPOFY$SFBN<QBDLBHFJOTFSU>#BMMFSVQ %FONBSL-&01IBSNBDFVUJ cal; 2009.

20 Zeichner JA, Lebwohl MG, Menter A, et al. Optimizing topical therapies for treating psoriasis: a consensus conference. Cutis. 2010;86(suppl 3):5â&#x20AC;&#x201C;31.

11 Vectical ointment [package insert]. Fort Worth, TX: Galderma Laborato ries; 2009.

21 Calcipotriene [package insert]. Hawthorne, NY: Taro Pharmaceuticals USA; 2010.

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November/December 2012 22 %PWPOFY4DBMQ<QBDLBHFJOTFSU>#BMMFSVQ %FONBSL-&01IBSNBDFVUJ cal; 2010.

betamethasone dipropionate ointment for the treatment of psoriasis. J Eur Acad Dermatol Venereol. 2006;20:39â&#x20AC;&#x201C;44.

23 ;IV9 8BOH# ;IBP( FUBM"OJOWFTUJHBUPSNBTLFEDPNQBSJTPOPGUIF efficacy and safety of twice daily applications of calcitriol 3 Îźg/g oint ment vs. calcipotriol 50 Îźg/g ointment in subjects with mild to moder BUFDISPOJDQMBRVFUZQFQTPSJBTJTJ Eur Acad Dermatol Venereol. 2007; 21:466â&#x20AC;&#x201C;472.

27 5BDMPOFY PJOUNFOU <QBDLBHF JOTFSU> %VCMJO  *SFMBOE -&0 1IBSNBDFVUJ cals; 2007.

24 Lebwohl M, Menter A, Weiss J, et al. Calcitriol 3 Îźg/g ointment in the management of mild to moderate plaque type psoriasis: results from 2 QMBDFCPDPOUSPMMFE  NVMUJDFOUFS  SBOEPNJ[FE EPVCMFCMJOE  DMJOJDBM TUVE ies. J Drugs Dermatol. 2007;6:428â&#x20AC;&#x201C;435. 25 Data on file. Fort Worth, TX: Galderma Laboratories, L.P. 26 Kragballe K, van de Kerhof PC. Consistency of data in six phase III DMJOJDBM TUVEJFT PG B UXPDPNQPVOE QSPEVDU DPOUBJOJOH DBMDJQPUSJPM BOE

28 Jemec GB, Ganslandt C, Ortonne JP, et al. A new scalp formulation of cal cipotriene plus betamethasone compared with its active ingredients and UIF WFIJDMF JO UIF USFBUNFOU PG TDBMQ QTPSJBTJT B SBOEPNJ[FE  EPVCMF blind, controlled trial. J Am Acad Dermatol. 2008;59:455â&#x20AC;&#x201C;463. 29 Zeichner JA, Lebwohl MG, Menter A, et al. Optimizing topical therapies for treating psoriasis: a consensus conference. Cutis. 2010;86(suppl 3):5â&#x20AC;&#x201C;31. 30 ,Ă&#x161;SWFS+& 7JTTFST8) WBO3FOT%8 FUBM"EPVCMFCMJOE SBOEPNJ[FE quantitative comparison of calcitriol ointment and calcipotriol oint ment on epidermal cell populations, proliferation and differentiation. Br J Dermatol. 2007;156:130â&#x20AC;&#x201C;137.

WAX MOULAGE

Bullous Pemphigoid, Moulage No 25, made by Otto Vogelbacher in Breisgau (Germany) in 1900. Museum of Wax Moulages Zurich. Courtesy: Michael Geiges, MD SKINmed. o



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November/December 2012  Volume 10  Supplement 1

SUPPLEMENT The Safety, EďŹ&#x192;cacy, and Tolerability of a Novel Silicone Gel Dressing Following Dermatological Surgery Sandhofer and Schauer


November/December 2012

EDITORIAL BOARD

EDITOR IN CHIEF

Lawrence Charles Parish, MD, MD (Hon) Philadelphia, PA

DEPUTY EDITORS William Abramovits, MD Dallas, TX

W. Clark Lambert, MD, PhD Newark, NJ

Larry E. Millikan, MD Meridian, MS

Vesna Petronic-Rosic, MD, MSc Chicago, IL

Marcia Ramos-e-Silva, MD, PhD Rio de Janeiro, Brazil

Jennifer L. Parish, MD Philadelphia, PA

EDITORIAL BOARD Mohamed Amer, MD Cairo, Egypt

Howard A. Epstein, PhD Philadelphia, PA

Jasna Lipozencic, MD, PhD Zagreb, Croatia

Noah S. Scheinfeld, MD, JD New York, NY

Robert L. Baran, MD Cannes, France

Ibrahim Hassan Galadari, MD, PhD, FRCP Dubai, United Arab Emirates

Eve J. Lowenstein, MD, PhD New York, NY

Virendra N. Sehgal, MD Delhi, India

Anthony V. Benedetto, DO Philadelphia, PA

Anthony A. Gaspari, MD Baltimore, MD

George M. Martin, MD Kihei, HI

Riccarda Serri, MD Milan, Italy

Brian Berman, MD, PhD Miami, FL

Michael Geiges, MD Zurich, Switzerland

Marc S. Micozzi, MD, PhD Rockport, MA

Charles Steffen, MD Oceanside, CA

Jack M. Bernstein, MD Dayton, OH

Michael H. Gold, MD Nashville, TN

George F. Murphy, MD Boston, MA

Alexander J. Stratigos, MD Athens, Greece

Sarah Brenner, MD Tel Aviv, Israel

Lowell A. Goldsmith, MD, MPH Chapel Hill, NC

Oumeish Youssef Oumeish, MD, FRCP Amman, Jordan

James S. Studdiford III, MD Philadelphia, PA

Joaquin Calap Calatayud, MD Cadiz, Spain

Aditya K. Gupta, MD, PhD, FRCP(C) London, Ontario, Canada

Joseph L. Pace, MD, FRCP Naxxar, Malta

Robert J. Thomsen, MD Los Alamos, NM

Henry H.L. Chan, MB, MD, PhD, FRCP Hong Kong, China

Seung-Kyung Hann, MD, PhD Seoul, Korea

Art Papier, MD Rochester, NY

Julian Trevino, MD Dayton, OH

Noah Craft, MD, PhD, DTMH Torrance, CA

Roderick J. Hay, BCh, DM, FRCP, FRCPath London, UK

Johannes Ring, MD, DPhil Munich, Germany

Snejina Vassileva, MD, PhD Sofia, Bulgaria

Ncoza C. Dlova, MBChB, FCDerm Durban, South Africa

Tanya R. Humphreys, MD Philadelphia, PA

Roy S. Rogers III, MD Rochester, MN

Daniel Wallach, MD Paris, France

Richard L. Dobson, MD Mt Pleasant, SC

Camila K. Janniger, MD Englewood, NJ

Donald Rudikoff, MD New York, NY

Michael A. Waugh, MB, FRCP Leeds, UK

William H. Eaglstein, MD Palo Alto, CA

Abdul-Ghani Kibbi, MD Beirut, Lebanon

Robert I. Rudolph, MD Wyomissing, PA

Wm. Philip Werschler, MD Spokane, WA

Boni E. Elewski, MD Birmingham, AL

Andrew P. Lazar, MD Highland Park, IL

Vincenzo Ruocco, MD Naples, Italy

Joseph A. Witkowski, MD Philadelphia, PA

Charles N. Ellis, MD Ann Arbor, MI

Ronni Wolf, MD Rechovot, Israel


SUPPLEMENT The Safety, EďŹ&#x192;cacy, and Tolerability of a Novel Silicone Gel Dressing Following Dermatological Surgery Sandhofer and Schauer

Publication of this supplement was sponsored by Stratpharma AG, Basel, Switzerland.


TABLE OF CONTENTS /PWFNCFS%FDFNCFSt7PMVNFt*TTVF

SUPPLEMENT The Safety, Efficacy, and Tolerability of a Novel Silicone Gel Dressing Following Dermatological Surgery ................................................................................................................. S1 Matthias Sandhofer, MD; Patrick Schauer, MD

ABOUT OUR JOURNAL SKINmed: Dermatology for the ClinicianÂŽ, print ISSN 1540-9740, online ISSN 1751-7125, is published bimonthly by Pulse Marketing & Communications, LLC, located at 4 Peninsula Avenue, Sea Bright, NJ 07760. Printed in the USA. Disclaimer: The Publisher, Editors, and Editorial Board cannot be held responsible for errors or any consequences arising from the use of information contained in this journal; the views and opinions expressed herein do not necessarily reďŹ&#x201A;ect those of the Publisher, Editors, and Editorial Board, neither does the publication of advertisements constitute any endorsement by the Publisher, Editors, and Editorial Board of the products or services advertised. The Publisher, Editors, Editorial Board, Reviewers, Authors, and AďŹ&#x192;liated Agents shall not be held responsible or in any way liable for the continued accuracy of the information or for any errors, inaccuracies, or omissions of any kind in this publication, whether arising from negligence or otherwise, or for any consequences arising thereafter. Copyright: Š2012 Pulse Marketing & Communications, LLC. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means without the prior permission in writing from the Publisher. Requests should be addressed to the Permissions Editor at: Pulse Marketing & Communications, LLC, 4 Peninsula Avenue, Sea Bright, NJ 07760.

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Published by Pulse Marketing & Communications, LLC 1FOJOTVMB"WFOVFt4FB#SJHIU /+ 5FM  t'BY  


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November/December 2012

SUPPLEMENT

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November/December 2012 HOW THIS NEW SILICONE GEL WOUND DRESSING WORKS ɨFTJMJDPOFHFMJTBQQMJFEUPUIFBĊFDUFEBSFBPGUIFTLJO GPSNJOHBnFYJCMF QSPUFDUJWFTIFFUUIBUJTHBTQFSNFBCMFCVUTFNJPDDMVTJWF*UCJOETUPUIFJOKVSFETLJOCVUEPFTOPUQFOFUSBUFJOUP UIFFQJEFSNJTPSEFSNJT"DDPSEJOHUPUIFNPTUSFDFOUTUVEJFTJO BCOPSNBM TDBST  UIF QSPUFDUJWF TJMJDPOF TIFFUT SFTUPSF UIF OBUVSBMCBSSJFSGVODUJPOPGUIFFQJEFSNJTBOESFEVDFUSBOTFQJEFSNBM XBUFS MPTT BU UIF JOKVSZ TJUF ɨJT XBUFS MPTT BOE UIF SFTVMUJOH EFIZESBUJPOBSFBTTVNFEUPCFDSJUJDBMGBDUPSTCFIJOEFYDFTTJWF QSPEVDUJPOPGDPMMBHFOmCFSTBOEUIVTGPSUIFGPSNBUJPOPGBO BCOPSNBMTDBS

XPVOE IFBMJOH 5IF QIZTJDBM FGGFDUT PG UIJT OFX HFM BSF QPUFOUJBMMZXFMMTVJUFEGPSUIFTFJOEJDBUJPOT BTJUDBOBMTPCF VTFEJNNFEJBUFMZQPTUQSPDFEVSF METHODS

ɨJT DBTF TFSJFT JMMVTUSBUFT UIF QFSGPSNBODF PG B OFX TJMJDPOF CBTFE QSPEVDU 4USBUBNFE  JO B TFSJFT PG TUBOEBSE QSPDFEVSFT QFSGPSNFEBUUIF;FOUSVNGàS)BVU ­TUIFUJL -BTFSVOE7FOFO JO -JO[  "VTUSJB  BOE %FSNBUPMPHJTDIF (FNFJOTDIBGUTQSBYJT  "TUIFUJTDIF .FEJ[JOF JO 1BTTBV  (FSNBOZ JODMVEJOH BCMBUJWF BOETVSHJDBMQSPDFEVSFT 4USBUBNFEJTBUVCFEJTQFOTFETJMJDPOF HFM 4USBUQIBSNB "(  #BTMF  4XJU[FSMBOE  XIJDI GPSNT B TFMG ESZJOHQSPUFDUJWFTIFFU*UDPOTJTUTPGJOFSUTJMJDPOFQPMZNFSTBOE #FDBVTF TFNJPDDMVTJWF XPVOE ESFTTJOHT XJUIPVU TJMJDPOF IBWF DBOCFBQQMJFEEJSFDUMZUPPQFOXPVOETBOEUPBSFBTPGUIFTLJO CFFOTIPXOUPCFMFTTFĊFDUJWFJOUSFBUJOHTDBST 12POFDBOBTTVNF XJUIXFBLFOFEJOUFHSJUZɨJTTUVEZEFTDSJCFTPVSPCTFSWBUJPOT UIBU TJMJDPOF QPTTFTTFT PUIFS QSPQFSUJFT UIBU QSPNPUF XPVOE XJUIUIJTQSPEVDUJOBTFSJFTPGQBUJFOUT IFBMJOH ɨF SFTVMUT PG DMJOJDBM TUVEJFT JOEJDBUF UIBU TJMJDPOF HFMNPEVMBUFTUIFMFWFMTPGUIFmCSPCMBTUHSPXUIGBDUPSbɨF PATIENT SELECTION GPSNBUJPOPGIZQFSUSPQIJDTDBSUJTTVFUIBUDPOUBJOTIJTUPMPHJDBMMZ 'SPN  UISPVHI   XF NPOJUPSFE UIF QFSGPSNBODF PG OPSNBM mCSPCMBTUT JT QSFWFOUFE CZ NPEVMBUJOH UIF FYQSFTTJPO 4USBUBNFEGPMMPXJOHWBSJPVTJOWBTJWFUSFBUNFOUTPOQBUJFOUT PG UIF HSPXUI GBDUPST ɨF EBUB QSPEVDFE TP GBS TVQQPSU UIF JOBDBTFTFSJFTBUUIFBVUIPSTDMJOJDT BTTVNQUJPO UIBU UIF QSPQFSUJFT PG UIF TJMJDPOF TVCTUBODFT QSPNPUJOHXPVOEIFBMJOHBSFCBTFEPOUIFUIFPSZUIBUUIFZDPSSFDU Table I. The Number and Reason for Intervention (N=105) BOFYJTUJOHTIPSUBHFPSFYDFTTPGHSPXUIIPSNPOFTUIBUDPOUSPM REASON FOR INTERVENTION NO. UIFSFQBJSQSPDFTTFTJOUJTTVFT13*OBCMBUJWFBOESFTVSGBDJOHQSP5BUUPPSFNPWBM 22 DFEVSFT UIFTJMJDPOFHFMXPVOEESFTTJOHQSPNPUFTBNPJTUBOE )ZQFSUSPQIJDTDBSUSFBUNFOU 15 QSPUFDUJWFXPVOEIFBMJOHFOWJSPONFOU ,FMPJEUSFBUNFOU

