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July/August 2013 • Volume 11 • Issue 4 EDITORIAL Angular Cheilitis: A Maligned Condition Campbell and Parish

DEPARTMENTS perils of dermatopathology Dendritic Melanocytic Pseudomelanomas Rankin, Gagna, Lambert, and Lambert

COMMENTARY Plantar Keratolysis: A Casual Finding or Underdiagnosed Illness?

Romero-Navarrete, Arenas,Vega-Memije, Castillo-Solana, and Ruiz-Esmenajaud

ORIGINAL CONTRIBUTIONS Serum Levels of Interleukins 2, 4, 6, and 10 in Veterans With Chronic Sulfur Mustard-Induced Pruritus: A Cross-Sectional Study Panahi, Davoudi, Beiraghdar, Amiri, Saadat, Marzony, Naghizadeh, and Sahebkar

Cutaneous Malignant and Premalignant Conditions Caused by Chronic Arsenicosis From Contaminated Ground Water Consumption: A Profile of Patients From Eastern India Ghosh, Bandyopadhyay, Bandyopadhyay, and Debbarma

new THERAPY UPDATE Efinaconazole 10% Nail Solution Gupta, Simpson, and Abramovits

new to the clinic Imquimod 2.5% Cream Scheinfeld

COSMETIC SCIENCE A Second Look at Vitamin E Epstein

case studies Sneddon’s Syndrome Presenting With Neuropathic Pain Dag, Gokce, and Kocak

Mucinous Carcinoma: A Translucent Blue Papule on an 89-Year-Old Man Hagele, Chiang, Serrao, and Trevino

REVIEW Nutrition Supplementation for Diabetic Wound Healing: A Systematic Review of Current Literature Maier, Ilich, Kim, and Spicer

CORE CURRICULUM Hair Biology and Its Comprehensive Sequence in Female Pattern Baldness: Clinical Connotation Diagnosis and Differential Diagnosis—Part II Sehgal, Srivastava, Aggarwal, and Midha

Lebanese Dermatological Society

TABLE OF CONTENTS July/August 2013 • Volume 11 • Issue 4


Angular Cheilitis: A Maligned Condition..................................................................................................... 198

Caren Campbell, MD; Lawrence Charles Parish, MD, MD (Hon)


Plantar Keratolysis: A Casual Finding or Underdiagnosed Illness?............................................................. 201

Marina Romero-Navarrete, MD; Roberto Arenas, MD; Ma. Elisa Vega-Memije, MD; Aureliano D. Castillo-Solana, MSP; Julieta Ruiz-Esmenajaud, MD


Serum Levels of Interleukins 2, 4, 6, and 10 in Veterans With Chronic Sulfur Mustard-Induced Pruritus: A Cross-Sectional Study.............................................................................................................. 205

Yunes Panahi, Pharm.D, MD; Seyyed Masoud Davoudi, MD; Fatemeh Beiraghdar, MD; Mojtaba Amiri, MD; Alireza Saadat, MD; Eisa Tahmasbpour Marzony, MSc; Mohmad Mehdi Naghizadeh, MSc; Amirhossein Sahebkar, Pharm.D, Ph.D

Cutaneous Malignant and Premalignant Conditions Caused by Chronic Arsenicosis From Contaminated Ground Water Consumption: A Profile of Patients From Eastern India................................. 211

Sudip Kumar Ghosh, MD, DNB; Debabrata Bandyopadhyay; MD; Samik Kumar Bandyopadhyay, MS, FNB (MAS); Kuntal Debbarma, MBBS


Nutrition Supplementation for Diabetic Wound Healing: A Systematic Review of Current Literature.......... 217

Haiyan M. Maier, MS; Jasminka Z. Ilich, PhD; Jeong-Su Kim, PhD; Maria T. Spicer, PhD

Core curriculum Virendra N. Sehgal, MD, Section Editor

Hair Biology and Its Comprehensive Sequence in Female Pattern Baldness: Clinical Connotation Diagnosis and Differential Diagnosis—Part II............................................................................................. 227

Virendra N. Sehgal, MD; Govind Srivastava, MD; Ashok K. Aggarwal, MD; Rashmi Midha, MBBS

Departments Perils of Dermatopathlogy W. Clark Lambert, MD, PhD, Section Editor

Dendritic Melanocytic Pseudomelanomas.................................................................................................. 237

James Rankin, MBS; Claude E. Gagna, PhD; Muriel W. Lambert, PhD; W. Clark Lambert, MD, PhD

New Therapy Update William Abramovits, MD; Aditya K. Gupta, MD, PhD, Section Editors

Efinaconazole 10% Nail Solution............................................................................................................... 239

Aditya K. Gupta, MD, PhD, FRCPC; Fiona C. Simpson, HBSc; William Abramovits, MD

New to the Clinic Noah Scheinfeld, MD, JD, Section Editor

Imquimod 2.5% Cream.............................................................................................................................. 243

Noah Scheinfeld, MD, JD


TABLE OF CONTENTS July/August 2013 • Volume 11 • Issue 4

Cosmetic Science Howard A. Epstein, PhD, Section Editor

A Second Look at Vitamin E....................................................................................................................... 247

Howard A. Epstein, PhD

case studies Vesna Petronic-Rosic, MD, MSc, Section Editor

Sneddon’s Syndrome Presenting With Neuropathic Pain............................................................................ 251

Ersel Dag, MD; Burcu Gokce, MD; Mukadder Kocak, MD

Mucinous Carcinoma: A Translucent Blue Papule on an 89-Year-Old Man.................................................. 254

Thomas J. Hagele, BS; Charles Chiang, MD; Rocco Serrao, MD; Julian J. Trevino, MD


ABOUT OUR JOURNAL SKINmed: Dermatology for the Clinician®, 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 reflect 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 Affiliated 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.


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Please forward your completed application for processing to: Larry Millikan, MD, Secretary-Treasurer General Ms Anna Gjeci, Executive Secretary 1508 Creswood Road Philadelphia, PA 19115, USA Tel: 215-677-3060 Cell: 267-438-2543 Fax: 215-695-2254 E-mail: Web: SMCOMP_v10_i2_ADS.indd 396 121 SMCOMP_v10_i1_ADS.indd SMCOMP_v9_i5_ADS.indd 60


28/03/12 1 24/12/11 19/01/12

July/August 2013



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

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

Virendra N. Sehgal, MD Delhi, India

Robert L. Baran, MD Cannes, France

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

George M. Martin, MD Kihei, HI

Riccarda Serri, MD Milan, Italy

Anthony V. Benedetto, DO Philadelphia, PA

Anthony A. Gaspari, MD Baltimore, MD

Marc S. Micozzi, MD, PhD Rockport, MA

Charles Steffen, MD Oceanside, CA

Brian Berman, MD, PhD Miami, FL

Michael Geiges, MD Zurich, Switzerland

George F. Murphy, MD Boston, MA

Alexander J. Stratigos, MD Athens, Greece

Jack M. Bernstein, MD Dayton, OH

Michael H. Gold, MD Nashville, TN

Venkataram Mysore, MD, FRCP (Hon, Glasgow) Bangalore, India

James S. Studdiford III, MD Philadelphia, PA

Sarah Brenner, MD Tel Aviv, Israel Joaquin Calap Calatayud, MD Cadiz, Spain Henry H.L. Chan, MB, MD, PhD, FRCP Hong Kong, China Noah Craft, MD, PhD, DTMH Torrance, CA Ncoza C. Dlova, MBChB, FCDerm Durban, South Africa Richard L. Dobson, MD Mt Pleasant, SC William H. Eaglstein, MD Menlo Park, CA Boni E. Elewski, MD Birmingham, AL Charles N. Ellis, MD Ann Arbor, MI