TIME AS A FACTOR IN TREATING WOUNDS WITH SILICONE ɨFLOPXMFEHFHBJOFEGSPNTUVEJFTTVHHFTUTUIBUUIFUJNFBU XIJDIBXPVOEJTUSFBUFEIBTBTJHOJmDBOUFĊFDUPOUIFMJLFMJIPPE PG BCOPSNBM TDBS GPSNBUJPO14 15  UIFSFGPSF  UIF HPBM TIPVMECFUPBDIJFWFUIFNPTUSBQJEQPTTJCMFFQJUIFMJBMJ[BUJPO PG UIF XPVOE JO PSEFS UP NJOJNJ[F TDBS GPSNBUJPO ɨJT JT QBSUJDVMBSMZUSVFGPSCVSOXPVOETBOEPUIFSTVSGBDFJOKVSJFT PG UIF FQJEFSNJT XIFSF FQJUIFMJBMJ[BUJPO JT EFMBZFE XJUIPVU BEEJUJPOBM USFBUNFOU IPXFWFS  QSJPS UP UIF JOUSPEVDUJPO PG UIJT OFX TJMJDPOF QSFQBSBUJPO  TFMGESZJOH TJMJDPOF HFM QSPEVDUTXFSFOPUJOEJDBUFEVOUJMUIFXPVOEIBEBMSFBEZIFBMFE BOEUIFFQJUIFMJBMGPSNBUJPOXBTDPNQMFUF EFMBZJOHUIFTUBSU PG USFBUNFOU CZ VQ UP TFWFSBM XFFLT ɨJT OFX TJMJDPOF HFM XPVOEESFTTJOHJTQPUFOUJBMMZXFMMTVJUFEGPSTDBSQSFWFOUJPO  CFDBVTF JU DBO CF VTFE JNNFEJBUFMZ PO PQFO XPVOET BOE EBNBHFETLJO *OBEEJUJPOUPFBSMZUSFBUNFOUGPSTDBSQSFWFOUJPO EFSNBUPMPHJDBMBCMBUJWFBOESFTVSGBDJOHQSPDFEVSFTSFRVJSFBNPJTU  QSPUFDUJWF FOWJSPONFOU JNNFEJBUFMZ UP GBDJMJUBUF BDDVSBUF SKINmed. 4o4

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4611-&.&/5

November/December 2012 5BCMF *  5BCMF **  BOE 5BCMF ** EFTDSJCF UIF EJĊFSFOU UZQFT PG QBUIPMPHJFT USFBUFE BOE UIF UFDIOJRVFT VTFE PO UIF TFSJFT PG QBUJFOUT5BCMF*PVUMJOFTUIFOVNCFSBOESFBTPOTGPSJOUFSWFOUJPOT POUIFQBUJFOUTɨSFFQBUJFOUTIBENPSFUIBOPOFJOUFSWFOUJPO5BCMF**EFTDSJCFTUIFGSFRVFODZ  BOEUZQFTPGJOUFSWFOUJPOTQFSGPSNFE XJUIOVNFSPVTQBUJFOUTVOEFSHPJOHBDPNCJOBUJPOPGUFDIOJRVFT5BCMF***EFTDSJCFTTQFDJmDBMMZUIFOVNCFSBOE SFBTPOTGPSTVSHJDBMFYDJTJPOTQFSGPSNFEPOQBUJFOUTXIPXFSF Table II. Frequency and Types of Interventions Used

TYPE OF INTERVENTION

NO.

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Table III. Surgical Excisions in Detail (N=17)

SURGICAL EXCISIONS

4PNFQBUJFOUT CBTFEPODMJOJDBMKVEHNFOUBOEQBUJFOUSJTLGBDUPST XFSFBMTPQSFTDSJCFEBOBOUJCJPUJDPJOUNFOUDPOUBJOJOHUIF BDUJWFJOHSFEJFOUGVTJEJDBDJEUXJDFEBJMZGPSUIFmSTUUPEBZT UIFSFGPSF PVSNBOBHFNFOUEJEOPUBMUFS FYDFQUGPSUIFBEEJUJPO PGUIFTJMJDPOFHFMBTBmSTUDPOUBDUMBZFS

ɨFBWFSBHFUSFBUNFOUUJNFGPSQBUJFOUTVTJOHUIFTJMJDPOFHFMXBT NPOUIT'PMMPXVQGPSUIFTFQBUJFOUTSBOHFEGSPNNPOUI UP  NPOUIT  EFQFOEJOH VQPO UIF QSPDFEVSF QFSGPSNFE CVU JOBDDPSEBODFXJUIPVSTUBOEBSEQBUJFOUGPMMPXVQ"MMQBUJFOUT XFSF QIPUPHSBQIFE EVSJOH UIF DPVSTF PG UIFJS GPMMPXVQ 'JHVSFT o  ɨF BVUIPST PCTFSWFE UIF HFOFSBM QFSGPSNBODF PGUIFTJMJDPOFQSPEVDUBOETVCKFDUJWFMZFWBMVBUFEUIFTFSFTVMUT  CBTFE PO QSFWJPVT DMJOJDBM FYQFSJFODF BOE FYQFDUBUJPOT *O BEEJUJPO QBUJFOUTTVCKFDUJWFPQJOJPOTXFSFSFDPSEFE

 SFWJPVTMZTDBSGSFFQSJPSUPUIFJSQSPDFEVSF1BUJFOUWBSJBCMFTTVDI Q BTBHF TFY BOEPUIFSJNQPSUBOUDPOGPVOEJOHWBSJBCMFT JODMVEJOH 'JU[QBUSJDLTLJOUZQF IBWFOPUCFFOEFTDSJCFE CFDBVTFUIFQVSQPTFPGUIJTTUVEZXBTUPPCTFSWFUIFPWFSBMMQFSGPSNBODFPGUIJT OFXTJMJDPOFHFMPONBOZUZQFTPGTVSHJDBMJOUFSWFOUJPOTBOEUP HBVHFUIFQBUJFOUTTBUJTGBDUJPOXJUIUIFOFXQSPEVDU*OBEEJUJPO  BDPOUSPMHSPVQ XIFSFTUBOEBSEQPTUPQFSBUJWFQSBDUJDFTBSFDPNQBSFEXJUIUIJTOFXUSFBUNFOU XBTOPUVOEFSUBLFO*OTUFBE BMM QBUJFOUTSFDFJWFEPVSTUBOEBSEQPTUPQFSBUJWFXPVOEDBSFQSPUPDPM XJUIUIFBEEJUJPOPGUIFOFXHFM

RESULTS AND OBSERVATIONS

'PSUIFDBTFTPGSFTVSGBDJOHQSPDFEVSFT TFWFSBMQPTJUJWFPCTFSWBUJPOT XFSF OPUFE ɨFSF XBT B SFEVDUJPO JO UIF JOnBNNBUPSZ SFTQPOTF JO CPUI UJNF BOE TFWFSJUZ UIF QSFDJTF IFBMJOH PG UIF XPVOEXBTPCTFSWFEBOEUIFSFXFSFOPDBTFTPGJSSJUBUJPO SFEEFOJOH PCTFSWFE8FBMTPPCTFSWFEBGBTUFSIFBMJOHPSSFFQJUIFMJBMJ[BUJPOPGUIFXPVOETVSGBDFXJUIWJTJCMZTBUJTGBDUPSZSFTVMUT TUBSUJOHBTFBSMZBTEBZT DPNQBSFEXJUIXIBUXFPCTFSWFXJUI PVS TUBOEBSE DBSF 'JHVSFT     BOE   ɨF QSPUFDUJWF TIFFU GPSNFE CZ UIF TJMJDPOF HFM JO UIFTF SFTVSGBDJOH DBTFT EJE OPU DESCRIPTION OF PROCEDURES JOUFSGFSF XJUI UIF XPVOE HSBOVMBUJPO *O BEEJUJPO  BGUFS UIF 'PSMBTFSSFTVSGBDJOH UIFTJMJDPOFHFMXBTBQQMJFEBTBOBEKVODU SFNPWBMPGUIFJOJUJBMEFUSJUVT UIFSFXBTOPOPUJDFBCMFBCOPSNBM UP PVS TUBOEBSE QPTUMBTFS XPVOE DBSF QSPUPDPM ɨBU JT  BMM HSBOVMBUJPOGPSNBUJPOɨFEFUSJUVTBSJTJOHGSPNGSBDUJPOBM$02 QBUJFOUT XFSF QSFTDSJCFE B NPJTUVSJ[JOH QFUSPMFVNCBTFE HFM USFBUNFOUXFSFFYGPMJBUFEBGUFSUPEBZT1BUJFOUTTVCKFDUJWFMZ SKINmed. 4o4

4

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4611-&.&/5

November/December 2012

Figure 1. 4DBSJNNFEJBUFMZBGUFSUIFJODJTJPOBOEBGUFSXFFLTPG4USBUBNFEUSFBUNFOUBTNPOPUIFSBQZ'JSTUQVCMJTIFEJO POXXXTUSBUBNFEDPN

Figure 2. &YJTUJOHIZQFSUSPQIJDTDBSGPMMPXJOHUIPSBDJDTVSHFSZCFGPSF EVSJOH BOEBGUFSBXFFL4USBUBNFEUSFBUNFOUBTDPNCJOBUJPO UIFSBQZXJUIGSBDUJPOBM$02 NPTBJDMBTFSBOESBEJPGSFRVFODZUSFBUNFOU'JSTUQVCMJTIFEJOPOXXXTUSBUBNFEDPN

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4611-&.&/5

November/December 2012

Figure 3. &YJTUJOHIZQFSUSPQIJDTDBSGPMMPXJOHFYDJTJPOPGBNFMBOPNBCFGPSFUSFBUNFOUBOEBGUFSBOEXFFLTPG4USBUBNFE USFBUNFOUJODPNCJOBUJPOUIFSBQZXJUI'6DPSUJDPTUFSPJEJOKFDUJPOT'JSTUQVCMJTIFEJOPOXXXTUSBUBNFEDPN

Figure 4. %FSNBCSBTJPOEVSJOHUSFBUNFOUBOEBGUFSXFFL4USBUBNFEUSFBUNFOUBTNPOPUIFSBQZ'JSTUQVCMJTIFEJO POXXXTUSBUBNFEDPN SKINmed. 4o4

4

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4611-&.&/5

November/December 2012

"MMQPTUPQFSBUJWFBQQMJDBUJPOSFDPNNFOEBUJPOTXFSFGPMMPXFE XJUIPVUFYDFQUJPO *OPOFTVSHJDBMFYDJTJPODBTF BGUFSFYDJTJPOPGBKVWFOJMFNFMBOPNBJOUIFDIFTUBSFB XFPCTFSWFEEFWFMPQNFOUPGBIZQFSUSPQIJDTDBSUIBUXBTTVDDFTTGVMMZUSFBUFEXJUIJOKFDUJPOUSFBUNFOU XJUI'6USJBNDJOPMPOFJODPNCJOBUJPOXJUIUIFTJMJDPOFHFM DISCUSSION ɨFHFOFSBMPCTFSWBUJPOTGSPNPVSDBTFFYQFSJFODFJOEJDBUFUIBU UIJT OFX TJMJDPOF HFM XPVOE ESFTTJOH JT XFMMTVJUFE GPS B XJEF SBOHF PG EFSNBUPMPHJDBM TVSHFSZ JOEJDBUJPOT  OBNFMZ UIF USFBUNFOU PG PQFO XPVOET  QPTUSFTVSGBDJOH QSPDFEVSFT  BOE UIF FBSMZ VTF JO BCOPSNBM TDBS QSFWFOUJPO ɨF HFM ESFTTJOH JT BMTP XFMMTVJUFE BT B DPNCJOBUJPO UIFSBQZ XJUI PVS TUBOEBSE QPTUPQFSBUJWF XPVOE DBSF QSPUPDPMT ɨF TJMJDPOF HFM QSPWFE QBSUJDVMBSMZIFMQGVMJOUIFQPTUPQFSBUJWFGSBDUJPOTZTUFNUSFBUNFOU  XIFSFXFPCTFSWFEUIBUFSPTJWFBOEBCMBUJWFXPVOETBSFCFUUFS QSPUFDUFE UIBO XJUI UIF QFUSPMFVNCBTFE NPJTUVSJ[JOH BHFOUT UIBUXFDPNNPOMZVTF ɨFIFBMJOHQSPDFTTXBTBMTPPCTFSWFEUPCFNPSFTUSPOHMZTVQQPSUFE8FQSPQPTFUIBUUIJTJTEVFUPUIFTJMJDPOFQPMZNFSTIBWJOH OP NFBTVSBCMF Q) WBMVF  BOE UIFSFGPSF UIFTF QPMZNFST EP OPUBĊFDUUIFQSPUFDUJWFBDJENBOUMFPGUIFTLJOBOEEPOPUSFBDU XJUIUIFOFXMZGPSNJOHFQJUIFMJBMUJTTVFTɨFSFTVMUJTBGBWPSBCMFFOWJSPONFOUGPSUIFTLJOIFBMJOHQSPDFTT XIJDIXFTVCKFDUJWFMZPCTFSWFEUPMFBEUPGBTUFSFQJUIFMJBMGPSNBUJPO 'SPNPVSUSJBMFYQFSJFODF XFDPODMVEFUIBUUIFSFJTOPOFFEUP BEBQUGVSUIFSPVSFYJTUJOHXPVOEUSFBUNFOUDPODFQUTXIFOTJMJDPOFHFMJTVTFE CFDBVTFJUJTBOBEEPOUIFSBQZɨFQSFQBSBUJPO XBT XFMMUPMFSBUFE  XJUIPVU FYDFQUJPO  BOE OP DPOUBDU TFOTJUJ[BUJPOPSHFMSFMBUFEJOGFDUJPOTXFSFPCTFSWFE*OOPJOTUBODFXBTJU OFDFTTBSZUPSFNPWFUIFQSFQBSBUJPO(JWFOUIBUUIFHFMJTJOFSUBOE UIBUOPBEWFSTFUPQJDBMTJMJDPOFHFMSFBDUJPOTIBWFCFFOQVCMJTIFE UPEBUFQSFEJDUFEUIJTSFTVMU1BUJFOUDPNQMJBODFXBTWFSZIJHIBOE XFQSPQPTFUIBUUIFGBDUPSTUIBUDPOUSJCVUFEUPUIJTSFTVMU XFSFJO QBSUJDVMBSUIFTJNQMJDJUZPGBQQMJDBUJPO XIJDIDPVMECFQFSGPSNFE CZBMMQBUJFOUTBUIPNFXJUIPVUEJċDVMUZBOEUIFUZQFPGDMJFOUFMFUSFBUFEBUUIFDMJOJDɨFQBUJFOUTTFFOBSFIJHIMZiDPTNFUJDBMMZ DPOTDJPVT w QBSUJDVMBSMZ XJUI SFHBSET UP QSFWFOUJPO PG BCOPSNBM TDBSSJOH BOEUIFBVUIPSTCFMJFWFUIJTMFBETUPBNBYJNVNMFWFMPG QPTUPQFSBUJWF DPNQMJBODF UIFSFGPSF  UIF  DPNQMJBODF SBUF PCTFSWFEXJUIUIFTVSHJDBMFYDJTJPOTJTOPUTVSQSJTJOH LIMITATIONS

Figure 5. -BTFSXSJOLMFUSFBUNFOUCFGPSF EVSJOH EBZ  BOEBGUFSEBZTUSFBUNFOUXJUI4USBUBNFEBTDPNCJOBUJPO UIFSBQZXJUIUIFSNBHF GSBDUJPOBM$02MBTFSBOE#PUPY'JSTU QVCMJTIFEJOPOXXXTUSBUBNFEDPN SKINmed. 4o4

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4

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4611-&.&/5

November/December 2012

Figure 6. -BTFSSFTVSGBDJOHPGBDOFTDBSTCFGPSF EVSJOH EBZ BOEBGUFSEBZTPGUSFBUNFOUXJUI4USBUBNFEBTDPNCJOBUJPO UIFSBQZXJUIUIFSNBHFBOEGSBDUJPOBM$02MBTFS'JSTUQVCMJTIFEJOPOXXXTUSBUBNFEDPN

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4

$SV[,PSDIJO /* &GGFDUJWFOFTT PG TJMJDPOF TIFFUT JO UIF QSFWFOUJPO PG IZQFSUSPQIJDCSFBTUTDBSTAnn Plast Surg.o

5

"IO45 .POBGP88 .VTUPF5"5PQJDBMTJMJDPOFHFMGPSUIFQSFWFOUJPO BOEUSFBUNFOUPGIZQFSUISPQIJDTDBSArch Surg.o

6

(PME.) 'PTUFS5% "EBJS." #VSMJTPO, -FXJT51SFWFOUJPOPGIZQFS USPQIJDTDBSTBOELFMPJETCZUIFQSPQIZMBDUJDVTFPGUPQJDBMTJMJDPOFHFM TIFFUTGPMMPXJOHBTVSHJDBMQSPDFEVSFJOBOPG├еDFTFUUJOHDermatol Surg. o

7

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REFERENCES 1

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Publication of this supplement was sponsored by Stratpharma AG, Basel, Switzerland.