Orin M. Goldblum, MD Pittsburgh, PA

Oumeish Youssef Oumeish, MD, FRCP Amman, Jordan

Lowell A. Goldsmith, MD, MPH Chapel Hill, NC Aditya K. Gupta, MD, PhD, FRCP(C) London, Ontario, Canada Seung-Kyung Hann, MD, PhD Seoul, Korea Roderick J. Hay, BCh, DM, FRCP, FRCPath London, UK Tanya R. Humphreys, MD Philadelphia, PA

Joseph L. Pace, MD, FRCP Naxxar, Malta Art Papier, MD Rochester, NY Johannes Ring, MD, DPhil Munich, Germany Roy S. Rogers III, MD Rochester, MN Donald Rudikoff, MD New York, NY

Camila K. Janniger, MD Englewood, NJ Abdul-Ghani Kibbi, MD Beirut, Lebanon

Robert I. Rudolph, MD Wyomissing, PA

Andrew P. Lazar, MD Washington, DC

Vincenzo Ruocco, MD Naples, Italy

Jasna Lipozencic, MD, PhD Zagreb, Croatia

Noah Scheinfeld, MD, JD New York, NY


Robert J. Thomsen, MD Los Alamos, NM Julian Trevino, MD Dayton, OH Graham Turner, PhD, CBiol, FSB Port Sunlight, UK Snejina Vassileva, MD, PhD Sofia, Bulgaria Daniel Wallach, MD Paris, France Michael A. Waugh, MB, FRCP Leeds, UK Wm. Philip Werschler, MD Spokane, WA Joseph A. Witkowski, MD Philadelphia, PA Ronni Wolf, MD Rechovot, Israel

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July/August 2013

Volume 11 • Issue 4


Angular Cheilitis: A Maligned Condition Caren Campbell, MD;1 Lawrence Charles Parish, MD, MD (Hon)2


hy an essay on angular cheilitis, an easily recognized cutaneous entity? One suggestion rests with the observation that angular cheilitis could be one of the most maligned conditions seen in contemporary practice. The fissuring, redness, and soreness at the angles of the mouth may not be catastrophic, but the embarrassment and soreness are disconcerting. Another feature that is more disturbing concerns the unnecessary testing and treatment often seen in the community. When a middle-aged man presented with angular cheilitis on routine examination, he asked whether this was due to a vitamin deficiency (Figure 1). He had been told by a physician and, of course, by Aunt Mabel that his diet was the problem.1 In addition to having been prescribed multivitamins, a high-potency steroid cream, and an antifungal preparation for presumed Candida albicans infection, he was instructed to eliminate several foods from his diet, including anything spicy and carbonated beverages.

Figure 1. Angular cheilitis that had been incorrectly diagnosed as candidosis, as well as a vitamin deficiency.

Causation Angular cheilitis, also known as perleche, cheilosis, or angular stomatitis, is simply an inflammatory condition of the labial commissures characterized by cracking, crusting, and in severe cases bleeding. The most common cause is the recession of the boney support of the lower aspects of the mouth. This can result in an overbite, with the upper lip protruding over the lower. The situation can then be aggravated by dentition in less than stellar condition or dentures that have not been adjusted in some time. A setup for the problem may even have been initiated by thumbsucking that continued long after the toddler years. There are innumerable other causes that could be listed in a differential diagnosis, such as lip licking or actinic cheilitis (Figures

2 and 3). For example, unilateral lesions caused by trauma are short-lived, while bilateral lesions are more likely long-standing.2 Perioral dermatitis may also extend to the commissures (Figure 4). Oral thrush could also be manifested at the commissures, but these causes are infrequent. Ultimately, mechanical trauma to the area is likely to be the primary culprit, but less common etiologies in practice better known by physicians in training are nutritional deficiency, particularly of riboflavin, iron, cobalamin, or zinc. These deficien-

From the Department of Dermatology, University of Louisville School of Medicine, Louisville, KY;1 and the 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 • E-mail:

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July/August 2013


Figure 2. Lip licking in a 10-year-old girl.

Figure 3. Actinic cheilitis.

cies are often cited to be caused by malabsorption from diseases such as celiac or malnutrition due to anorexia nervosa or bulimia nervosa.3 Patients with diabetes, chronic renal failure, hepatitis, Sjogren’s, Plummer Vinson, or Crohn’s disease can present with angular cheilitis.4–6 Medications have also been shown to cause angular cheilitis. Antineoplastic agents, such as sorafenib and selumetinib, can cause cheilitis in patients being treated with them for various types of malignancies.7,8 The condition is uncommonly caused or exacerbated by oral candidiosis or secondary bacterial infections.9 In patients who are immunocompromised or have diabetes, malignancy, or anemia, the likelihood of infection is increased.10 Intervention With the multifactorial origin of angular cheilitis, treatment is focused on eliminating precipitating factors.11 If the patient is a cigarette, cigar, or pipe smoker, this could be a problem. Midto low-potency steroid ointment is helpful. Almost never is a lipstick allergy, or for that matter a reaction to toothpaste, the cause. While angular cheilitis could masquerade as contact dermatitis (Figure 5), the chronic nature of the condition and the ineffectiveness of the mid- to low-potency steroids can indicate that another condition should be considered, such as impetigo or herpes zoster.

Figure 4. Perioral dermatitis extending to the commissures.

Conclusions Angular cheilits remains a chronic problem and is usually mechanical. While there are esoteric causes to be considered, more mundane etiologies are more likely. Identifying the underlying etiology is useful and allows for a more appropriate therapeutic approach, but looking for zebras should be reserved for the next safari! SKINmed. 2013;11:198–200


Figure 5. Contact dermatitis due to neomycin ointment Angular Cheilitis: A Maligned Condition

July/August 2013


References 1 Parish LC, Witkowski JA. The most important medical source: Aunt Mabel knows best. Skinmed. 2010;8:7–8. 2 Konstantinidis AB, Hatziotis JH. Angular cheilosis: an analysis of 156 cases. J Oral Med. 1984;39:199–206. 3 Strumia R. Dermatologic signs in patients with eating disorders. Am J Clin Dermatol. 2005;6:165–173. 4 Udayakumar P, Balasubramanian S, Ramalingam KS, et al. Cutaneous manifestations in patients with chronic renal failure on hemodialysis. Indian J Dermatol Venereol Leprol. 2006;72:119–125. 5 Soy M, Piskin S. Cutaneous findings in patients with primary Sjogren’s syndrome. Clin. Rheumatol. 2007;26:1350–1352. 6 Novacek G. Plummer-Vinson syndrome. Orphanet J Rare Dis. 2006;1:36.

7 Yang C-H, Lin W-C, Chuang C-K, et al. Hand-foot skin reaction in patients treated with sorafenib: a clinicopathological study of cutaneous manifestations due to multitargeted kinase inhibitor therapy. Br J Dermatol. 2008;158:592–596. 8 Balagula Y, Barth Huston K, Busam KJ, et al. Dermatologic side effects associated with the MEK 1/2 inhibitor selumetinib (AZD6244, ARRY-142886). Invest New Drugs. 2010. pubmed/20978926. Accessed August 10, 2012. 9 Sharon V, Fazel N. Oral candidiasis and angular cheilitis. Dermatol Ther. 2010;23:230–242. 10 Rogers RS 3rd, Bekic M. Diseases of the lips. Semin Cutan Med Surg. 1997;16:328–336. 11 Park KK, Brodell RT, Helms SE. Angular cheilitis, part 2: nutritional, systemic, and drug-related causes and treatment. Cutis. 2011;88:27–32.


Courtesy of BuyEnlarge, Philadelphia, PA

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Angular Cheilitis: A Maligned Condition

July/August 2013

Volume 11 • Issue 4


Plantar Keratolysis: A Casual Finding or Underdiagnosed Illness? Marina Romero-Navarrete, MD;1 Roberto Arenas, MD;2 Ma. Elisa Vega-Memije, MD;3 Aureliano D. Castillo-Solana, MSP;4 Julieta Ruiz-Esmenajaud, MD5


lantar keratolysis is a dermatological condition of the stratum corneum of the soles of the feet, commonly occurring on the weight-bearing areas of the metatarsals, heel, and toes. Occasionally it can affect both palms.1 There are only 63 studies reported in the biomedical literature in MEDLINE.

fissures, erythema,6 pitting, depressions, and erosions of varying numbers and sizes, both circular or irregular, varying in color from white to yellow-green or grey to dark brown1 (Figures 1 and 2). If lesions are inconspicuous, they may be better observed by soaking in water for 10 to 15 minutes.

Prevalence rates range from 1.5% in industry workers,1 8% in children,2,3 13% in athletes,1,4 20.4% in homeless men,4 23% in coal mine workers,1 30% in adolescents,5 42.5% in rice field workers, 53% in marines, and 48.5% to 77.1% in soldiers exposed to heat, humidity, and occlusive footwear.1,4 In 2012 we published a case of 25 firemen (64%) with plantar keratolysis.1

The clinical diagnosis can be confirmed by a shave biopsy, because the lesions are located in the stratum corneum. Then, the coccoid elements or thin bacillary filaments are observed microscopically1, as depicted in Figures 3 and 4.

Clinical Findings Some of the relevant aspects of plantar keratolysis include the peculiar worldwide distribution1,6 and the fact that there is no preference concerning race, sex, or cultures,4,6,8 with a wide age range affecting people aged 6 to 70 years.1,2,8,9 Predisposing factors are associated with humidity and either being barefooted or wearing occlusive footwear for long periods.4,6,8 Unfortunately, the only condition that has been evaluated is hyperhidrosis.1 Causative agents have not been clearly identified, but the condition has been associated with Gram-positive filamentous bacteria related to Corynebacterium sp. and Kitococcus sedentarius, as well as Staphylococcus epidermidis, group D Streptococcus, and Pseudomonas aeruginosa.1,7 Fetid foot odor (70% to 100%) is usually reported by both the patient and attending physician.1,6 This is accompanied by hyperhidrosis, sticky feet, burning, and itching.1,6,9 In soldiers, pain during walking and marching activities has been reported (10% of cases).11 Physical examination reveals malodor, hyperkeratosis, maceration,

Associated dermatoses include onychomycosis, tinea pedis (Figures 4–6), tinea pedis, onychomycosis, palmar and plantar keratoderms, and plantar warts.1,6 Therapeutic Approach Treatment should be directed toward correcting the predisposing factors, the clinical appearance of the lesions, and any associated disease. Current recommended treatment includes erythromycin 4% gel. If there is also hyperkeratosis, salicylic acid is added (3%, 5%, or 10% cream). If there is severe maceration, use of potassium permanganate (KMNO4) as the drying agent and astringent and an oral macrolide, such as clarithromycin or azithromycin, is prescribed.6 For the accompanying hyperhidrosis, botulinum toxin has also been employed.11 Conclusions Plantar keratolysis is a problematic disease, fraught with recurrences. For example, at 1 year, 17% of patients have been found to have a flare, with this occurring anywhere for 4 to 12 months, following treatment.6 To prevent the disease and relapse, good hygiene by keeping the areas dry is recommended. Proper foot care employs absorbent powders, antiperspirants, 25% aluminum chloride solutions, cotton socks, and frequent rotation of shoes.

From the Departments of Dermatology1 and Epidemiology,4 Acapulco Guerrero General Hospital, México; the Sections of Mycology2 and Dermatopathology,3 “Dr. Manuel Gea González” General Hospital, México; and the Mexican Academy of Dermatology5 Address for Correspondence: Marina Romero-Navarrete, MD, Calle La Nao No. 1809, Consultorio 501, Torre Médica del Pacifico, Fraccionamiento La Bocana, Acapulco, Guerrero, México CP 39670 • E-mail:

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July/August 2013


Figure 3. Bacillary and coccoid structures. Periodic acid-Schiff stain, original magnification ×60.

Figures 1 and 2. Depressions and erosions of the plantar surface.

Figure 4. Bacillary and coccoid structures. Periodic acid-Schiff stain, original magnification ×100. SKINmed. 2013;11:201–203


Plantar Keratolysis

July/August 2013

COMMENTARY References 1 Romero NM, Castillo SA, Vega MM, Arenas R, Fernández MR. Queratólisis plantar: frecuencia y factores predisponentes en bomberos de Acapulco, Guerrero y revisión de la literatura en México. Dermatología CMQ. 2012;10:90–92. 2 Prado N, Vera I, Arenas R, Toussaint S, Castillo M, Ruiz J. “Queratólisis plantar en pediatría. Informe clínico e histopatológico de 13 casos. Dermatología Pediátrica Latinoamericana. 2004;2:117–124. 3 Ruiz Esmenjaud J, Arenas R, Rodríguez-Alvarez M, Monroy E, Felipe Fernández R. Tinea pedis and onychomicosis in children of the Mazahua Indian Community in México. Gac Med Mex. 2003;139:215–220. 4 Singh G, Naik CL. Pitted keratolysis. Indian J Dermatol Venereol Leprol. 2005;71:213–215. 5 Arenas R, Jiménez R, Díaz A, et al. Queratólisis plantar. Estudio clínico-epidemiológico y microbiológico en 100 pacientes. Revista Mexicana de Dermatología. 1992;36:152– 158. 6 Kaptanoglu A, Yukselt O, Ozyurt S. Plantar pitted keratolysis: a study from nonrisk groups. Dermatology Reports. 2012;4:14–16. 7 Kaminska-Winciorek G, Spiewak R. Pitted keratolysis. How to treat? Pol Merkur Lekarski. 2011;31:127–129.

Figure 5. Filaments and arthroconidia of the stratum corneum (periodic acid-Schiff stain, original magnification ×60).

8 Nail CL, Shing G. Clinico epidemiological study of pitted keratolysis. Indian J Dermatol. 2007;52:35–38. 9 Blaise G, Nikkels AF, Hermanns-Lê T, Nikkels-Tassoudji N, Piérard GE. Corynebacterium-associated skin infections. Int J Dermatol. 2008;47:884–890. 10 Walling HW. Primary hyperhidrosis increases the risk of cutaneous infection: a case-control study of 387 patients. J Am Acad Dermatol. 2009;61:242–246. 11 van der Snoek EM, Ekkelenkamp MB, Suykerbuyk JC. Pitted keratolysis: physicians’ treatment and their perceptions in Dutch army personnel. J Eur Acad Dermatol Venereol. 20012;23:512–515

Figure 6. Filaments and arthroconidia of the stratum corneum (periodic acid-Schiff stain, original magnification ×100).