Stratpharma AG, Centralbahnplatz 8, CH-4051 Basel, Switzerland


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November/December 2012

CORE CURRICULUM Virendra N. Sehgal, MD, Section Editor

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From the Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Panchwati-Delhi, Department of Dermatology and STD, University College of Medical Sciences, and associated Guru Teg Bahadur Hospital, Shahdara, Delhi, India Address for Correspondence: Virendra N. Sehgal, MD, Dermato Venerology (Skin/VD) Center, Sehgal Nursing Home, A/6 Panchwati, %FMIJ *OEJBt&NBJMESTFIHBM!OEGWTOMOFUJO

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Figure 2. Fixed-drug eruption, round and/or oval, edematous, dusky red macules/plaques on the skin. 1BUIPQIZTJPMPHZPG"EWFSTF$VUBOFPVT%SVH3FBDUJPOT


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DRUG-DEPENDENT PEMPHIGUS

%SVHJOEVDFECVMMPVTQFNQIJHPJE JODPOUSBTUUPJEJPQBUIJD %SVHEFQFOEFOUQFNQIJHVTDBOCFEJWJEFEJOUPUIFGPMMPXJOH CVMMPVT QFNQIJHPJE  UFOET UP PDDVS JO ZPVOHFS QBUJFOUT HSPVQT%SVHEFQFOEFOUQFNQIJHVTJTQSFDJQJUBUFECZJOHFTUJPO SKINmed. 2012;10:373–383



1BUIPQIZTJPMPHZPG"EWFSTF$VUBOFPVT%SVH3FBDUJPOT


$03&$633*$6-6.

November/December 2012 PG UIJPM 4)  DPOUBJOJOH ESVHT  TVDI BT %QFOJDJMMBNJOF BOEDBQUPQSJMɨFMFTJPOTVTVBMMZEJTBQQFBSBTUIFESVHJTEJTDPOUJOVFE ɨJPM ESVHT BSF QPTUVMBUFE UP JOEVDF BDBOUIPMZTJT UISPVHICJPDIFNJDBMNFDIBOJTNTXJUIPVUBOUJCPEZGPSNBUJPO &YQFSJNFOUT XJUI TLJO FYQMBOUT IBWF EFNPOTUSBUFE UIBU UIJPM ESVHT DBO JOEVDF BDBOUIPMZTJT EJSFDUMZ 4FWFSBM IZQPUIFTFT GPS UIJTIBWFCFFOQSPQPTFE OBNFMZUIJPMESVHTNBZJOUFSGFSFXJUI DSJUJDBM FO[ZNFT  TVDI BT LFSBUJOPDZUF USBOTHMVUBNJOBTF  SFTVMUJOHJOMPTTPGFQJEFSNBMDFMMDPIFTJPOɨJPMESVHTNBZBDUJWBUF FOEPHFOPVT QSPUFPMZUJD FO[ZNFT  TVDI BT QMBTNJOPHFO BDUJWBUPST  XJUI TVCTFRVFOU DMFBWBHF PG EFTNPTPNBM BOUJHFOT ɨFZ NBZCJOEEFTNPHMFJOPSEFTNPHMFJO DSFBUJOHBOFPBOUJHFO  XIJDINBZUIFOFMJDJUBOJNNVOFSFTQPOTF-BTUMZ UIJPMESVHT NBZ CJOE UP UIF QFNQIJHVT BOUJHFOT BOE JOUFSGFSF XJUI UIFJS OPSNBMGVODUJPO SFTVMUJOHJOBDBOUIPMZTJT

DRUG-TRIGGERED TRUE PEMPHIGUS ɨJTNBZPDDVSJOJOEJWJEVBMTXIPIBWFBHFOFUJDQSFEJTQPTJUJPO ɨ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ɨJT  BMTP FYQMBJOT UIF JODSFBTFE NVDPTBM JOWPMWFNFOUTFFOJOUIFTFQBUJFOUT*OGBDU UIJTHSPVQUFOETUP IBWFDMJOJDBM IJTUPMPHJD JNNVOPMPHJD BOEQSPHOPTUJDGFBUVSFT UIBUNJNJDLJEJPQBUIJDQFNQIJHVTWVMHBSJT DRUG ERUPTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS DRESS ɨJT IZQFSTFOTJUJWJUZ TZOESPNF JT DIBSBDUFSJ[FE CZ GFWFS  GBDJBM FEFNB  JOmMUSBUFE QBQVMFT  BOE HFOFSBMJ[FE QBQVMPQVTUVMBS BOEFYBOUIFNBUPVTFSVQUJPOT *UJTBMTPSFDPHOJ[FEBTESVH JOEVDFE EFMBZFE NVMUJPSHBO IZQFSTFOTJUJWJUZ TZOESPNF The EJBHOPTJTPGESVHFSVQUJPOXJUIFPTJOPQIJMJBBOETZTUFNJDTZNQUPNT %3&44  TIPVME CF CBTFE PO UISFF DSJUFSJB DVUBOFPVT FSVQUJPO  IFNBUPMPHJD BCOPSNBMJUJFT XJUI FJUIFS FPTJOPQIJMJB  PG QBUJFOUT  PS BUZQJDBM MZNQIPDZUPTJT o PG QBUJFOUT EFQFOEJOHPOUIFDBVTBUJWFESVH BOETZTUFNJDTJHOT BEFOPQBUIZ IFQBUJUJT JOUFSTUJUJBMOFQISJUJT JOUFSTUJUJBMQOFVNPOJUJT  PS DBSEJUJT  'FWFS  BDDPNQBOJFE CZ WBSJPVT TLJO MFTJPOT  NBZCFUIFQSFTFOUJOHTJHOT&SZUIFNBUPVTBOENBDVMPQBQVMBS SKINmed. 2012;10:373–383

MFTJPOT UZQJDBMMZ BQQFBS mSTU PO UIF USVOL  GBDF  BOE VQQFS FYUSFNJUJFT  BOE NBZ QSPHSFTT UP CMJTUFST  WFTJDMFT  QVTUVMFT  PS QVSQVSB &YGPMJBUJWF EFSNBUJUJT NBZ SFTVMU ɨF MBUF POTFU BOE MPOHEVSBUJPOPG%3&44 BMPOHTXJUIUIFQSFTFODFPGIFNBUPMPHJDBMBCOPSNBMJUJFT EJĊFSFOUJBUFTJUGSPNPUIFSIZQFSTFOTJUJWJUZSFBDUJPOT OBNFMZUPYJDFQJEFSNBMOFDSPMZTJT"MPOHMBTUJOH DMJOJDBM DPVSTF  EFTQJUF XJUIESBXBM PG UIF DBVTBUJWF ESVH  JT JUT VODPNNPOGFBUVSF *UT QSFDJTF QBUIPHFOFTJT JT TUJMM TQFDVMBUJWF " HFOFUJD NFUBCPMJDEFGFDU EFmDJFOUFQPYJEFIZESPMBTF SFRVJSFEGPSUIF EFUPYJmDBUJPO PG BSFOF PYJEF  IBT CFFO JEFOUJmFE ɨF NFUBCPMJDEFGFDUJTDPNNPOUPUIFBSPNBUJDBOUJDPOWVMTBOUTXIFSF UIF QBUJFOU JT GSFRVFOUMZ DSPTTSFBDUJWF UP UIF ESVHT "SFOF PYJEFTBSFGPSNFEJOUIFMJWFSCZPYJEBUJPOPGUIFESVHT XIJDI CJOE UP UIF NBDSPNPMFDVMFT PG LFSBUJOPDZUFT BOE JNNVOF DFMMT  MFBEJOH UP JNNVOF QFSUVSCBUJPOT UIBU NBOJGFTU BT UZQF *7 IZQFSTFOTJUJWJUZ %SVHTQFDJmD 5 DFMMT NBZ CF EJSFDUMZ TUJNVMBUFE CZ UIF SFTQFDUJWF ESVH Q* DPODFQU  BOE UIFO TFDSFUF MBSHF BNPVOUT PG *- BOE *'/γ 3FDFOUMZ  IVNBO IFSQFTWJSVT ))7 SFBDUJWBUJPOJO%3&44IBTBMTPCFFO JNQMJDBUFE*UJTQSPQPTFEUIBUBHBJOTUBHFOFUJDCBDLHSPVOE  TPNFESVHTNBZJOEVDFUIFQSPEVDUJPOPGSFBDUJWFNFUBCPMJUFT UIBUNBZQSPWPLF))7SFBDUJWBUJPOBOEQSPQBHBUJPOCZUIF XBZPGDZUPLJOFQSPEVDUJPOɨFSPMFPG))7NBZOPUCF MJNJUFEUPUIFJOJUJBMEFWFMPQNFOUPG%3&44))7SFQMJDBUJPODBOMFBEUPTZTUFNJDWJSBMEJTTFNJOBUJPOUPUBSHFUPSHBOT *U NBZ BMTP CF EJSFDUMZ JNQMJDBUFE JO TZTUFNJD NBOJGFTUBUJPOT JO%3&44 PSEUDOLYMPHOMATOUS SYNDROME ɨFQTFVEPMZNQIPNBUPVTTZOESPNFVTVBMMZEFWFMPQTXFFLT UPZFBSTBGUFSJOJUJBUJOHESVHTTVDIBTQIFOZUPJOTPEJVN*U QSFTFOUT BT B TPMJUBSZ  MPDBMJ[FE QBQVMF  QMBRVF  BOEPS OPEVMF TFWFSBMMPDBMJ[FEQMBRVFTNVMUJQMFQMBRVFTPSOPEVMFTPOEJĊFSFOU QBSUT PG UIF TLJO PS BT B HFOFSBMJ[FE FSVQUJPO ɨFTF GFBUVSFTBSFJOTUSJLJOHDPOUSBTUUPPUIFSESVHSFBDUJPOT XIJDINBZ EFWFMPQ JO B TIPSUFS JODVCBUJPO QFSJPE BOE SFTPMWF RVJDLMZ PO DFTTBUJPO PG UIF ESVH UIFSBQZ ɨ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

377

1BUIPQIZTJPMPHZPG"EWFSTF$VUBOFPVT%SVH3FBDUJPOT


$03&$633*$6-6.

November/December 2012 PHOTOSENSITIVITY 1IPUPBMMFSHJDBOEQIPUPUPYJDSFBDUJPOTBSFJUTWJBCMFJOHSFEJFOUT ɨFDPOEJUJPOJTDIBSBDUFSJ[FECZMPDBMJ[BUJPOPGUIFMFTJPOTUPUIF TVOFYQPTFEBSFBTPGUIFCPEZJODMVEJOHUIFGBDF EPSTBMBTQFDUPG UIFGPSFBSNT 7PGUIFOFDL 'JHVSF BOECBDLPGUIFIBOET TQBSJOHUIFQPTUBVSJDVMBSBSFB TVCNFOUBMSFHJPO BOEUIFTLJOGPMET

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1JHNFOUBUJPO SFBDUJPOT BSF EFmOFE CZ ESVHJOEVDFE BMUFSBUJPO JOTLJODPMPS*UTQBUIPHFOFTJTNBZCFESVHPSESVHNFUBCPMJUF EFQPTJUJPOJOUIFEFSNJTBOEFQJEFSNJT FOIBODFENFMBOJOQSPEVDUJPOXJUIXJUIPVUBOJODSFBTFJOUIFOVNCFSPGBDUJWFNFMBOPDZUFT BOEESVHJOEVDFEQPTUJOnBNNBUPSZDIBOHFTJOTLJO 4JNJMBSMZ DIFNJDBMIZQPQJHNFOUBUJPOJTBMTPUIPVHIUUPPDDVS UISPVHIBWBSJFUZPGQBUIPMPHJDNFDIBOJTNT JODMVEJOHBSFEVDFE OVNCFSPGTLJONFMBOPDZUFT FO[ZNBUJDCMPDLBEFPGNFMBOPHFOFTJT BOEJOIJCJUJPOPGNFMBOPTPNFUSBOTGFS

ɨFQIPUPUPYJDSFBDUJPOPOUIFPUIFSIBOEJTOPOJNNVOPMPHJDBMBOEDBOPDDVSPOmSTUFYQPTVSFUPUIFQIPUPUPYJDTVCTUBODF JG FOPVHI PG UIF DISPNPQIPSF BCTPSCT BEFRVBUF BNPVOUT PG UIF BQQSPQSJBUF SBEJBUJPO JO UIF SFBDUJWF UJTTVF ɨF QIPUPUPYJD SFBDUJPO NBZ CF QIPUPEZOBNJD PS OPOQIPUPEZOBNJD

ACNEIFORM ERUPTION

Figure 4. Localization of the lesions on the V of the neck.