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Plantar Keratolysis

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 10th World Congress of the International Academy of Cosmetic Dermatology in Rio de Janeiro, Brazil, July 18-20, 2014. 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 10th World Congress of the International Academy of Cosmetic Dermatology in Rio de Janeiro, Brazil, July 18-20, 2014. The scholarship will provide reasonable travel expenses, lodging for 3 nights, the Congress registration fee, and a basic spending stipend. Abstracts should be submitted via email to vrosic@medicine.bsd.uchicago. edu before noon, CDT, March 15, 2014 via e-mail and should be no longer than 2,500 characters including spacing. Material that was previously presented, published, or submitted for publication should not be offered. 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. The winner(s) will publish their outstanding case report(s) in SKINmed: Dermatology for the Clinician, an official publication of the International Academy of Cosmetic Dermatology. All applicants will receive e-mail notice of the Resident Case Report Review Committee’s decision by May 1, 2014. 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

Official publication of IACD

July/August 2013

Volume 11 • Issue 4


Serum Levels of Interleukins 2, 4, 6, and 10 in Veterans With Chronic Sulfur Mustard-Induced Pruritus: A Cross-Sectional Study Yunes Panahi, Pharm.D, MD;1 Seyyed Masoud Davoudi, MD;1 Fatemeh Beiraghdar, MD;2 Mojtaba Amiri, MD;1 Alireza Saadat, MD;3 Eisa Tahmasbpour Marzony, MSc;1 Mohmad Mehdi Naghizadeh, MSc;4 Amirhossein Sahebkar, Pharm.D, Ph.D5 Abstract Inflammation is a key component in the pathogenesis of sulfur mustard (SM)–induced skin complications. Here, the levels of interleukin (IL) -2, IL-4, IL-6, and IL-10 were evaluated in patients with chronic SM-induced complications. Seventy-four serum samples were collected from SM-injured veterans (SM group; n=37) and nonchemically injured patients (control group; n=37) with skin pruritus. The levels of IL-2, IL-4, IL-6, and IL-10 were evaluated by sandwich enzyme-linked immunosorbant assay technique in both nil and mitogen medium. No significant difference was found in pruritus score between SM (74.16±5.93) and control (74.48±6.15) groups (P>.05). The mean serum concentrations of IL-2 and IL-6 were found to be significantly elevated in the control compared with the SM group (P<.05). However, no significant difference was observed between the study groups regarding serum levels of IL-4 and IL-10 (P>.05). Serum IL-2 (in both SM and control groups) and IL-6 (in the control group) concentrations were significantly correlated with pruritus score while no significant association was found for IL-4 and IL-10. Serum concentrations of IL-2, IL-6, and IL-10 are significantly decreased in SM-exposed patients with chronic pruritus. Such alterations might represent a plausible mechanism for tissue damage and skin itching following SM exposure. Therefore, variation of ILs may also contribute to skin pruritus induced by SM. (SKINmed. 2013;11:205–209)


ommonly known as sulfur mustard (SM), 2,2’-dichlorodiethyl sulfide is an oily lipophilic substance that has been used as a chemical warfare agent. This gas has several pathological effects in various organs and systems of the victims, which have previously been reported.1 The eyes, skin, and respiratory system are the main targets of SM toxicity.2–4 When absorbed, SM undergoes intra-molecular cyclization to form a sulphonium ion, which, in turn, alkylates DNA and proteins leading to DNA strand breaks and eventually cell death.5,6 As a result of cell cycle arrest and death, the proliferating cells of bone marrow are damaged, thereby leading to leukopenia and severe inhibition of the immune system.7 Synthesis and release of inflammatory mediators is another sequelae of SM toxicity.8

Currently, there is no effective therapy for SM-intoxicated veterans because of a lack of understanding of the pathophysiological processes of SM injury.9 Skin injury and chronic pruritus are the foremost negative effects of SM, which affect the quality of life in chemically injured veterans10; therefore, identifying effective strategies to mitigate the toxicity of SM in exposed veterans seems to be valuable in clinic. It appears one cause of this problem is the sudden and massive release of pro-inflammatory cytokines such as interleukins (ILs) is an important contributor in the development of SM complications.11 Some researchers have reported that there are significant variations in circulating inflammatory mediators of patients with itchy skin lesions, especially in interferon γ and some ILs.9,12 Hence, there are various

From the Chemical Injuries Research Center,1 Nephrology and Urology Research Center,2 and the Department of Internal Medicine,3 Baqiyatallah University of Medical Sciences, Tehran; the School of Medicine, Fasa University of Medical Sciences, Fasa;4 and Biotechnology Research Center, Mashhad University of Medical Sciences, Mashhad,5 Iran Address for Correspondence: Yunes Panahi, Professor of Pharmacotherapy, Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Molla-Sadra Avenue, PO Box 19945/581, Vanak Sqare, Tehran, Iran • E-mail:

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drugs for the treatment of this problem in patients with nonchemical-related pruritus in which their therapeutic effects rely on the alteration of inflammatory mediators.13–20 In spite of several animal reports, previous clinical investigations regarding the effects of SM on chronic pruritus, its relation with serum cytokine status and its management have been scant; therefore, the present study sought to investigate serum levels of IL-2, IL-4, IL-6, and IL-10 in the serum of SM-exposed veterans and compare them with those of nonexposed veterans with itchy skin lesions. Materials and Methods This study was conducted from April 2009 to January 2010 in the outpatient dermatology clinic of the Baqiyatallah Hospital in Tehran, Iran. This hospital provides medical care for SM-exposed veterans and maintains a large number of medical records from such patients during the Iraq-Iran war. The sample population consisted of men (between the ages of 30 to 65 years) who were experiencing from pruritus. The Baqiyatallah University of Medical Sciences Ethics Committee approved the study protocol and all patients gave written informed consent prior to enrollment.

Seventy-four serum samples were collected from chemically injured veterans (SM group; n=37) and nonchemically injured patients (control group; n=37) with pruritus. At the onset of the study, each patient was instructed to complete a questionnaire that included information about age, pruritus score, history of treatment, leukopenia, history of respiratory problems, and adrenal dysfunction. Pruritus score was measured for each patient. The severity, distribution, and frequency of pruritus and pruritus-related sleep disturbance were determined and total pruritus severity was calculated (Table I). Pruritus has a range from 0 to 48, with higher scores indicating more severe pruritus. The severity of pruritus was graded as mild (1–16 points), moderate (17–32 points), and severe (33–48 points). After collection of venous blood samples, serum was isolated and levels of four important and well characterized pro-inflammatory cytokines including IL-2, IL-4, IL-6 and IL-10 were determined using a sandwich enzyme-linked immunosorbant assay kit (Biosource, Camarillo, CA) technique.

Table I. Calculation of Total Pruritus Score From Detailed Related Variables Score


Total Score


1 2 4 5

Slight itching sensation without necessity of scratching Slight itching sensation with necessity to scratch, but without excoriations Scratching accompanied by excoriation Pruritus causing total restlessness



1 5

For each region (arms, trunk, or legs) Generalized itching



0.5 1 5

Two periods of less than 10 minutes For each period more than 10 minutes Maximally


The score of severity, distribution, and frequency of pruritus was recorded separately for the morning and the afternoon so that a maximum of 30 points could be achieveda


Each scratching episode leading to excoriation during the night; maximum=5 Each episode of waking up due to itching; maximum=10

5 10

For each time, morning, evening, and night with itching one point added to the score. Max=1+1+1=3b


Sleep disturbance

1 2

Total score


a For example, in patients who showed maximal frequency both in the morning and the afternoon, their score for frequency was calculated as 5+5=10. b For example, if a patient had itching through the morning and the evening that affected sleep, 2 points were added to the total score

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Statistical Analysis Concentration, pg/mL


Data were analyzed using SPSS software, version 11.5 (SPSS Inc, Chicago, IL). Data were expressed as mean±standard deviation. Between-group comparisons were made using independent samples t test. The correlation between total pruritus severity and serum level of each cytokine was determined by Spearman rank correlation. Mann-Whitney U test was applied to compare the percentage of patients with mild, moderate, and sever pruritus between the groups. A P value <.05 was considered statistically significant.