SKINmed. 2012;10:373–383

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10 Crowson AN, Magro CM. Recent advances in the pathology of cutaneous drug eruptions. Dermatol Clin. 1999;17:537â&#x20AC;&#x201C;560. 11 Sidoroff A, Halvey S, Bavinck JN, Vaillant L, Roujeau JC. Acute generalJ[FEFYBOUIFNBUPVTQVTUVMPTJT "(&1 BDMJOJDBMSFBDUJPOQBUUFSOJ Cut Pathol. 2001;28:113â&#x20AC;&#x201C;119. 12 Britschgi M, Steiner UC, Schmid S, et al. T-cell involvement in druginduced acute generalized exanthematous pustulosis. J Clin Invest. 2001;107:1433â&#x20AC;&#x201C;1441. 13 Wolkenstein P, Chosidow O, FlĂŠchet ML, et al. Patch testing in severe cutaneous adverse drug reactions, including Stevens-Johnson

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syndrome and toxic epidermal necrolysis. Contact Dermatitis. 1996; 35:234â&#x20AC;&#x201C;236. 14 Watsky KL. Acute generalized exanthematous pustulosis induced by metronidazole: the role of patch testing. Arch Dermatol. 1999;135:93â&#x20AC;&#x201C;94. 15 Halevy S. Acute generalized exanthematous pustulosis. Curr Opin Allergy Clin Immunol. 2009;9:322â&#x20AC;&#x201C;328. 16 Korkij W, Soltani K. Fixed drug eruption. Arch Dermatol. 1984;120:520â&#x20AC;&#x201C; 524. 17 4FIHBM7/ 4SJWBTUBWB('JYFEESVHFSVQUJPO '%& DIBOHJOHTDFOBSJP of incriminating drugs. Int J Dermatol. 2006;45:897â&#x20AC;&#x201C;908. 18 Shiohara T. Fixed drug eruption: pathogenesis and diagnostic tests. Curr Opin Allergy Clin Immunol. 2009;9:316â&#x20AC;&#x201C;321. 19 Sehgal VN, Jain S, Bhattachrya SN. Cutaneous drug reactions. J Eur Acad Dermatol. 1993;2:281â&#x20AC;&#x201C;295. 20 Hennino A, Be´rard F, Guillot I, et al. Pathophysiology of urticaria. Clin Rev Allergy Immunol. 2006;30:3â&#x20AC;&#x201C;11. 21 Shipley D, Ormerod AD. Drug-induced urticaria. Recognition and treatment. Am J Clin Dermatol. 2001;2:151â&#x20AC;&#x201C;158. 22 Dibbern, DA Jr, Dreskin SC. Urticaria and angioedema: an overview. Immunol Allergy Clin North Am. 2004;24:141â&#x20AC;&#x201C;162. 23 Baxi S, Dinakar C. Urticaria and angioedema. Immunol Allergy Clin North Am. 2005;25:353â&#x20AC;&#x201C;367. 24 Kaplan AP, Greaves MW. Angioedema. J Am Acad Dermatol. 2005;53:373â&#x20AC;&#x201C;388; quiz 389â&#x20AC;&#x201C;392. 25 SĂĄnchez-Borges M, GonzĂĄlez-Aveledo LA. Angiotensin-converting enzyme inhibitors and angioedema. Allergy Asthma Immunol Res. 2010;2:195â&#x20AC;&#x201C;198. 26 Mlynarek A, Hagr A, Kost K. Angiotensin-converting enzyme inhibitor inhibitor-induced unilateral tongue angioedema. Otolaryngol Head Neck Surg. 2003;129:593â&#x20AC;&#x201C;595. 27 Byrd JB, Touzin K, Sile S, et al. Dipeptidyl peptidase IV in angiotensinconverting enzyme inhibitor associated angioedema. Hypertension. 2008;51:141â&#x20AC;&#x201C;147. 28 %VBO2- /JLQPPS# %VCF.1 FUBM"WBSJBOUJO91/1&1JTBTTPDJBUFE with angioedema induced by angiotensin I-converting enzyme inhibitors. Am J Hum Genet. 2005;77:617â&#x20AC;&#x201C;626. 29 Weber MA, Messerli FH. Angiotensin-converting enzyme inhibitors and angioedema: estimating the risk. Hypertension. 2008;51:1465â&#x20AC;&#x201C;1467. 30 #SFBUIOBDI 4. &SZUIFNB NVMUJGPSNF  4UFWFOT+PIOTPO TZOESPNF BOE UPYJDFQJEFSNBMOFDSPMZTJT*O#VSOT5 #SFBUIOBDI4. $PY/ (SJGĂĽUI$  eds. Rookâ&#x20AC;&#x2122;s Textbook of Dermatology. 7th ed, vol 4. Oxford: Blackwell 4DJFOUJĂĽD1VCMJDBUJPOo 31 Paul C, Wolkenstein P, Adle H, et al. Apoptosis as a mechanism of keratinocyte death in toxic epidermal necrolysis. Br J Dermatol. 1996;134:710â&#x20AC;&#x201C;714. 32 /BTTJG" #FOTVTTBO" %PSPUIFF( FUBM%SVHTQFDJĂĽDDZUPUPYJD5DFMMT in the skin lesions of a patient with toxic epidermal necrolysis. J Invest Dermatol. 2002;118:728â&#x20AC;&#x201C;733. 33 Nassif A, Bensussan A, Boumsell L, et al. Toxic epidermal necrolysis: FGGFDUPSDFMMTBSFESVHTQFDJĂĽDDZUPUPYJD5DFMMTJ Allergy Clin Immunol. 2004;114:1209â&#x20AC;&#x201C;1215. 34 Abe R, Shimizu T, Shibaki A, et al. Toxic epidermal necrolysis and Stevensâ&#x20AC;&#x201C;Johnson syndrome are induced by soluble Fas ligand. Am J Pathol. 2003;162:1515â&#x20AC;&#x201C;1520. 35 Viard I, Wehrli P, Bullani R, et al. Inhibition of toxic epidermal necrolysis by blockade of CD95 with human intravenous immunoglobulin. Science. 1998;282:490â&#x20AC;&#x201C;493. 36 Bachot N, Revuz J, Roujeau JC. Intravenous immunoglobulin treatment for Stevensâ&#x20AC;&#x201C;Johnson syndrome and toxic epidermal necrolysis: BQSPTQFDUJWFOPODPNQBSBUJWFTUVEZTIPXJOHOPCFOFĂĽUPONPSUBMJUZPS progression. Arch Dermatol. 2003;139:33â&#x20AC;&#x201C;36.

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November/December 2012 37 4FIHBM 7/  4SJWBTUBWB ( 5PYJD FQJEFSNBM OFDSPMZTJT 5&/  -ZFMMT TZOdrome. J Dermatolog Treat. 2005;16:278â&#x20AC;&#x201C;286.

59 $SBJH,4 &EXBSE8$ "OUIPOZ"($VUBOFPVT%SVH3FBDUJPOTPharmacol Rev. 2000;53:357â&#x20AC;&#x201C;379.

38 Keane JT, Pearson RW, Malkinson FD. Nalidixic acid-induced photosensitivity in mice: a model for pseudoporphyria. J Invest Dermatol. 1984;82:210â&#x20AC;&#x201C;213.

60 Wills I, Kligman AM. The mechanism of photoallergic dermatitis. J Invest Dermatol. 1968;51:378.

39 %BCTLJ$ #FVUOFS&)4UVEJFTPGMBNJOJOBOEUZQF*7DPMMBHFOJOCMJTUFST of porphyria cutanea tarda and drug-induced pseudoporphyria. J Am Acad Dermatol. 1991;25:28-32. 40 Breathnach SM. Drug reactions. In: Burns T, Breathnach SM, Cox N, (SJGĂĽUI$ FETRookâ&#x20AC;&#x2122;s Textbook of Dermatology. 8th ed, vol 4. Oxford: #MBDLXFMM4DJFOUJĂĽD1VCMJDBUJPOo 41 Friedmann PS, Lee MS, Friedmann AC, Barnetson RS. Mechanisms in cutaneous drug hypersensitivity reactions. Clin Exp Allergy. 2003; 33:861â&#x20AC;&#x201C;872. 42 Wojnarowska F, Marsden RA, Bhogal B, Black MM. Chronic bullous disease of childhood, childhood cicatricial pemphigoid, and linear IgA disease of adults. A comparative study demonstrating clinical and immunopathologic overlap. J Am Acad Dermatol. 1988;19:792â&#x20AC;&#x201C;805. 43 ,VFDIMF., 4UFHFNFJS& .BZOBSE# FUBM%SVHJOEVDFEMJOFBS*H"CVMlous dermatosis: Report of six cases and review of the literature. J Am Acad Dermatol. 1994;30:187â&#x20AC;&#x201C;192. 44 Nousari HC, Kimyai-Asadi A, Caeiro JP, Anhalt GJ. Clinical, demographic, and immunohistologic features of vancomycin-induced linear IgA bullous disease of the skin. Report of 2 cases and review of the literature. Medicine (Baltimore). 1999;78:1â&#x20AC;&#x201C;8. 45 Wakelin SH, Allen J, Zhou S, Wojnarowska F. Drug-induced linear IgA disease with antibodies to collagen VII. Br J Dermatol. 1998;138:310â&#x20AC;&#x201C;314. 46 Paul C, Wolkenstein P, Prost C, et al. Drug-induced linear IgA disease: target antigens are heterogeneous. Br J Dermatol. 1997;136:406â&#x20AC;&#x201C;411. 47 Palmer RA, Ogg G, Allen J, et al. Vancomycin-induced linear IgA disease with autoantibodies to BP 180 and LAD 285. Br J Dermatol. 2001;145:816â&#x20AC;&#x201C;820. 48 Wolf R, Brenner S. An active amide group in the molecule of drugs that induce pemphigus: a casual or causal relationship? Dermatology. 1994;189:1â&#x20AC;&#x201C;4. 49 Brenner S, Bialy-Golan A, Anhalt GJ. Recognition of pemphigus antigens in drug-induced pemphigus vulgaris and pemphigus foliaceus. J Am Acad Dermatol. 1997;36:919â&#x20AC;&#x201C;923. 50 Sullivan JR, Shear NH. The drug hypersensitivity syndrome: what is the pathogenesis? Arch Dermatol. 2001;137:357â&#x20AC;&#x201C;364. 51 Peyriere H, Derreure O, Bretton H, et al. Variability in clinical patterns of DVUBOFPVTTJEFFGGFDUTPGESVHTXJUITZTUFNJDTZNQUPNT%PFT%3&44 syndrome really exist? Br J Dermatol. 2006;155:422â&#x20AC;&#x201C;428. 52 Sontheimer RD, Houpt KR. DIDMOHS: a proposed consenus nomenclature for the drug-induced delayed multiorgan hypersensitivity syndrome. Arch Dermatol. 1998;134:874â&#x20AC;&#x201C;875. 53 (SFFG%& .FOOJF, .VJTF"%SVHSFBDUJPOXJUIFPTJOPQIJMJBBOETZTtemic systems. CMAJ. 2010;182:481. 54 Peyriere H, Dereure O, Breton H, et al. Variability in the clinical pattern of DVUBOFPVTTJEFFGGFDUTPGESVHTXJUITZTUFNJDTZNQUPNTEPFTB%3&44 syndrome really exist? Br J Dermatol. 2006;155:422â&#x20AC;&#x201C;428. 55 /BJTCJUU %+  'BSSFMM +  8POH (  FU BM $IBSBDUFSJ[BUJPO PG ESVHTQFDJĂĽD T cells in lamotrigine hypersensitivity. J Allergy Clin Immunol. 2003; 111:1393â&#x20AC;&#x201C;1403. 56 %FTDBNQT7 $PMMPU4 .BIĂ?& FUBM"DUJWFIVNBOIFSQFTWJSVTJOGFDtion in a patient with drug rash with eosinophilia and systemic symptoms. J Invest Dermatol. 2003;121:215â&#x20AC;&#x201C;216. 57 Shear NH, Spielberg SP. Anticonvulsant hypersensitivity syndrome. In vitro assessment of risk. J Clin Invest. 1988;82:1826â&#x20AC;&#x201C;1832. 58 Magro CM, Crowson AN, Kovatich AJ, Burns F. Drug-induced reversible lymphoid dyscrasia: a clonal lymphomatoid dermatitis of memory and activated T cells. Hum Pathol. 2003;34:119â&#x20AC;&#x201C;129.

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61 Crowson AN, Magro CM. Recent advances in the pathology of cutaneous drug eruptions. Dermatol Clin. 1999;17:537. 62 Halder RM, Nandedkar MA, Neal KW. Pigmentary disorders in ethnic skin. Dermatol Clin. 2003;21:617â&#x20AC;&#x201C;628. 63 Kaidbey KH, Kligman AM. The pathogenesis of topical steroid acne. J Invest Dermatol. 1974;62:31â&#x20AC;&#x201C;36. 64 0MJFU&+ &TUFT4"1FSJBOBMDPNFEPOFTBTTPDJBUFEXJUIDISPOJDUPQJDBM fluorinated steroid use. J Am Acad Dermatol. 1982;7:405â&#x20AC;&#x201C;407. 65 Gloor M, Mildenberger KH. On the influence of an external therapy with dexamethasone-21-sodium-m-sulfobenzoate on the amount of free fatty acids in the skin surface lipids. Arch Dermato Res. 1978;261: 33â&#x20AC;&#x201C;38. 66 %F8JUU $"  4JSPZ "&  4UPOF 41 "DOFJGPSN FSVQUJPOT BTTPDJBUFE XJUI epidermal growth factor receptor-targeted chemotherapy. J Am Acad Dermatol. 2007;56:500â&#x20AC;&#x201C;505. 67 .BIĂ?& .PSFMPO& -FDIBUPO4 FUBM"DOFJOSFDJQJFOUTPGSFOBMUSBOTplantation treated with sirolimus: clinical, microbiologic, histologic, therapeutic, and pathogenic aspects. J Am Acad Dermatol. 2006;55: 139â&#x20AC;&#x201C;142. 68 #BTTJ& 1PMJ' $IBSBDIPO" 3FWV[+*OĂ˝JYJNBCJOEVDFEBDOFSFQPSUPG two cases. Br J Dermatol. 2007;156:402â&#x20AC;&#x201C;403. 69 Bencini PL, Montagnino G, Sala F, et al. Cutaneous lesions in 67 cyclosporin-treated renal transplant recipients. Dermatologica. 1986;172:24â&#x20AC;&#x201C;30. 70 Fyrand O, Fiskaadal HJ, Trygstad O. Acne in pubertal boys undergoing treatment with androgens. Acta Derm Venereol. 1992;72:148â&#x20AC;&#x201C;149. 71 Chan HH, Wing Y, Su R, Van Krevel C, Lee S. A control study of the cutaneous side effects of chronic lithium therapy. J Affect Disord. 2000;57:107â&#x20AC;&#x201C;113. 72 &YOFS+) %BIPE4 1PDIJ1&1ZPHFOJDHSBOVMPNBMJLFBDOFMFTJPOTEVSing isotretinoin therapy. Arch Dermatol. 1983;119:808â&#x20AC;&#x201C;811. 73 #FSFTUPO &4 3FBDUJPOT UP BOUJUVCFSDVMPVT ESVHT J Invest Dermatol. 1959;33:427â&#x20AC;&#x201C;439. 74 Cohen LK, George W, Smith R. Isoniazid-induced acne and pellagra. Occurrence in slow inactivators of isoniazid. Arch Dermatol. 1974; 109:377â&#x20AC;&#x201C;381. 75 4IFSFSU[ &' "DOFJGPSN FSVQUJPO EVF UP iNFHBEPTFw WJUBNJOT # BOE B12. Cutis. 1991;48:119â&#x20AC;&#x201C;120. 76 Sontheimer RD. Lichenoid tissue reaction/interface dermatitis: clinical and histological perspectives. J Invest Dermatol. 2009;129:1088â&#x20AC;&#x201C;1099. 77 Sehgal VN, Srivastava G, Sharma S, Sehgal S, Verma P. Lichenoid tisTVF SFBDUJPOJOUFSGBDF EFSNBUJUJT 3FDPHOJUJPO  DMBTTJĂĽDBUJPO  FUJPMPHZ  and clinicopathological overtones. Indian J Dermatol Venereol Leprol. 2011;77:418â&#x20AC;&#x201C;430. 78 Sehgal VN, Dogra S, Srivastava G, Aggarwal AK. Psoriasiform dermatoses. Indian J Dermatol Venereol Leprol. 2008;74:94â&#x20AC;&#x201C;99. 79 Seneschal J, Milpied B, Vergier B, Lepreux S, Schaeverbeke T, TaĂŻeb A. Cytokine imbalance with increased production of interferon-alpha in psoriasiform eruptions associated with antitumour necrosis factor-alpha treatments. Br J Dermatol. 2009;161:1081â&#x20AC;&#x201C;1088. 80 Devos SA, Van Den Bossche N, De Vos M, Naeyaert JM. Adverse skin reactions to anti-TNF-alpha monoclonal antibody therapy. Dermatology. 2003;206:388â&#x20AC;&#x201C;390. 81 Aeberli D, Oertle S, Mauron H, Reichenbach S, Jordi B, Villiger PM. Inhibition of the TNF-pathway: use of infliximab and etanercept as remission-inducing agents in cases of therapy-resistant chronic inflammatory disorders. Swiss Med Wkly. 2002;132:414â&#x20AC;&#x201C;422.