Serum concentrations of IL-2 and IL-6 (0.32±0.07 and 1.53±0.36 in the SM and control groups, respectively) were significantly higher in the control compared with the SM group (P<.05); however, no significant difference was observed in serum IL-4 (P=.14) and IL-10 (P=.73) between SM and control groups (Figure).

1000 800 600 400 P>.05

200 0





Figure. Comparison of serum interleukin (IL) 2, IL-4, and IL-10 concentrations between the sulfur mustard (SM) and control groups.

Results There was no significant difference between the age of SM and control groups (P=.143). The mean age of SM and control groups were 46.31±9.82 years and 44.69±11.20 years, respectively. Mean pruritus score was not found to be significantly different between SM (39.08±6.12) and control (37.55±7.71) groups (P=.652; Table II).

SM Control


Table III summarizes the correlation between serum cytokine concentrations and total pruritus severity score. A significant positive correlation was observed between pruritus score and IL-2 in both SM (r=0.44; P<.05) and control (r=0.30; P<.05) groups. Serum IL-6 concentrations were positively correlated with pruritus score in the control r=0.34; P<.05) but not the SM (r=0.30; P=.62) group. There was no significant correlation between levels of other measured cytokines with pruritus score (P>.05).

Table II. Pruritus Severity and Different Pruritus Scores in 2 Groups Treatment Status



P Value

Pruritus severity (total score)




12 (2.44) 17 (45.94) 8 (21.62)

8 (21.62) 20 (54.05) 10 (27.03)


Pruritus score

Mild Moderate Severe

Table III. Correlation Between Serum Interleukin (IL) Levels and Pruritus Severity Cytokines

Sulfur Mustard



P Value


P Value

IL-2, pg/mL





IL-4, pg/mL





IL-6, pg/mL





IL-10, pg/mL





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It is well documented that exposure to SM is associated with inflammatory response and imbalances in the immune system function.21,22 The marked inflammation response following SM exposure in human and animals is manifested as erythema followed by edema that subsequently progresses to skin itching, blister formation, ulceration, necrosis, and desquamation.11

The findings of the present study indicate a significant reduction of IL-2 and IL-6 concentrations in the sera of SM-intoxicated veterans who had chronic pruritus compared with patients with nonchemical pruritus. These results suggest that pro-inflammatory mediators such as IL-2 and IL-6 may play a major role in the mediation of chronic pruritus following SM intoxication; therefore, altered levels of these cytokines could be regarded as a potential therapeutic target for the development of antipruritic agents to be used by SM-exposed veterans.

Pro-inflammatory cytokines are essential for cell to cell signaling in physiological and pathological reactions. Nevertheless, under normal conditions, these cytokines act as crucial signals in the development of appropriate defenses, but they can lead to pathological effects in exaggerated or prolonged secretions.23 In this research, we measured the concentrations of main inflammatory mediators including IL-2, IL-4, IL-6, and IL-10, and compared them between SM-exposed veterans and nonexposed patients with pruritus. The findings demonstrated a significant reduction of serum IL-2 and IL-6 but not IL-4 and IL-10 concentrations in SM-exposed patients with chronic pruritus compared with patients with nonchemical-related pruritus.


The findings of the current study on the decline of serum inflammatory cytokines in patients with chronic SM-induced complications correspond with previously reported findings.24,25 Moreover, several studies have investigated the in vitro effects of SM on pro-inflammatory cytokine levels. The SM-induced increasing of ILs was demonstrated in the mouse ear model.11,23 Researchers reported the high expression of inflammatory mediators in rabbit skin exposed to SM.26 In vitro studies have also provided evidence on the elevated production and release of IL-1β, IL-8, and IL-6.11,27 IL-6 and IL-8 are suspected to exert profound effects on cellular proliferation, differentiation, and immune modulation in cutaneous vesication caused by SM.23, 28, 29 Researchers studied the in vivo cutaneous response of the inflammatory cytokines IL-6, IL-1α, and IL-1β in an SM-exposed mouse model. They did not observe significantly increased cytokine levels for IL-1β or tumor necrosis factor α (TNF-α) in both mouse ear and hairless skins. The levels of IL-6 were elevated in both hairless mouse and ear skins. Although IL-1α was significantly elevated in hairless mouse skin exposed to SM, they saw no increased IL-1α in mouse ear skin.30 In another study, the in vitro expression of pro-inflammatory cytokines (IL-1β, IL-6, IL-8, and TNF-α) in human respiratory epithelial cells was examined. Their results showed that SM stimulates the overproduction of pro-inflammatory cytokines IL-1β, IL-6, IL-8, and TNF-α in human respiratory epithelial cells.9 In addition, a study showed that SM increased expression of IL-8 in human keratinocytes.22 SKINmed. 2013;11:205–209


1 Hassan ZM, Ebtekar M. Modeling for immunosuppression by sulfur mustard. Int Immunopharmacol. 2001;1:605–610. 2 Jahanshahi M, Bahadoran H, Asadi MH. Acute effects of sulphur mustard gas on the number of lymphocytes in the rat’s spleen. Int J Morphol. 2008;26:433–436. 3 Balali M. Clinical and laboratory findings in Iranian fighters with chemical gas poisoning. Arch Beges. 1984;suppl:254–259. 4 Vijayaraghavan R. Modifications of breathing pattern induced by inhaled sulphur mustard in mice. Arch Toxicol. 1997;71:157–164. 5 Balali-Mood M, Hefazi M, Mahmoudi M. Longterm complications of sulphur mustard poisoning in severely intoxicated Iranian veterans. Fundam Clin Pharmacol. 2005;19:713–721. 6 Rao PV, Vijayaraghavan R, Bhaskar AS. Sulphur mustard induced DNA damage in mice after dermal and inhalation exposure. Toxicology. 1999;139:39–51. 7 Hefazi M, Maleki M, Mahmoudi M, Tabatabaee A, Balali-Mood M. Delayed complications of sulfur mustard poisoning in the skin and the immune system of Iranian veterans 16–20 years after exposure. Int J Dermatol. 2006;45:1025–1031. 8 Amir A, Chapman S, Kadar T, et al. Sulfur mustard toxicity in macrophages: effect of dexamethasone. J Appl Toxicol. 2000;20:S51–S58. 9 Gao X, Ray R, Xiao Y, Barker PE, Ray P. Inhibition of sulfur mustard-induced cytotoxicity and inflammation by the macrolide antibiotic roxithromycin in human respiratory epithelial cells. BMC Cell Biology. 2007;8:1–9. 10 Panahi Y, Davoudi SM, Sadr SB, Naghizadeh MM, Mohammadi-Mofrad M. Impact of pruritus on quality of life in sulfur mustard-exposed Iranian veterans. Int J Dermatol. 2008;47:557–561. 11 Wormser U, Brodsky B, Proscura E, et al. Involvement of tumor necrosis factor-α in sulfur mustard-induced skin lesion: effect of topical iodine. Arch Toxicol. 2005;79:660–670. 12 Tewari-Singh N, Rana S, Gu M, et al. Inflammatory biomarkers of sulfur mustard analog 2-chloroethyl ethyl sulfide–induced skin injury in SKH-1 hairless mice. Toxicolo Sci. 2009;108:194–206.

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13 Panahi Y, Davoudi SM, Beiraghdar F, Saadat A, Sahebkar A. Relationship between levels of IFNγ, TNFα, and TGFβ and pruritus in sulfur mustard-exposed veterans. J Immunotoxicol. 2013;10:173–177.

21 Holliday MR, Dearman RJ, Corsini E, Basketter DA, Kimber I. Selective stimulation of cutaneous interleukin 6 expression by skin allergens. J Appl Toxicol. 1995;16:65– 70.

14 Panahi Y, Taherzadeh ES, Davoudi SM, Sahebkar A, Ranjbar R. Investigation of serum substance P status in patients with chronic pruritic skin lesions due to sulfur mustard: A cross-sectional study. Cutan Ocul Toxicol. 2013;32:4–8.

22 Ricketts KM, Santai CT, France JA, et al. Inflammatory cytokine response in sulfur mustard-exposed mouse skin. J Appl Toxicol. 2002;20:S73–S76.

15 Panahi Y, Sahebkar A, Parvin S, Saadat A. A randomized controlled trial on the anti-inflammatory effects of curcumin in patients with chronic sulphur mustardinduced cutaneous complications. Ann Clin Biochem. 2012;49:580–588. 16 Panahi Y, Sahebkar A, Amiri M, Davoudi SM, Beiraghdar F, Hoseininejad SL, et al. Improvement of sulphur mustard-induced chronic pruritus, quality of life and antioxidant status by curcumin: Results of a randomised, double-blind, placebo-controlled trial. Br J Nutr. 2012;108:1272–1279. 17 Panahi Y, Sarayani A, Beiraghdar F, Amiri M, Davoudi SM, Sahebkar A. Management of sulfur mustard-induced chronic pruritus: A review of clinical trials. Cutan Ocul Toxicol. 2012;31:220–225. 18 Sahebkar A. Baicalin as a potentially promising drug for the management of sulfur mustard induced cutaneous complications: A review of molecular mechanisms. Cutan Ocul Toxicol. 2012;31:226–234. 19 Panahi Y, Davoudi SM, Sahebkar A, Beiraghdar F, Dadjo Y, Feizi I, et al. Efficacy of aloe vera/olive oil cream versus betamethasone cream for chronic skin lesions following sulfur mustard exposure: A randomized double-blind clinical trial. Cutan Ocul Toxicol. 2012;31:95–103. 20 Panahi Y, Sahebkar A, Davoudi SM, Amiri M, Beiraghdar F. Efficacy and safety of immunotherapy with interferon-gamma in the management of chronic sulfur mustard-induced cutaneous complications: Comparison with topical betamethasone 1%. ScientificWorldJournal. 2012;2012.

23 Sabourin CL, Petrali JP, Casillas RP. Alterations in inflammatory cytokine gene expression in sulfur mustard-exposed mouse skin. J Biochem Molecular Toxicol. 2000;14:291–302. 24 Pourfarzam S, Ghazanfari T, Yaraee R, et al. Serum levels of IL-8 and IL-6 in the long term pulmonary complications induced by sulfur mustard: Sardasht-Iran Cohort Study. Int Immunopharmacol. 2009;9:1482–1488. 25 Yaraee R, Ghazanfari T, Ebtekar M, et al. Alterations in serum levels of inflammatory cytokines (TNF, IL-1alpha, IL-1beta and IL-1Ra) 20 years after sulfur mustard exposure: Sardasht-Iran cohort study. Int Immunopharmacol. 2009;9:1466–1470. 26 Tsuruta J, Sugisaki K, Dannenberg AM, et al. The cytokines NAP-1 (IL-8), MCP-1, IL-1 beta, and GRO in rabbit inflammatory skin lesions produced by the chemical irritant sulfur mustard. Inflammation. 1996;20:293–318. 27 Arroyo CM, Schafer RJ, Kurt EM, Broomfield CA, Carmichael AJ. Response of normal human keratinocytes to sulfur mustard: cytokine release. J Appl Toxicol. 2000;20:S63–S72. 28 Arroyo CM, Broomfield CA, Hackley BA. The role of interleukin-6 in human sulfur (HD) toxicology. Int J Toxicol. 2001;20:281–296. 29 Arroyo CM, Kan RK, Burman DL, et al. Regulation of 1-α, 25-dihydroxyvitamin D3 on interleukin-6 and interleukin-8 induced by sulfur mustard (HD) on human skin cells. Pharmacol Toxicol. 2003;92:204–213. 30 Lardot C, Dubois V, Lison D. Sulfur mustard upregulates the expression of interleukin-8 in cultured human keratinocytes. Toxicol Lett. 1999;110:29–33.


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July/August 2013

Volume 11 • Issue 4

Original contribution

Cutaneous Malignant and Premalignant Conditions Caused by Chronic Arsenicosis From Contaminated Ground Water Consumption: A Profile of Patients From Eastern India Sudip Kumar Ghosh, MD, DNB;1 Debabrata Bandyopadhyay; MD;1 Samik Kumar Bandyopadhyay, MS, FNB (MAS);2 Kuntal Debbarma, MBBS1 Abstract Natural arsenic pollution is a major global health problem. The two worst affected areas in the world are Bangladesh and West Bengal, India. Arsenic is a well-documented human carcinogen that affects many organs including the skin. The authors sought to find out the clinical patterns of different malignant and premalignant conditions associated with chronic arsenicosis from drinking contaminated ground water in a group of patients from eastern India. This was a clinical observational study. Patients with chronic arsenicoses with suspected cutaneous malignancies for whom dermatology service was sought were enrolled in the study. A total of 24 patients (male to female ratio, 11:1; age range, 32–71 years; mean age, 52.2 years) were evaluated. Squamous cell carcinoma (SCC) was the commonest malignancies in our series, seen in 10 (41.7%) patients. This was followed by Bowen’s disease (9 [37.5%]) and basal cell carcinoma (8 [33.3%]). Three patients (12.5%) had >1 type of cutaneous malignancies. Multicentric lesions were seen in 3 cases. The most common site of involvement was the chest (8 [33.3%]). No statistically significant correlation was found between number of lesions and arsenic content in the hairs and nails of the patients. (SKINmed. 2013;11:211–216)


rsenic toxicity is a major global health problem that affects a large number of people from many parts of the world.1 Natural arsenic pollution has created an alarming situation in many countries of the world, including Bangladesh, India, Argentina, China, Chile, Thailand, and Mexico. The two most affected areas in the world are Bangladesh and West Bengal, India. In many districts in southern Bangladesh and in adjacent districts in the state of West Bengal, millions of people are exposed to toxic levels of groundwater arsenic concentrations.1 In both of these countries, the source of arsenic is geological in origin, contaminating aquifers that provide water for more than 1 million tube wells.1 Dyspigmentation and keratosis are the characteristic cutaneous lesions of chronic arsenicosis. The pigmentation usually assumes a “raindrop” pattern that predominantly involves the trunk and extremities. Diffuse hyperpigmentation, localized patchy pigmentation, leucomelanosis, and oral mucosal pigmentation also occur.2

Arsenical keratosis appears as diffuse thickening of the palms and soles, studded with multiple keratotic papules or nodules. Keratotic lesions may be found elsewhere in the body.2 Arsenic is a well-documented human carcinogen3 that affects many organs including the skin.4 Although the nonmalignant cutaneous effects of chronic exposure to inorganic arsenic are well-documented,5 there is a relative paucity of literature focusing on the cutaneous malignancies associated with chronic arsenicosis from ingestion of contaminated water. The objective of the present study was to investigate the clinicodemographic patterns of different malignant and premalignant conditions associated with chronic arsenicoses. Methods

Patients This was a clinical observational study. Consecutive patients with cutaneous malignancies associated with chronic arsenico-

From the Department of Dermatology, Venereology, & Leprosy,1 and the Department of Surgery,2 R.G.Kar Medical College, Kolkata, India Address for Correspondence: Sudip Kumar Ghosh, Department of Dermatology, Venereology, & Leprosy, R.G.Kar Medical College, 1, Khudiram Bose Sarani, Kolkata-700004, India • E-mail:

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sis, attending the dermatology clinic of a tertiary care hospital of Kolkata, India, directly or referred from other departments during a 3-year period (September 2007â&#x20AC;&#x201C;August 2010) were enrolled in the study. Permission of the institutional review board was sought. Informed consent was taken from the patients. All patients were residents of the state of West Bengal, India. A detailed history with special emphasis on demographic profile, symptoms, and duration of cutaneous lesions was obtained. The patients were thoroughly clinically examined with special attention on cutaneous malignancies, lymph node status, and features of visceral metastasis. Routine laboratory examinations, estimation of arsenic level (of hair, nail, and drinking water), chest radiography, ultrasonography of the abdomen, other relevant investigations, and histopathological examination of the suspected cutaneous malignancies were performed.