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November/December 2012 82 Gill R, Mohammed F, Badyal R, et al. High-resolution structure of myoinositol monophosphatase, the putative target of lithium therapy. Acta Crystallogr D Biol Crystallogr. 2005;61:545â&#x20AC;&#x201C;555.

91 4IBQJSP-& 6FUSFDIU+ 4IFBS/).JOPDZDMJOF QFSJOVDMFBSBOUJOFVUSPphilic cytoplasmic antibody, and pigment: the biochemical basis. J Am Acad Dermatol. 2001;45:787â&#x20AC;&#x201C;789.

83 Karvonen SL, Korkiamaki T, Yla-Outinen H, et al. Psoriasis and altered calcium metabolism: downregulated capacitative calcium influx and defective calcium-mediated cell signaling in cultured psoriatic keratinocytes. J Invest Dermatol. 2000;114:693â&#x20AC;&#x201C;700.

92 (VOUPO+& 4UJFM+ $BUFSTPO3+ .D&MEVGG"$MJOJDBMDBTFTFNJOBS"OUJ thyroid drugs and antineutrophil cytoplasmic antibody positive vasculitis. A case report and review of the literature. J Clin Endocrinol Metab. 1999;84:13â&#x20AC;&#x201C;16.

84 Takahashi H, Honma M, Miyauchi Y, et al. Cyclic AMP differentially SFHVMBUFTDFMMQSPMJGFSBUJPOPGOPSNBMIVNBOLFSBUJOPDZUFTUISPVHI&3, activation depending on the expression pattern of B-Raf. Arch Dermatol Res. 2004;296:74â&#x20AC;&#x201C;82.

93 Otsuka S, Kinebuchi A, Tabata H, Yamakage A, Yamazaki S. Myeloperoxidase-antineutrophil cytoplasmic antibody-associated vasculitis following propylthiouracil therapy. Br J Dermatol. 2000;142:828â&#x20AC;&#x201C;830.

85 Wolf R, Schiavo AL, Lombardi ML, et al. The in vitro effect of hydroxychloroquine on skin morphology in psoriasis. Int J Dermatol. 1999;38:154â&#x20AC;&#x201C;157. 86 Marzano AV, Vezzoli P, Crosti C. Drug-induced lupus: an update on its dermatologic aspects. Lupus. 2009;18:935â&#x20AC;&#x201C;940. 87 Jain KK. Drug-induced cutaneous vasculitis. Adverse Drug React Toxicol Rev. 1993;12:263â&#x20AC;&#x201C;276. 88 Lotti T, Ghersetich I, Comacchi C, Jorizzo JL. Cutaneous small-vesselvasculitis. J Am Acad Dermatol. 1998;39:667â&#x20AC;&#x201C;687. 89 Schaffer JV, Davidson DM, McNiff JM, Bolognia JL. Perinuclear antineutrophilic cytoplasmic antibody-positive cutaneous polyarteritis nodosa associated with minocycline therapy for acne vulgaris. J Am Acad Dermatol. 2001;44:198â&#x20AC;&#x201C;206. 90 Schrodt BJ, Kulp-Shorten CL, Callen JP. Necrotizing vasculitis of the skin and uterine cervix associated with minocycline therapy for acne vulgaris. South Med J. 1999;92:502â&#x20AC;&#x201C;504.

94 Helfgott SM, Smith RN. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 21-2002. A 21-year-old man with arthritis during treatment for hyperthyroidism. N Engl J Med. 2002;347:122â&#x20AC;&#x201C;130. 95 Nolan D, Mallal S. Antiretroviral-therapy-associated lipoatrophy: current status and future directions. Sex Health. 2005;2:153â&#x20AC;&#x201C;163. 96 Lassalle S, Cervera P, Hofman V, et al. Antiretroviral treatments-relatFE MJQPEZTUSPQIZ TZOESPNF DMJOJDPQBUIPMPHJDBM ĂĽOEJOHT Ann Pathol. 2005;25:309â&#x20AC;&#x201C;317. 97 Buffet M, Schwarzinger M, Amellal B, et al. Mitochondrial DNA depletion in adipose tissue of HIV-infected patients with peripheral lipoatrophy. J Clin Virol. 2005;33:60â&#x20AC;&#x201C;64. 98 Vigourox C, Maachi M, Nguyen TH, et al. Serum adipocytokines are related to lipodystrophy and metabolic disorders in HIV-infected men under antiretroviral therapy. AIDS. 2003;17:1503â&#x20AC;&#x201C;1511.

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November/December 2012

Volume 10 • Issue 6

PERILS OF DERMATOPATHOLOGY W. Clark Lambert, MD, PHD, Section Editor

On Bossing: Taking Charge Without the Facts Cindy Wassef, BA; Cristian Serna-Tamayo, BS; Patrick McDonough, BA; Gizem Tumer, MD; W. Clark Lambert, MD, PhD Ours is not to reason why, Ours is but to do, or die. —Alfred, Lord Tennyson, The Charge of the Light Brigade (1854)

I

t is common practice in many dermatopathology reports to include a section beyond the diagnosis, which provides surgical recommendations for lesions. Such recommendations often raise a dispute regarding the role of dermatopathologists in the treatment plan of such cases. Are dermatopathologists, as Glogau1 described, “pretending” to be dermatologists? Or do such recommendations provide a necessary and reliable facet to treating dermatologists? “OURS IS NOT TO REASON WHY” In determining the usefulness of dermatopathologists’ recommendations, it is important to keep in mind factors involved in choosing treatment. While the value of clinical presentation is often debated, with differing opinions from dermatologists and dermatopathologists,2–4 other factors, such as surgical and medical history as well as family history of cutaneous malignancy, influence the treatment plan. This information, in addition to other knowledge gained only through contact and conversation with the patient, is most often absent from histological requisition forms1,5 and, thus, the dermatopathologist who makes treatment recommendations may do so without all of the relevant facts. In addition, dermatologists also have noted that often terse diagnoses given in dermatopathology reports such as “basal cell carcinoma, nose” are of very little benefit to their treatment plans.1 Basing a treatment plan on such information can be challenging for dermatologists who at least have access to the clinical presentation; however, dermatopathologists often do not have access to this clinical information and thus offer blinded treatment suggestions. The information received through requisition forms that dermatopathologists base their diagnosis and treatment plans on is often incomplete as well. In a study conducted in 2008, dermatopathol-

ogy requisition forms received from private dermatology offices for 100 consecutive melanocytic lesions were assessed. While all 100 requisition forms included information about patient age, sex, and site of lesion, no morphological characteristics were provided for 67 of the 100 lesions. Other clinical data were also reported at low frequency, including asymmetry (4% reported), border irregularity (8%), color (39%), and diameter/size (22%). No requisition form included any mention of prior history, family history of melanoma, or past treatment at the site and whether the biopsy was a partial or complete specimen. Only 1% included dermatoscopic conclusions and a clinical photograph, which are the mainstay findings used for diagnosis to many dermatologists.5 Rendering a treatment with such limited and inconsistent information is without clinical basis and is both unreliable and imprecise. Diagnosis and treatment is based on a correlation between clinical presentation and histopathology, and if either of these factors is missing, an accurate conclusion cannot be reached.6 DERMATOPATHOLOGISTS’ RECOMMENDATIONS Dermatopathologists’ recommendations are also controversial given that many dermatopathologists have scant clinical dermatologic training.7 Dermatopathologists who complete a residency in pathology receive only 6 months of clinical dermatology training, compared with dermatologists who spend the bulk of their 3-year residency on clinical dermatology. Pathology residents with 6 months of clinical dermatologic training cannot be expected to have the same level of knowledge about surgical and pharmacologic interventions as dermatologists. ILLUSTRATIVE CASES A reciprocal scenario can also arise: A 45-year-old woman presented to her dermatologist with an 8-month history of an

From the Departments of Pathology and Dermatology, UMDNJ-New Jersey Medical School, Newark, NJ Address for Correspondence: W. Clark Lambert, MD, PhD, Room C520 MSB, UMDNJ-NJMS, 185 South Orange Avenue, Newark, NJ 07101 • E-mail: lamberwc@umdnj.edu

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November/December 2012

PERILS OF DERMATOPATHOLOGY

Figure. (A) Pseudoepitheliomatous hyperplasia with fibrosis and chronic inflammation (hematoxylin-eosin stain, original magnification ×20). (B) Granulomatous inflammation with brown pigment deposition (black arrows) (hematoxylin-eosin stain, original magnification ×40).

annular erythematous eruption around areas of red tattoo pigment from a tattoo performed in Puerto Rico 3 years previously. A punch biopsy was taken to differentiate between granulomatous tattoo hypersensitivity and chronic infection. The ordering clinician specified that an acid-fast bacilli test be performed to rule out tuberculosis infection; however, when a granulomatous lesion was observed by a pathologist, many conditions were considered within the differential diagnosis. Microscopic examination dictated to the dermatopathologist whether an acid-fast bacilli test was appropriate (Figure  1A and 1B). In this case, demand for an acid-fast bacilli test by the clinician was made based on clinical suspicion, but on microscopic examination, it was not justified. The granulomatous appearance was altered by overlying pseudoepitheliomatous hyperplasia. As expected, results from the acid-fast bacilli test were negative. Another example encountered by one of us (WCL) involved treatment of parapsoriasis. This author had published in many textbooks, and in order to promote appropriate treatment of parapsoriasis, he thought that treatment must be undertaken. An astute reader from India sent him a letter describing one of his patients who traveled 3 days per week to receive UV radiation twice a week. While treatment of parapsoriasis is recommended, other factors, such as access to medical care, which our author could not have known about in this case, must also be factored into the treatment plan.

dermatopathologists to supplement their macroscopic findings with a precise diagnosis that only microscopic findings can provide.4 Dermatopathologists, in turn, rely on dermatologists for clinical evidence and further clues to guide their assessment. In the case of treatment planning, dermatologists have more intimate knowledge of the patient and often a greater knowledge of potential therapeutic options; thus, it is the responsibility of the dermatologist to formulate the treatment plan. Similarly, dermatologists should make requests of the dermatopathologist, and textbook authors should give advice, with care and humility, because only the recipient knows the true situation. All parties involved should continue to make suggestions but be aware that the individual situation will ultimately dictate the best measures to be taken. REFERENCES 1

Glogau RG. Collegiality and dermatology. J Am Acad Dermatol. 2005; 53:701–702.

2

Ackerman AB. Dermatologist not equal to dermatopathologist: no place in a profession for pretenders. J Am Acad Dermatol. 2005;53:698–699.

3

Gromet MA. Dermatopathologist/academic not equal arbiter of competence/ethics/morality: no place in a profession for sanctimony. J Am Acad Dermatol. 2006;55:170–172.

4

Conrad N, Haque R, Cockerell CJ. Delivery of dermatopathologic health care in the twenty-first century. Dermatol Clin. 2000;18:241–249.

5

Waller JM, Zedek DC. How informative are dermatopathology requisition forms completed by dermatologists? A review of the clinical information provided for 100 consecutive melanocytic lesions. J Am Acad Dermatol. 2010;62:257–261.

“OURS IS BUT TO DO, OR DIE”

6

It is important not to lose sight of the complementary nature of dermatology and dermatopathology. Dermatologists rely on

Sellheyer K, Bergfield WF. “Lesion”, Rule out…,” and other vagaries of filling out pathology requisition forms. J Am Acad Dermatol. 2005;52:914–915.

7

Boyd AS, Fang F. A survey-based evaluation of dermatopathology in the United States. Am J Dermatopathol. 2011;33:173–176.

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Volume 10 • Issue 6

HISTORY OF DERMATOLOGY SOCIETY NEWSLETTER Eve J. Lowenstein, MD, PhD, Section Editor

Mosquito Wars: Malaria and Bioterrorism in Italy, 1943–1945 Frank M. Snowden, PhD

B

y July 1943, Italian hopes for victory in World War II lay in ruins. Axis armies were in disarray on all fronts, the Allies had landed in Sicily, and bombs were falling on Italian cities. In this impending disaster, Mussolini’s dictatorship collapsed on July 25. On September 8, the successor government of Pietro Badoglio reversed sides, declaring war on Germany as a “cobelligerent” of the Allies.1

Immediately after this volte-face, the German army occupied Italy, imposing a brutal policy of recruiting forced labor, plundering resources, and punishing Italians for their betrayal. German troops also carried out a series of massacres, killing unarmed men, women, and children in a “war against civilians.” The distinction between the eastern and western fronts was blurred in the Italian theater.2 VENGEANCE The Pontine Marshes south of Rome also experienced a war crime. The German army used malaria as an instrument of bioterrorism in violation of the Hague Treaty3 and the Geneva Convention.4 The signatories, including Germany, had pledged to inflict no unnecessary harm on civilians and to renounce chemical and biological weapons. Nazi policy had a special focus in the Pontine Marshes because its reclamation and settlement was a celebrated accomplishment of Italian Fascism. Undoing this project, restoring the swamps, and unleashing malaria were means of inflicting humiliation as well as suffering. Furthermore, a substantial malaria epidemic could slow the Allied armies and complicate the task of governing the liberated territories. Finally, the project was an experiment in Nazi medical science whose goal was to cause rather than alleviate suffering. The result between 1944 and 1946 was a great malaria epidemic in which nearly all of the 150,000 settlers contracted malaria, and especially the virulent form caused by Plasmodium falciparum, despite the fact that the Littoria province was declared malaria-free in 1939.5

THE NAZI SCIENCE OF TERROR The architect of this project was Erich Martini, one of the leading malariologists in Europe. Martini was Professor of Medicine at Hamburg, an early member of the Nazi Party, a protégé of Heinrich Himmler, and a biological warfare specialist.6 He was also an expert on the sanitary infrastructure of the Pontine Marshes who had worked there with his Italian colleague and fellow malariologist Alberto Missiroli. Their work had contributed to understanding an outstanding malaria puzzle—the natural history and speciation of anopheles mosquitoes. One aspect of their discoveries was directly relevant: the role of the malariavector Anopheles labranchiae. Alone of mosquitoes in the former Pontine Marshes, A labranchiae could breed in both fresh and brackish water. Martini’s experiment, therefore, involved two steps. The first was to stop the powerful pumps installed by Mussolini’s regime to discharge runoff from the hills into the sea. This act, taken in the autumn of 1943, caused the reclaimed land to revert to marshland as it had been before the Fascist bonification program.7 The flooding has been understood as a legitimate act of war intended to slow the advancing Allied armies. This first step, however, was followed by a second step that was useless for military purposes but had dire health consequences. This second step was to put the pumps into reverse action, drawing seawater to heighten the level of salinity. One result was to blight the crops and to harm domestic and farm animals. The most important consequence, however, was to modify the environment in order not only to increase the numbers of mosquitoes exponentially but also to ensure that nearly all were A labranchiae, the highly efficient vector. This was “species sanitation” in reverse. The Italian malariologist Alberto Coluzzi, who played a leading role in combating the resulting epidemic, conducted on-site inspections and concluded that the epidemic was “man-made malaria.”8 One clue was geographical. Extensive zones were flooded, he discovered, that had no military value. Furthermore, increasing