Figure 1. Arsenical keratosis of the palms and soles.

Methods of Arsenic Estimation Arsenic was measured by an atomic absorption spectrophotometry.

Inclusion Criteria Patients with chronic arsenicoses and suspected cutaneous malignancies for whom dermatology service was sought were included in the study.

Exclusion Criteria Patients with absence of histopathological evidence of malignancy and premalignancy in the skin biopsy specimen were excluded from the study.

Case Definition Chronic arsenicoses was defined as a chronic health condition arising from prolonged ingestion (not less than 6 months) of arsenic above a safe dose, usually manifested by characteristic skin lesions, with or without involvement of internal organs.6

Figure 2. Raindrop pigmentations on the abdomen with arsenical keratosis of the palms.

Statistical Analysis Data were recorded in a predesigned, pretested, semistructured schedule and were analyzed accordingly. Mean and standard deviation were calculated for quantitative data and proportions for categorical variables. Unpaired t test was used, and a value of P<.05 was considered significant. Results A total of 24 patients (age range, 32 to 71 years; mean, 52.2 years) were evaluated. Most of the patients were men (22 [91.7%]) with a male to female ratio of 11:1. Fourteen patients (58.3%) were agricultural workers, 3 patients (12.5%) were clerical workers, 3 patients (12.5%) were manual laborers, 2 SKINmed. 2013;11:211â&#x20AC;&#x201C;216


Figure 3. Huge squamous cell carcinoma on the hand. Cutaneous Malignant and Premalignant Conditions

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Figure 4. Squamous cell carcinoma of the hand along with arsenical keratosis.

Figure 6. Multiple Bowen’s disease on the chest and abdomen.

Figure 5. Squamous cell carcinoma along with raindrop pigmentation.

patients (8.3%) were housewives, and 2 patients (8.3%) were teachers. All of the patients in the present series sought medical opinion for their dyspigmented and ulcerated skin lesions. In addition, 4 patients (16.7%) had an intermittent history of lesional pain and 2 (8.3%) had a history of recurrent bleeding. None of our patients had any systemic symptoms. Arsenical keratosis involving the palms and soles (Figure 1) was noted in all of the patients. In addition, 6 patients (25%) also had keratotic lesions on different parts of the trunk and extremities. Raindrop pigmentation (Figure 2) was seen in 22 patients (91.7%), leucomelanosis in 4 SKINmed. 2013;11:211–216

patients (16.7%), localized pigmentation in 2 patients (8.3%), and diffuse pigmentation in 1 patient. Squamous cell carcinoma (SCC) (Figures 3–5) were the most common malignancies in our series, seen in 10 patients (41.7%). This was followed by Bowen’s disease (9 [37.5]) (Figure 6) and basal cell carcinoma (BCC) (8 [33.3%]). (Figure 7) Three patients (12.5%) in our series had >1 type of cutaneous malignancies (1 patient had both SCC and BCC; 2 patients had both Bowen’s disease and BCC). Three cases of SCC in our series developed on to pre-existing arsenical keratosis. Multicentric lesions were seen in 3 patients (12.5%). The sites of involvement in decreasing order of frequency were chest (8 [33.3%]), palms (4 [16.7]), forehead (3 [12.5%]), ankle (2 [8.3%]), thumb (2 [8.3%]), abdomen (2 [8.3%]), back (1 [4.2%]) wrist (1 [4.2%]), foot (1 [4.2%]), buttock (1 [4.2%]), neck (1 [4.2%]), ear (1 [4.2%]), thigh (1 [4.2%]), and forearm (1 [4.2%]) (Table). Estimated mean arsenic levels in drinking water, hairs, and nails were 0.1 mg/L, 4.5 µg/g, and 7.1 µg/g, respectively. The levels of arsenic content of hairs and nails in patients with multiple malignant and premalignant lesions were 7.0 µg/g and 7.5 µg/g, respectively. To the contrary, arsenic levels of hairs and nails in patients having solitary lesions were 4.2 µg/g and 7 µg/g, respec-


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ORIGINAL CONTRIBUTION Table. Distribution of Arsenical Malignancies Different Pattern of Malignancies (N=24)

Figure 7. Pigmented basal cell carcinoma involving the nipple along with multiple hypopigmented and hyperpigmented macules.


Number of Patients (Types of Malignancies)



8 (Bowen’s=5, BCC=4, SCC=1)



4 (SCC=4)



3 (BCC=3)



2 (SCC=2)



2 (SCC=2)



2 (Bowen’s=1, BCC=1)



1 (Bowen’s=1, BCC=1)



1 (Bowen’s=1)



1 (Bowen’s=1)



1 (SCC=1)



1 (BCC=1)



1 (BCC=1)



1 (Bowen’s=1)



1 (Bowen’s=1)


Abbreviations: BCC, basal cell carcinoma; SCC, squamous cell carcinoma.


Figure 8. Classical cannon ball metastasis in the lung from squamous cell carcinoma of the hand.

tively. The difference, however, was not statistically significant. A decreased hemoglobin level was noted in 4 patients. One of our patients had pulmonary metastases (Figure 8) from SCC of the hand. No other case of nondermatologic malignancy was found in the present study. Most of the patients were offered surgical excision of the lesions and were referred to surgery and oncology departments. In 2 patients, Bowen’s disease was treated with topical imiquimod cream with good therapeutic response. SKINmed. 2013;11:211–216

Effects of prolonged exposure to high levels of arsenic in drinking water have been observed and documented in epidemiological studies from all over the world. For centuries, arsenic has traditionally been used as a component in cosmetics, paints, wood preservatives, insecticides, fungicides, pesticides, and cotton desiccants. It is also used in the manufacture of semiconductors, components of lasers and microwave circuits, and light-emitting diodes. Arsenic trioxide has recently emerged as a treatment option to induce remission in patients with acute promyelocytic leukaemia.1 Arsenic continues to be an essential component of many nonWestern traditional herbal and homeopathic medicinal products. They are mainly used for asthma, psoriasis, syphilis, hemorrhoids, rheumatism, cough, and pruritus. They are also used as a general health tonic, analgesic, anti-inflammatory agent, and to treat some malignant tumors.1