From the Program in History of Science and History of Medicine, History Department, Yale University, New Haven, CT Address for Correspondence: Frank M. Snowden, PhD, Andrew Downey Orrick Professor of History, Chair, Program in History of Science and History of Medicine, Yale University, History Department, P.O. Box 208324, New Haven, CT 06520-8324 • E-mail: frank.snowden@yale.edu

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HISTORY OF DERMATOLOGY

the salinity was a procedure whose consequences were known best of all to Martini, the expert on A labranchiae and on biological warfare. Furthermore, before departing, the German army took additional measures that maximized the impact on public health. These measures included destroying the sanitary infrastructure by removing as many water pumps as possible and transporting them to Germany while dynamiting the ones they were unable to move. This action had no purpose except to make certain that the impact on the civilian population was lasting and maximally difficult to repair, particularly when the Wehrmacht planted mine fields surrounding the former pumping stations. There was also a sinister logic in the decisions to confiscate the supplies of the antimalarial medication quinine from the Department of Health in Rome and to destroy the boats used to keep the drainage canals free-flowing and clear of vegetation.9

REFERENCES

ITALIAN SCIENTIFIC COMPLICITY Mussolini’s foreign policy comprehensively destroyed his most celebrated domestic program when his Axis partner carried out the only instance of biological warfare in 20th-century Europe, at the expense of the Italian civilian population. Surprisingly, however, the extent of the epidemic was magnified by Missiroli, the Italian High Commissioner of Health and Martini’s former colleague. He wrote in his own hand that he and other Italians had beseeched the Germans to have due regard for Italian civilians and for international law. Once the experiment had begun, however, Missiroli was anxious to see whether DDT was a weapon potent enough to contain malaria. He, therefore, systematically withheld antimalarial medication from the population to observe the power of DDT alone.10

1

Deakin FW. The Brutal Friendship: Mussolini, Hitler, and the Fall of Italian Fascism. London: Weidelfeld and Nicolson, 1962; Lamb R. War in Italy, 1943–1945: A Brutal Story.London: Murray, 1993); and Plehwe F von, The End of an Alliance: Rome’s Defection from the Axis in 1943. London and New York: Oxford; 1971. 2 Battini M, Pezzini P. Guerra aicivili: occupazionetedesca e politica del massacro. Toscana 1944.Venice: Marsilio, 1997); Collotti E, Klinkhammer L. L’occupazionetedesca, 1943–1945. Rome, 1996; and Schreiber G. La vendetta tedesca, 1943–1945: le rappresaglienaziste in Italia, trans. M. Buttarelli. Milan: Mondadori, 2000. 3 The text of the Hague Convention. http://avalon.law.yale.edu/ 20th_century/hague04.asp. Accessed June 5, 2010. 4 Protocol for the prohibition of the use in war of asphyxiating, poisonous or other gases, and of bacteriological methods of warfare. http://www.fas.harvard.edu/~hsp/1925.html. Accessed June 5, 2010. 5 Snowden FM. The Conquest of Malaria: Italy, 1900–1962. New Haven: Yale; 2006: chap 7. 6 Hering R. Nazi Persecution and the Pursuit of Science: Correspondence between Erich Martini and Otto Hecht, 1946–1947. Jewish Culture Hist. 2000;3:95–124. 7 McCormic AO. Abroad: undoing the German campaign of the mosquito. New York Times. September 13, 1944; Kumm HW. Malaria Control West of Rome during the Summer of 1944, 26 January 1945. Rockefeller Archive Center, Record Group 1.2, 700 Europe, box 12, Folder 102. 8 Private Archive of Mario Coluzzi. Rome, Italy, Coluzzi, A. Diary, 18-24. 9 Missiroli A. La malaria nella zona di Maccarese. January 24, 1947. Central State Archive, Rome, Italy. Ms, ISS, Laboratorio di Parassitologia, b. 6, fasc. 19, sottofasc. Maccarese: Difesa antimalarica.. 10 Missiroli A. La malaria nellazfona di Maccarese. January 24, 1947. Archivio Centrale dello Stato, Rome. MS, ISS, Laboratorio di Parassitologia, b. 6, fasc. 19, sottofasc. Maccarese: Difesa antimalarica.

HISTORY OF DERMATOLOGY SOCIETY

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November/December 2012

CASE STUDY Vesna Petronic-Rosic, MD, MSc, Section Editor

Radiation Port Erythema Multiforme: Erythema Multiforme Localized to the Radiation Port in a Patient With Non–Small Cell Lung Cancer Hubert M. Chodkiewicz, MD;1 Philip R. Cohen, MD2,3,4, "ZFBSPMENBOXBTUSFBUFEXJUITUFSFPUBDUJDSBEJBUJPOUPHSBZVOJUTJOGSBDUJPOTGPSTUBHF*#OPOoTNBMMDFMMMVOHDBODFS3BEJPUIFSBQZ XBTEJSFDUFEBUUIFSJHIUMPXFSMPCFTFHNFOUPGUIFMVOHBOEMBTUFEEBZT)FEFWFMPQFESBEJPEFSNBUJUJT XIJDIDPNQMFUFMZSFTPMWFEXJUIJO BGFXXFFLTBGUFSSBEJPUIFSBQZXBTmOJTIFEɨSFFNPOUITBGUFSDPNQMFUJOHSBEJBUJPOUIFSBQZ IFEFWFMPQFEBQSVSJUJDSFEMFTJPOXJUIJOIJT SBEJBUJPOQPSUPOIJTSJHIUNJECBDLXJUIUIFGPSNBUJPOPGCMJTUFSTBXFFLMBUFS5XPXFFLTBGUFSUIFPOTFUPGUIFQBUJFOUTCMJTUFST DVUBOFPVTFYBNJOBUJPOTIPXFEJOEJWJEVBMBOEDPOWFSHFOUFSZUIFNBUPVTQBQVMFTBOEQMBRVFTXJUITVQFSmDJBMTDBMJOHBUTJUFTPGSFTPMWJOHWFTJDMFT MPDBUFEXJUIJOUIFSBEJBUFEBSFB 'JHVSFTBOE ɨFQBUJFOUIBEOFJUIFSTZNQUPNTPGNZDPQMBTNBQOFVNPOJBF OPSMFTJPOTPSIJTUPSZPG QSFTFOUPSQBTUIFSQFUJDJOGFDUJPO"MTP IFIBEOPUSFDFOUMZCFFOQMBDFEPOBOZOFXNFEJDBUJPOT BOEIFEJEOPUIBWFBOZPUIFSFSZUIFNB NVMUJGPSNFoBTTPDJBUFESJTLGBDUPST"CJPQTZGSPNUIFFSZUIFNBUPVTMFTJPOTTIPXFEBCBOEMJLFJOmMUSBUFPGMZNQIPDZUFTJOUIFEFSNJT ɨFPWFSMZJOHFQJEFSNJTDPOUBJOFEOFDSPUJDLFSBUJOPDZUFTBOEUIFSFXBTBMUFSBUJPOPGUIFCBTBMMBZFS$PSSFMBUJPOPGUIFDMJOJDBMQSFTFOUBUJPOBOEQBUIPMPHJDDIBOHFTFTUBCMJTIFEBEJBHOPTJTPGFSZUIFNBNVMUJGPSNFMPDBMJ[FEUPUIFSBEJBUJPOQPSUɨFQBUJFOUXBTUSFBUFEXJUI UPQJDBMUSJBNDJOPMPOFBDFUPOJEFDSFBNUXJDFEBJMZGPSEBZTBOEPODFEBJMZGPSEBZT)JTMFTJPOTSFTPMWFEBOEUIFSFXBTNJME IZQFSQJHNFOUBUJPOPGUIFBĊFDUFEBSFB

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From The Medical School, The University of Texas-Houston Medical School;1 The University of Houston Health Center, University of Houston;2 the Department of Dermatology, The University of Texas M.D Anderson Cancer Center;3 and the Department of Dermatology, University of Texas-Houston Medical School,4 Houston, TX "EESFTTGPS$PSSFTQPOEFODF1IJMJQ3$PIFO .% 5XJOMFBG$PVSU 4BO%JFHP $"t&NBJMNJUFIFBE!HNBJMDPN

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Figure 1. Distant view of right mid back showing individual and confluent erythematous papules and plaques confined to the area of radiation.

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Figure 2. Closer view of radiation port location on the patient’s right mid back shows that some of the erythematous plaques have dusky-appearing central areas. The centrally located black keratotic plaque is an inflamed seborrheic keratosis.

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.JDBMJ( -JOUIJDVN, )BO/ 8FTU%1*ODSFBTFESJTLPGFSZUIFNBNVMtiforme major with combination anticonvulsant and radiation therapies. Pharmacotherapy. 1999;19:223โ€“227.

7

#PSH .'  1SPCFSU +$  ;XJ -+ *T QIFOZUPJO DPOUSBJOEJDBUFE JO QBUJFOUT receiving cranial irradiation? Australas Radiol. 1995;39:42โ€“46.

8

)VGG+$ 8FTUPO8- 5POOFTFO.(&SZUIFNBNVMUJGPSNFBDSJUJDBMSFview of characteristics, diagnostic criteria, and causes. J Am Acad Dermatol. 1983;8:763โ€“775.

CONCLUSIONS

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'MFJTDIFS "#  3PTFOUIBM %*  #FSOBSE 4"  0,FFGF &+ 4LJO SFBDUJPOT UP radiotherapyโ€”a spectrum resembling erythema multiforme: case report and review of the literature. Cutis. 1992;49:35โ€“39.

2

5POOFTFO .(  4PUFS /" &SZUIFNB NVMUJGPSNF J Am Acad Dermatol. 1979;1:357โ€“364.

3

"INFE  *  3FJDIFOCFSH +  -VDBT "  4IFIBO +. &SZUIFNB NVMUJGPSNF associated with phenytoin and cranial radiation therapy: a report of three patients and review of the literature. Int J Dermatol. 2004;43:67โ€“73.

4

"VRVJFS%VOBOU" .PDLFOIBVQU. /BMEJ- FUBM$PSSFMBUJPOTCFUXFFO clinical patterns and causes of erythema multiforme majus, Stevens+PIOTPOTZOESPNF BOEUPYJDFQJEFSNBMOFDSPMZTJTSFTVMUTPGBOJOUFSOBtional prospective study. Arch Dermatol. 2002;138:1019โ€“1024.

5

#BSCPTB-" 5FJYFJSB$3&SZUIFNBNVMUJGPSNFBTTPDJBUFEXJUIQSPQIZlactic use of phenytoin during cranial radiation therapy. Am J Health Syst Pharm. 2008;65:1048โ€“1050.

10 8PISM4 -PFXF3 1JDLM8' 4UJOHM( 8BHOFS4/&.1"$5TZOESPNFJ Dtsch Dermatol Ges. 2005;3:39โ€“43. 11 Pandya AG, Kettler AH, Bruce S. Radiation-induced erythema multiforme. An unusual presentation with elastic tissue phagocytosis. Int J Dermatol. 1989;28:600โ€“602. 12 3VPDDP7 #SVOFUUJ( 1VDB37 3VPDDP&5IFJNNVOPDPNQSPNJTFEEJTtrict: a unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites. J Eur Acad Dermatol Venereol. 2009;23:1364โ€“1373. 13 .VM7& WBO(FFTU"+ 1JKMT+PIBOOFTNB.$ FUBM3BEJBUJPOJOEVDFECVMlous pemphigoid: a systematic review of an unusual radiation side effect. Radiother Oncol. 2007;82:5โ€“9. 14 'PMMJFSP( ;VSMP" "NBOUJ$ 5PNCPMJOJ7 %J1BPMB.#VMMPVTQFNQIJgoid induced by radiation therapy. Clin Oncol. 1995;7:266โ€“267. 15 Okamoto S, Takahashi S, Inoue T, et al. Cutaneous chronic graft-versushost disease localized to the field of total lymphoid irradiation. Bone Marrow Transplant. 1996;17:111โ€“113. 16 4PDJF( (MVDLNBO& $PTTFU+. FUBM6OVTVBMMPDBMJ[BUJPOPGDVUBOFPVT chronic graft-versus-host disease in the radiation fields in four cases. Bone Marrow Transplant. 1989;4:133โ€“135. 17 4IVSNBO %  3FJDI )-  +BNFT 8% -JDIFO QMBOVT DPOรฅOFE UP B SBEJBtion field: the โ€œisoradiotopicโ€ response. J Am Acad Dermatol. 2004;50: 482โ€“483. 18 ,JN+) ,SJWEB4+-JDIFOQMBOVTDPOรฅOFEUPBSBEJBUJPOUIFSBQZTJUFJ Am Acad Dermatol. 2002;46:604โ€“605. 19 :BUFT7. ,JOH$. %BWF7,-JDIFOTDMFSPTVTFUBUSPQIJDVTGPMMPXJOH radiation therapy. Arch Dermatol. 1985;121:1044โ€“1047. 20 $BSSPUUF-FGFCWSF* %FMBQPSUF& .JSBCFM9 1JFUUF'3BEJBUJPOJOEVDFETLJO reactions (except malignant tumors). Bull Cancer. 2003;90:319โ€“325. 21 3PCCJOT"$ -B[BSPWB; +BOTPO.. 'BJSMFZ+"1FNQIJHVTWVMHBSJTQSFsenting in a radiation portal. J Am Acad Dermatol. 2007;56:S82โ€“S85. 22 %FMBQPSUF& 1JFUUF' #FSHPFOE)1FNQIJHVTWVMHBSJTJOEVDFECZSBEJPtherapy. Ann Dermatol Venereol. 1991;118:447โ€“451. 23 Polat M, Yalรงin B, Alli N. Vitiligo at the site of radiotherapy for nasopharyngeal carcinoma. Am J Clin Dermatol. 2007;8:247โ€“249.

VINTAGE LABEL

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November/December 2012

Volume 10 • Issue 6

CASE STUDY Vesna Petronic-Rosic, MD, MSc, Section Editor

Cladosporium Scalp Infection Erwin Eduardo Argueta Sosa, MD;1 Philip R. Cohen, MD;2,3,4 Jaime A. Tschen, MD4,5,6

An 11-year-old healthy red-haired girl presented with a 3-year history of hair loss and mild pruritus of her scalp. She had previously been diagnosed with trichotillomania. Cutaneous examination showed scant hair loss with neither crusting nor scaly lesions. The scalp hair was diffusely thin, dry, and brittle on the frontal, mid-parietal, and anterior occipital scalp (Figure 1A). A pull test was negative, and a significant number of hair shafts were not detached on repeated traction. Closer examination using a dermatoscope showed follicles with broken hair shafts. The dermatoscopic evaluation also showed frequent pinpoint black dots scattered among the terminal hair shafts at their bases. No scale, scar, or inflammatory changes were seen in the involved areas (Figure 1B). A 20% potassium hydroxide (KOH) preparation of material obtained after gentle scrapping of the black dots on the scalp provided fragments of hair fibers containing aggregates of pigmented yeast forms (Figure 2A) and brown septate hyphae (Figure 2B). Two samples were sent for fungal culture and both showed dark brown colonies on the surface and black coloration when viewed from the reverse side (Figure 3A). Lactophenol cotton blue preparation of the fungal colonies revealed long and septate hyphae with laterally branching conidiophores ending in round-shaped conidia (Figure 3B). The microorganism was identified by the reference laboratory as Cladosporium species. The conidia were usually noted to be single-celled with a distinct dark hilum. They also exhibited prominent attachment scars that caused the cells to appear “shield-shaped.” These features were considered to be diagnostic for Cladosporium; however, the reference laboratory could not identify the organism to the species level. The girl’s Cladosporium scalp infection was treated with itraconazole at an oral daily dose of 200 mg for 2 months. Upon re-evaluation, she showed significant improvement with not only discontinuation of her alopecia and new hair growth (Figure 4A), but also an absence of broken hair shafts and the dark pigmentation found initially at their base when her scalp was examined using a dermatoscope (Figure 4B). In addition, a new KOH preparation did not reveal the presence of conidia.

DISCUSSION Cladosporium is classified as a dematiaceous fungus. This refers to fungi whose cell walls produce melanin and therefore are naturally pigmented black or brown. The melanin also results in the dark pigment that is clearly visible when colonies of dematiaceous organisms grow in fungal culture media. Cladosporium is considered to be a saprophyte that can be found in soil, a site common to keratinophilic fungi.1,2 In addition to plants and decaying matter, Cladosporium has also been documented in hospital air equipment.1 Direct inoculation of the fungal microorganism into the involved human tissue is considered necessary for Cladosporium infections to occur. Cladosporium isolates have been cultured from superficial infections of skin (Cladosporium carrionii), mucosa (Cladosporium cladosporioides), and nails (Cladosporium

species): chromoblastomycosis, keratomycosis, and onychomycosis, respectively.3–6 In addition, Cladosporium infection of superficial skin (Cladosporium cladosporioides) may extend into the subcutaneous tissue2; occasionally, more severe central nervous system involvement (secondary to Caldosporium bantianum— which has recently been named Cladophialophora bantiana—or Cladosporium macrocarpum) has also been described.7–9 The diagnosis of Cladosporium infection may be suspected by finding the characteristic morphological features of the fungus when examining a 20% KOH preparation taken from a cutaneous lesion for which the possibility of a fungal skin infection is being entertained. Subsequently, the diagnosis can be confirmed by isolating the organism on Sabouraud glucose agar culture media. Superficial Cladosporium infections have been effectively treated with daily oral itraconazole for extended periods.

From the Universidad Francisco Marroquin, Guatemala, Guatemala;1 the University of Houston Health Center, University of Houston, Houston, TX;2 the Department of Dermatology, University of Texas M.D. Anderson Cancer Center, Houston, TX;3 the Department of Dermatology, University of Texas-Houston Medical School, Houston, TX;4 St. Joseph Dermpath, Houston, TX;5 and the Department of Dermatology, Baylor College of Medicine, Houston, TX6 Address for Correspondence: Philip R. Cohen, MD, 10991 Twinleaf Court, San Diego, CA 92131. • E-mail: mitehead@gmail.com

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A

CASE STUDY

B

A

Figure 1. Initial scalp evaluation demonstrates hair loss (A). A view of the scalp using a dermatoscope shows evidence of broken hair shafts and dark spots at the hair base (B).

Figure 4. Clinical examination of patient’s scalp at re-evaluation performed after 2 months of oral itraconazole daily treatment demonstrates hair growth (A). In contrast to her evaluation prior to oral antifungal therapy, there is an absence of broken hair shafts and the dark spots at the base of the hair shafts when the scalp is examined using a dermatoscope (B).

B

A

scope examination of her scalp and microscopic examination of the 20% KOH preparation from scalp scrapings prompted us to suspect a fungal scalp infection. The fungal culture established the identification of the causative organism. Two months of daily oral treatment with 200 mg of itraconazole were sufficient to resolve our patient’s symptoms and to eliminate the offending organism of her Cladosporium scalp infection. Albeit rare, a fungal infection secondary to Cladosporium should be considered when evaluating young patients with hair loss.

Figure 2. A 20% potassium hydroxide preparation of the patient’s scalp scrapings show clusters of brown, round to ellipsoid-shaped spores (original magnification ×400) (A). Brown septate hyphae are also observed (original magnification ×400) (B). A

REFERENCES

B

Figure 3. The fungal colonies show the characteristic black coloration of Cladosporium when viewed from the reverse side (A). Lactophenol cotton blue preparation shows the characteristic morphology of Cladosporium: a long, septate hyphae with laterally branching conidiophores that end in round to ellipsoid-shaped conidia (original magnification ×220) (B).

CONCLUSIONS Cladosporium is a not a classic dermatophyte. The opportunity to discover Cladosporium spores from our patient’s scalp scrapings is extraordinary. Indeed, to the best of our knowledge, this is the first individual in whom Cladosporium scalp infection has been reported. Our patient’s hair loss had previously been incorrectly diagnosed as trichotillomania; however, dermato-

SKINmed. 2012;10:393–394

B

394

1

Hedayati MT, Mohseni-Bandpi A, Moradi S. A survey on the pathogenic fungi in soil samples of potted plants from Sari hospitals, Iran. J Hosp Infect. 2004;58:59–62.

2

Sang H, Zheng XE, Zhou WQ, et al. A case of subcutaneous phaeohyphomycosis caused by Cladosporium cladosporioides and its treatment. Mycoses. 2012;55:195–197.

3

Namratha N, Nadgir S, Kale M, Rathod R. Chromoblastomycosis due to Cladosporium carrionii. J Lab Physicians. 2010;2:47–48.

4

Hafidh RR, Abdulamir AS. Cladosporium spp. as a causative agent of white superficial onychomycosis. East Mediterr Health. J 2008;14: 231–233.

5

Chew FLM, Subrayan V, Chong PP, Goh MC, Ng KP. Cladosporium cladosporioides keratomycosis: a case report. Jpn J Ophthalmol. 2009; 53:657–659.

6

Surjushe A, Kamath R, Oberai C, et al. A clinical and mycological study of onychomycosis. Indian J Dermatol Venereol Leprol. 2007;73: 397–401.

7

Singh S, Singh P, Sarkar C, et al. Fungal granuloma of the brain caused by Cladosporium bantianum—a case report and review of the literature. J Neurol Sci. 2005:228:109–112.

8

George IA, Mathews MS, Karthik R, et al. Fatal cerebral abscess caused by Cladophialophora bantiana. J Assoc Physicians India. 2008;56: 470–472.

9

Lalueza A, Lopez-Medrano F, del Palacio A, et al. Cladosporium macrocarpum brain abscess after endoscopic ultrasound-guided celiac plexus block. Endoscopy. 2011;43 suppl 2 UCTN:E9–E10.

Cladosporium Scalp Infection


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November/December 2012

CASE STUDY Vesna Petronic-Rosic, MD, MSc, Section Editor

Metastatic Melanoma From an Unknown Primary Site Presenting as Skin-Colored Nodules and Multiple Visceral Involvement Sudip Kumar Ghosh, MD, DNB;1 Debabrata Bandyopadhyay, MD;1 Kuntal Deb Barma, MBBS;1 Swapnendu Basu, MD;2 Amit Roy, MS3

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Figure 1. Multiple, discrete, skin-colored nodules of varying sizes on chest wall and abdomen. The skin overlying some of the nodules is erythematous.

Figure 2. Depigmented patch (measuring 3 cm Ã&#x2014; 3 cm) around a central pigmented macule (4 mm Ã&#x2014; 4 mm).

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Figure 4. Oval to polygonal tumor cells containing melanin pigments (original magnification, hematoxylin-eosin stain, original magnification Ã&#x2014;400).

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Das Gupta T, Bowden L, Berg JW. Malignant melanoma of unknown primary origin. Surg Gynecol Obstet. 1963;117:341â&#x20AC;&#x201C;345.

6

+PIOTPO 85  )FMXJH &# #FOJHO OFWVT DFMMT JO UIF DBQTVMF PG MZNQI nodes. Cancer. 1969;23:747.

7

,BEJWBS5' 7BOFL78 ,SJTIOBO&61SJNBSZNBMJHOBOUNFMBOPNBPGUIF small bowel: a case study. Am Surg. 1992;58:418â&#x20AC;&#x201C;422.

8

"WJUBM 4  3PNBHVFSB 3-  4BOET -  .BSDIFUUJ '  )FMMJOHFS .% 1SJNBSZ malignant melanoma of the right colon. Am Surg. 2004;70:649â&#x20AC;&#x201C;651.

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.BOPVSBT "  (FOFU[BLJT .  -BHPVEJBOBLJT &  FU BM .BMJHOBOU gastrointestinal melanomas of unknown origin: should it be considered primary? World J Gastroenterol. 2007;13:4027â&#x20AC;&#x201C;4029.

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15 "ULJOT .#  -PU[F .5  %VUDIFS +1  FU BM )JHIEPTF SFDPNCJOBOU JOUFSleukin 2 therapy for patients with metastatic melanoma: analysis of 270 patients treated between 1985 and 1993. J Clin Oncol. 1999;17: 2105â&#x20AC;&#x201C;2116.

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.FMBOPNB PG UIF 4LJO *O &EHF 4#  #ZSE %3  $PNQUPO $$  FU BM  eds. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer; 2010:325.

2

Bishop JAN. Lentigos, melanocytic naevi and melanoma. In: Burns T, Breathnach S, Cox N, Griffiths C, eds. Rookâ&#x20AC;&#x2122;s Textbook of Dermatology. 8th ed. Oxford: Wiley-Blackwell; 2010:54.1â&#x20AC;&#x201C;54.57

3

(JVMJBOP "&  .PTFMFZ )4  .PSUPO %- $MJOJDBM BTQFDUT PG VOLOPXO primary melanoma. Ann Surg. 1980;191:98â&#x20AC;&#x201C;104.

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#BBC ()  .D#SJEF $. .BMJHOBOU NFMBOPNB UIF QBUJFOU XJUI BO unknown site of primary origin. Arch Surg. 1975;110:896â&#x20AC;&#x201C;900.

10 $IBOH 1  ,OBQQFS 8) .FUBTUBUJD NFMBOPNB PG VOLOPXO QSJNBSZ Cancer. 1982;49:1106â&#x20AC;&#x201C;1111. 11 Balch CM, Buzaid AC, Soong SJ, et al. Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma. J Clin Oncol. 2001;19:3635â&#x20AC;&#x201C;3648. 12 #BMDI $.  4PPOH 4+  (FSTIFOXBME +&  FU BM 1SPHOPTUJD GBDUPST analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system. J Clin Oncol. 2001;19:3622. 13 .BOPMB+ "ULJOT. *CSBIJN+ ,JSLXPPE+1SPHOPTUJDGBDUPSTJONFUBTUBUJD NFMBOPNB B QPPMFE BOBMZTJT PG &BTUFSO $PPQFSBUJWF 0ODPMPHZ Group trials. J Clin Oncol. 2000;18:3782. 14 &HHFSNPOU". ,JSLXPPE+.3FFWBMVBUJOHUIFSPMFPGEBDBSCB[JOFJO metastatic melanoma: what have we learned in 30 years? Eur J Cancer. 2004;40:1825â&#x20AC;&#x201C;1836.

16 /BTIBO %  .àMMFS .-  (SBCCF 4  8VTUMJDI 4  &OL " 4ZTUFNJD UIFSBQZ of disseminated malignant melanoma: an evidence-based overview of the state-of-the-art in daily routine. J Eur Acad Dermatol Venereol. 2007;21:1305â&#x20AC;&#x201C;1318. 17 #BKFUUB& %J-FP" ;BNQJOP.( FUBM.VMUJDFOUFSSBOEPNJ[FEUSJBMPG dacarbazine alone or in combination with two different doses and schedules of interferon alfa-2a in the treatment of advanced melanoma. J Clin Oncol. 1994;12:806â&#x20AC;&#x201C;811. 18 'BMLTPO$* *CSBIJN+ ,JSLXPPE+. FUBM1IBTF***USJBMPGEBDBSCB[JOF versus dacarbazine with interferon alpha-2b versus dacarbazine with tamoxifen versus dacarbazine with interferon alpha-2b and tamoxifen in QBUJFOUT XJUI NFUBTUBUJD NBMJHOBOU NFMBOPNB BO &BTUFSO $PPQFSBUJWF Oncology Group study. J Clin Oncol. 1998;16:1743â&#x20AC;&#x201C;1751. 19 4DIMBHFOIBVGG# 4USPFCFM8 &MMXBOHFS6 FUBM.FUBTUBUJDNFMBOPNBPG unknown primary origin shows prognostic similarities to regional metastatic melanoma: recommendations for initial staging examinations. Cancer. 1997;80:60â&#x20AC;&#x201C;65.

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Wailea Marriott, Maui | January 16-18, 2013

Register Now for the 2nd Annual Conference! Exclusively for Dermatologic Nurse Practitioners + Physician Assistants Refresh & Renew : January 16-18, 2013 at the Wailea Marriott, Maui Join us for the 2nd annual ACMD:NP+PA course which is offered exclusively for nurse practitioners and physician assistants who already provide dermatologic healthcare. Join our world class faculty who combine basic science and clinical medicine to keep you informed of the latest developments in wide variety of clinical topics relevant to your daily practice. Our sessions are highly interactive and case based. You will learn some alternate ways to handle common problems and emerging methods to tackle those tough cases. Presentations are geared toward providing pearls you can put to use your ďŹ rst day back at work!

Faculty COURSE DIRECTOR

FACULTY

George Martin, MD

L. Aldredge, MSN, RN, ANP-BC Neal Bhatia, MD Andrew Blauvelt, MD Joel Cohen, MD Gordon Day, R. Ph., PA-C Sheila Fallon-Friedlander, MD Keri Holyoak, PA-C, MPH Arthur Kavanaugh, MD

Suzanne Kilmer, MD Ashfaq Marghoob, MD Ted Rosen, MD Bruce Stober, MD, PhD James Treat, MD Hensin Tsao, MD, PhD Melodie Young, MSN, ANP-c John Zone, MD

Content #UTANEOUS/NCOLOGY 0EDIATRIC$ERMATOLOGYs!CNE2OSACEA0SORIASISs%CZEMAs!GING3KIN #OSMECEUTICALSs)NFECTIOUS $ISEASESs3KIN3URGERYs.EW$RUGSAND4HERAPIESs(OT4OPICSIN$ERMATOLOGYs7ORKSHOPSANDPRODUCTTHEATERSs#LINICAL REVIEWSANDUPDATESONLASERS TOXINSDERMALlLLERSANDTHEMANAGEMENTOFVARICOSEVEINS

Information + Registration For more details, visit our website at:

acmd-derm-hawaii.com

Scan the QR tag for a direct link to the AMCD: NP+PA website.


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November/December 2012

BOOK REVIEW Jennifer L. Parish, MD, Section Editor

ACS(I) Textbook on Cutaneous and Aesthetic Surgery Venkataram M. Textbook on Cutaneous and Aesthetic Surgery. New Delhi, Jaypee Brothers Medical Publishers (P) Ltd; 2012: 952p. $150 1SPDFEVSBM BOE DPTNFUJD EFSNBUPMPHZ IBT CFDPNF B GVOEBNFOUBM BTQFDU PG DVUBOFPVT NFEJDJOF1 ɨF TQFDJBMUZ IBT SBQJEMZ BEWBODFE TJODF UIF mSTU IBJSUSBOTQMBOUJOCZ/PSNBO 0SFOUSFJDI .% 2 BOE UIF EFWFMPQNFOU PG UIF mSTU .PIT GFMMPXTIJQ JO  CZ 1FSSZ 3PCJOT .% 3CPUIPG/FX:PSL The Textbook on Cutaneous and Aesthetic Surgery  DPNQJMFE CZ UIF "TTPDJBUJPO PG $VUBOFPVT 4VSHFPOT PG *OEJB  JT SFNBSLBCMFJOJUTFYUFOTJWFBOEDPNQSFIFOTJWFSFWJFXPGUIJTWBTUBOE QSPHSFTTJWFmFME ɨF FEJUPS PG UIF CPPL  UIF QSFTJEFOU PG UIF "$4 *  BOE QBTU FEJUPSPGJournal of Cutaneous and Aesthetic Surgery JOWJUFE BVUIPST XIP BSF NFNCFST PG UIF 4PDJFUZ UP QBSUJDJQBUF ɨF DBSFGVMBUUFOUJPOUIBUUIFFEJUPSUPPLJOEFTJHOJOHUIFCPPLBOE CSJOHJOHUIFCPPLUPGSVJUJPONBLFTJUBXPOEFSGVMBEEJUJPOUP UIFTQFDJBMJTUTMJCSBSZ ɨFDIBQUFSTFODPNQBTTCPUITVSHJDBMBOEDPTNFUJDEFSNBUPMPHZɨFUPQJDTBSFCSPBEBOESBOHFGSPNUIFTVSHJDBMNBOBHFNFOU PG BDOF TDBST BOE QFSJPSCJUBM SFKVWFOBUJPO UP UJQT GPS CFHJOOFSTBOETVQQMJFSTEFUBJMTɨFPSHBOJ[BUJPOPGFBDIDIBQUFSJTVOJGPSNXJUILFZNFTTBHFTBOEQSBDUJDBMUJQTIJHIMJHIUFE  XJUI UIF SFGFSFODFT CFJOH DVSSFOU BOE JODMVTJWF ɨF DPMPS JMMVTUSBUJPOT BSF TQFDUBDVMBS  BT EFNPOTUSBUFE JO UIF DIBQUFST PO Local Anesthesia, Cosmetic Uses of Botulinum Toxin  BOE Wound Management and DressingsɨFmHVSFT EFNPOTUSBUJOH BQQSPQSJBUFCBOEBHJOHPGEJÄ&#x160;FSFOUXPVOETJUFT FYFNQMJmFTUIF

BUUFOUJPO UP EFUBJM ɨF DMBSJUZ BOE EFUBJM PG UIF JNBHFT BOE mHVSFTNBLFUIFCPPLJOWBMVBCMF 0OFPGUIFIJHIMJHIUTPGUIFCPPLJTUIFTQFDJBMGPDVTPOiCSPXO TLJO wXIJDIJTMBDLJOHJOUIFMJUFSBUVSFɨJTNBLFTJUQBSUJDVMBSMZ VTFGVMUPUIFTQFDJBMJTUXIPUSFBUTQBUJFOUTPGDPMPSɨFDPOUSJCVUPST IBWF QSPWJEFE QFSUJOFOU UJQT GPS BWPJEJOH QJUGBMMT JO UIF USFBUNFOUPGCSPXOTLJO BTFYFNQMJmFEJOUIFSFWJFXPGWJUJMJHP ɨFSFBSFDIBQUFSTPOUIJTTVCKFDUSBOHJOHGSPNOverview of Vitiligo SurgeryUPComplications of Vitiligo SurgeryɨFUFYUCPPL FNQIBTJ[FT UIBU UIF QIZTJDJBO NVTU SFDPHOJ[F UIF EJÄ&#x160;FSFODFT CFUXFFOTLJOUZQFTUPFÄ&#x160;FDUJWFMZUSFBUQBUJFOUT QBSUJDVMBSMZUIPTF GSPNUIF*OEJBOTVCDPOUJOFOU ɨFDIBQUFSTPOCircumcisionBOELeprosy SurgeryEFNPOTUSBUF UIF CSPBE TDPQF PG UIJT UFYUCPPL "MUIPVHI NPTU EFSNBUPMPHJTUTXJMMOPUQFSGPSNUIFTFQSPDFEVSFT JUQSPWJEFTUIFQIZTJDJBO XJUIBOFYDFQUJPOBMPWFSWJFXPGUIFTFTVSHFSJFTɨFTFDUJPOPO SFDPOTUSVDUJWFTVSHFSZGPSEFGPSNJUJFT TVDIBTMBHPQIUIBMPNPT  EFQSFTTFEOPTF BOEGPPUESPQDBVTFECZMFQSPTZ JTPGQBSUJDVMBS JOUFSFTUɨFEJTDVTTJPOBOEJNBHFTJOUIFTFDIBQUFSTFYFNQMJGZ UIFCSPBETDPQFPGUIJTCPPLBOEUIFBUUFOUJPOUPEFUBJM ɨJT UFYUCPPL NFFUT UIF OFFE PG B HMPCBM BVEJFODF *U JT BO FYFNQMBSZSFGFSFODFCPPLGPSCPUIUIFCFHJOOJOHBOETFBTPOFE EFSNBUPMPHJTU *U BMSFBEZ PDDVQJFT BO JNQPSUBOU QMBDF PO NZ MJCSBSZTIFMG REFERENCES 1

Coleman WP 3rd, Hanke CW, Orentreich N, et al. A history of dermatologic surgery in the United States. Dermatol Surg. 2000;26:5â&#x20AC;&#x201C;11.

2

Hanke CW. Key moments in the history of dermatologic surgery (19522000). Semin Cutan Med Surg. 2012;31:52â&#x20AC;&#x201C;59.

3

Robins P. 44 years in dermatologic surgery: a retrospective. J Drugs Dermatol. 2009;8:519â&#x20AC;&#x201C;525.

Reviewed by Jennifer L. Parish, MD Assistant Clinical Professor of Dermatology and Cutaneous Biology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, and Assistant Professor of Dermatology, Tulane University School of Medicine, New Orleans, LA t&NBJMKFOEFSN!ZBIPPDPN

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Edward L. Keyes Resident Contest for Outstanding Case Reports To be awarded for the best Case Report submitted by a physician in training (resident, fellow, or registrar) for presentation at the 9th World Congress of the International Academy of Cosmetic Dermatology in Athens, Greece, June 27–30, 2013. We invite you to submit original Case Reports that reflect the presentation of new ideas and original observations to the Academy membership and other attendees of the Congress. The author whose abstract receives the highest score during the review process will be awarded a scholarship by the IACD to present the full paper at the 9th World Congress of the International Academy of Cosmetic Dermatology in Athens, Greece, June 27–30, 2013. Abstracts should be submitted before noon, CDT, February 15, 2013 via e-mail and should be no longer than 2,500 characters including spacing. Previously published material should not be submitted; however, it is acceptable if the case report has been submitted for publication but not actually published as of February 15, 2013. Applicants should not submit abstracts that include material that has been previously presented. Applications will be graded based upon the educational value of the abstract and the extent to which it presents new and significant work. The Review Committee strongly recommends that abstracts have an organized, coherent, well-thought-out, and complete presentation. All applicants will receive e-mail notice of the Resident Case Report Review Committee’s decision by April 1, 2013. Vesna Petronic-Rosic, MD, MSc Chair, Resident Contest Committee Associate Professor Ambulatory Practice Medical Director University of Chicago Pritzker School of Medicine, Section of Dermatology Tel: +1.773.702.6559 vrosic@medicine.bsd.uchicago.edu


SORILUX

BRIEF SUMMARY The enlarged fontanelles are most likely due to calcipotriene’s (calcipotriene) Foam, 0.005% ribs. effect upon calcium metabolism. The maternal and fetal no-effect

The following is a brief summary only; see full prescribing information for complete product information.

exposures in the rat (43.2 mcg/m2/d) and rabbit (17.6 mcg/m2/d) studies are approximately equal to the expected human systemic exposure level (18.5 mcg/m2/d) from dermal application.

INDICATIONS AND USAGE

Nursing Mothers

SORILUX Foam is indicated for the topical treatment of plaque psoriasis in patients aged 18 years and older.

It is not known whether calcipotriene is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when SORILUX Foam is administered to a nursing woman.

CONTRAINDICATIONS

Pediatric Use

SORILUX Foam should not be used by patients with known hypercalcemia.

Safety and effectiveness of SORILUX Foam in pediatric patients less than 18 years of age have not been established.

WARNINGS AND PRECAUTIONS

Geriatric Use

Flammability The propellant in SORILUX is flammable. Instruct the patient to avoid fire, flame, and/or smoking during and immediately following application.

Effects on Calcium Metabolism Transient, rapidly reversible elevation of serum calcium has occurred with use of calcipotriene. If elevation in serum calcium outside the normal range should occur, discontinue treatment until normal calcium levels are restored.

Ultraviolet Light Exposure Instruct the patient to avoid excessive exposure of the treated areas to either natural or artificial sunlight, including tanning booths and sun lamps. Physicians may wish to limit or avoid use of phototherapy in patients who use SORILUX Foam. [See Nonclinical Toxicology (13.1).]

Unevaluated Uses SORILUX Foam has not been evaluated in patients with erythrodermic, exfoliative, or pustular psoriasis.

ADVERSE REACTIONS Clinical Trials Experience Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in clinical practice. SORILUX Foam was studied in 3-vehicle controlled trials. Seven hundred and thirty-one subjects with plaque psoriasis, including 473 exposed to SORILUX Foam were treated twice daily for 8 weeks. Adverse events reported in greater than 1% of subjects and in a higher rate in subjects treated with SORILUX Foam compared to vehicle were limited to erythema.

DRUG INTERACTIONS

No drug interaction studies were conducted with SORILUX Foam.

USE IN SPECIFIC POPULATIONS Pregnancy Teratogenic Effects, Pregnancy Category C: There are no adequate and well-controlled studies in pregnant women. Therefore, SORILUX Foam should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Studies of teratogenicity were done by the oral route where bioavailability is expected to be approximately 40–60% of the administered dose. Increased rabbit maternal and fetal toxicity was noted at 12 mcg/kg/d (132 mcg/m2/d). Rabbits administered 36 mcg/kg/d (396 mcg/m2/d) resulted in fetuses with a significant increase in the incidences of incomplete ossification of pubic bones and forelimb phalanges. In a rat study, doses of 54 mcg/kg/d (318 mcg/m2/d) resulted in a significantly higher incidence of skeletal abnormalities consisting primarily of enlarged fontanelles and extra

Clinical studies of SORILUX Foam did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients.

OVERDOSAGE

Topically applied calcipotriene can be absorbed in sufficient amounts to produce systemic effects. Elevated serum calcium has been observed with use of topical calcipotriene. [See Warnings and Precautions (5.2).]

NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Calcipotriene topically administered to mice for up to 24 months at dose levels of 3, 10, or 30 mcg /kg/d (corresponding to 9, 30, or 90 mcg /m2/d) showed no significant changes in tumor incidence when compared to controls. In a study in which albino hairless mice were exposed to both UVR and topically applied calcipotriene, a reduction in the time required for UVR to induce the formation of skin tumors was observed (statistically significant in males only), suggesting that calcipotriene may enhance the effect of UVR to induce skin tumors. [See Warnings and Precautions (5.3).] The genotoxic potential of calcipotriene was evaluated in an Ames assay, a mouse lymphoma TK locus assay, a human lymphocyte chromosome aberration assay, and a mouse micronucleus assay. All assay results were negative. Studies in rats at doses up to 54 mcg /kg/d (318 mcg /m2/d) of calcipotriene indicated no impairment of fertility or general reproductive performance.

PATIENT COUNSELING INFORMATION

[See FDA-approved Patient Labeling in full Prescribing Information]. The patient should be instructed as follows: t %o not place SORILUX Foam in the refrigerator or freezer. t "WPJd excessive exposure of the treated areas to either natural or artificial sunlight, including tanning beds and sun lamps. t *f SORILUX Foam gets in or near their eyes, to rinse thoroughly with water. t Talk to their doctor if their skin does not improve after treatmen with SORILUX Foam for 8 weeks. t Wash their hands after applying SORILUX Foam unless their hands are the affected site t "WPJd fire, flame, or smoking during and immediately following application since SORILUX Foam is flammable. SOR:4BRS

SORILUX is a trademark of Stiefel Laboratories, Inc. ©2011 Stiefel Laboratories, Inc. April 2011


Indicated for the topical treatment of plaque psoriasis in patients aged 18 years or older

My doctor has prescribed SORILUX Foam for my plaque psoriasis...

My Life. My Treatment.

The only vitamin D3 analog treatment in a topical foam formulation VersaFoam®-AEF: Aqueous-based Emulsion Formulation Free of ethanol, preservatives, parabens, and fragrance SORILUX Foam, with VersaFoam technology, penetrates the skin barrier to deliver the molecule into the epidermis and dermis1 The contribution to efficacy of individual components of the vehicle has not been established.

Important Safety Information for SORILUX Foam SORILUX Foam should not be used by patients with known hypercalcemia The propellant in SORILUX Foam is flammable. Instruct the patient to avoid fire, flame, and/or smoking during and immediately following application Transient, rapidly reversible elevation of serum calcium has occurred with use of calcipotriene. If elevation in serum calcium outside the normal range should occur, discontinue treatment until normal calcium levels are restored Instruct the patient to avoid excessive exposure of the treated areas to either natural or artificial sunlight, including tanning booths and sun lamps. Physicians may wish to limit or avoid use of phototherapy in patients who use SORILUX Foam SORILUX Foam has not been evaluated in patients with erythrodermic, exfoliative, or pustular psoriasis

Adverse events reported in greater than 1% of subjects and in a higher rate in subjects treated with SORILUX Foam compared with vehicle were limited to erythema SORILUX Foam should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus It is not known whether calcipotriene is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when SORILUX Foam is administered to a nursing woman Safety and effectiveness of SORILUX Foam in pediatric patients less than 18 years of age have not been established SORILUX Foam is not for oral, ophthalmic, or intravaginal use

Please see Brief Summary of Prescribing Information on the previous page. Reference: 1. Data on file, Stiefel Laboratories, Inc. SORILUX is a trademark and VersaFoam is a registered trademark of Stiefel Laboratories, Inc. ©2012 Stiefel Laboratories, Inc. All rights reserved. Printed in USA. SLX001R0 March 2012


Nov. / Dec., 2012