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Contaminated ground water is the commonest source of chronic arsenic poisoning in the world. In West Bengal, 6 million people are exposed to arsenic-contaminated ground water (>50 μg/L) in 79 blocks in 8 districts of the state. Different studies in West Bengal and in Bangladesh revealed that significantly higher numbers of cases were found in men compared with women.7 Chronic arsenic toxicity is a multisystem disorder that may lead to malignancies of the lung, liver, and genitourinary tract.8 Skin is the most common organ associated with arsenic-related malignancies.9 Cutaneous malignancies in chronic arsenicoses can arise on top of the hyperkeratotic areas as well as on nonkeratotic skin of different body parts. Unlike nonarsenical cutaneous malignancies, arsenic-related cutaneous malignancies are often multiple and involve both exposed as well as covered parts of the body.8 Chronic arsenicoses has mainly been associated with nonmelanomatous skin cancers: Bowen’s disease, BCC, and SCC.10,11 Markel cell carcinoma has also been reported in association with chronic arsenicoses.10 The exact mechanisms of tumor promotion by arsenic are not clearly understood. Toxic effects of arsenic on DNA repairing, modulation of expression of several key transcription factors, including tumor suppressor gene p53, and others may play an important role in the carcinogenesis.12 Arsenic may act as a tumor promoter, co-carcinogen, or tumor progressor under certain circumstances. Whether chronic arsenicosis can lead to malignant melanoma is not clearly understood; however, higher levels of toenail arsenic concentration have been linked with higher risk of melanoma.11 No case of melanoma was found in our series. This is probably in view of the fact that darkskinned Asian populations have a much lower risk of developing melanoma than white populations. Although previous studies showed a higher prevalence rate of arsenic-related skin lesions in men than women,12 data are sparse regarding the relationship of cutaneous malignancies of chronic arsenicoses with age, sex, or occupation. The present study showed a strong male predominance. The precise reason for this could not be elucidated; however, we speculate that this difference may be attributable to metabolic, pharmacokinetic, and other biological factors, as in other cases of chronic arsenicosis. 13 In addition, owing to the socioeconomic structure of the Indian community, men are predominantly engaged in outdoor activities, which may increase their likelihood of UV exposure compared with women. This may, in turn, increase the potential for the development of cutaneous malignancies. We could not quantify the actual amount of sun exposure in our patients, however. Furthermore, total energy expenditure, which may affect the amount of water consumption and therefore the SKINmed. 2013;11:211–216

amount of arsenic intake, is usually more in average men than in women.13 The mean age of the patients in our series was 52.2 years. This may reflect that prolonged exposure to arsenic might be needed prior to the development of cutaneous malignancies. In the present series, a significant male predominance was noted and patients were mostly from the older age groups. According to Western literature, Bowen’s disease is by far the most common form of cutaneous cancer induced by the chronic exposure to arsenic.14 In contrast, SCC was the most frequent form of malignancy noted in our series. As exact duration of arsenic exposure could not be ascertained, we could not determine the latent period of development of malignancies from the onset of exposure. A previous study showed the latent period of development of Bowen’s disease and SCC was 39 years and 41 years, respectively.14 SCC may occur de novo or on the preexisting hyperkeratoses or Bowen’s disease. Large keratotic nodules are particularly the forerunners of skin malignancies.9 Thirty percent of patients with SCC in our series developed malignancies on the pre-existing keratotic lesions. Our study supports the view that Bowen’s disease and BCC are frequently multiple and found in sun-protected areas as well. In consonance with the existing data,15 we found no histological difference between tumors associated with chronic arsenicoses and tumors unrelated to arsenic. In nearly all cases where internal malignancies are attributed to arsenic exposure, there has been cutaneous evidence of arsenic exposure in the form of arsenical keratosis, hyperpigmentation, and multiple cutaneous malignancies. In our series we found only 1 case of internal malignancy in the form of metastatic lung carcinoma arising from large SCC on the palm. Study Limitation The limitation of the present study was that we could not prospectively follow-up the patients after referring them to surgery and oncology departments. Conclusions The present study highlights that those individuals with known exposure to arsenic need regular cutaneous examination as well as close follow-up by their treating physicians to detect malignancy at the earliest stage. Dermatologists play a pivotal role in early case detection of chronic arsenicoses, associated malignancies, and subsequent management. Early diagnosis and surgical intervention are important and have a significant impact on the long-term survival of patients. On the other hand, we emphasize that clinicians must exclude chronic arsenic exposure in every case of cutaneous malignancies.


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References 1 Ratnaike RN. Acute and chronic arsenic toxicity. Postgrad Med J. 2003;79:391–396. 2 Guha Mazumder DN. Chronic arsenic toxicity & human health. Indian J Med Res. 2008;128:436–447. 3 Maloney ME. Arsenic in dermatology. Dermatol Surg. 1996;22:301–304. 4 Watson K, Creamer D. Arsenic-induced keratoses and Bowen’s disease. Clin Exp Dermatol. 2004;29:46–48. 5 Walvekar RR, Kane SV, Nadkarni MS, et al. Chronic arsenic poisoning: a global health issue—a report of multiple primary cancers. J Cutan Pathol. 2007;34:203–206. 6 World Health Organization Regional Office for SouthEast Asia. Arsenicosis Case-Detection, Management and Surveillance. Report of a Regional Consultation New Delhi, India. November 5–9, 2002. New Delhi; 2003:7. 7 Mazumder DG, Ghosh A, Majumdar KK, et al. Arsenic contamination of ground water and its health impact on population of district of Nadia, West Bengal, India. Indian J Community Med. 2010;35:331–338. 8 Smith ML. Environmental and sports-related skin diseases. In: Bolognia JL, Jorizzo JL, Rapini RL eds. Dermatology. 2nd ed. Philadelphia, PA: Mosby-Elsevier. 2010:1353–1375.

9 Saha KC. Cutaneous malignancy in arsenicosis. Br J Dermatol. 2001;145:185. 10 Lien HC, Tsai TF, Lee YY, Hsiao CH. Merkel cell carcinoma and chronic arsenicism. J Am Acad Dermatol. 1999;41:641–643. 11 Beane Freeman LE, Dennis LK, Lynch CF, Thorne PS, Just CL. Toenail arsenic content and cutaneous melanoma in Iowa. Am J Epidemiol. 2004;160:679–687. 12 Tondel M, Rahman M, Magnuson A, et al. The relationship of arsenic levels in drinking water and the prevalence rate of skin lesions in Bangladesh. Environ Health Perspect. 1999;107:727–729. 13 Ohtsuka R, Sudo N, Sekiyama M, et al. Gender difference in daily time and space use among Bangladeshi villagers under arsenic hazard: application of the compact spot-check method. J Biosoc Sci. 2004;36:317–332. 14 Wong SS, Tan KC, Goh CL. Cutaneous manifestations of chronic arsenicism: review of seventeen cases. J Am Acad Dermatol. 1998;38:179–185. 15 Centeno JA, Mullick FG, Martinez L, et al. Pathology related to chronic arsenic exposure. Environ Health Perspect. 2002;110 suppl 5:883–886.


Courtesy of BuyEnlarge, Philadelphia, PA SKINmed. 2013;11:211–216


Cutaneous Malignant and Premalignant Conditions

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Volume 11 • Issue 4


Nutrition Supplementation for Diabetic Wound Healing: A Systematic Review of Current Literature Haiyan M. Maier, MS; Jasminka Z. Ilich, PhD; Jeong-Su Kim, PhD; Maria T. Spicer, PhD Abstract There are 25.8 million people with diabetes in the United States (Centers for Disease Control and Prevention 2011 National Diabetes Fact Sheet). This number is expected to increase by 1 million per year. Diabetic foot ulcers (DFUs) occur in patients with a history of poorly controlled blood glucose. Almost 30% of people with diabetes aged 40 years or older experience DFUs caused by an impaired nerve sensation. It is one of the more persistent types of chronic wounds, which poses an economic burden on individuals and society and reduces the quality of life of patients and their families. This paper reviews the efficacy of nutrition supplementation in diabetic wound healing, including both human and animal studies. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methods, the search was conducted in PubMed and ISI’s Web of Science databases. Studies in which diabetic wounds/foot ulcers were treated with specific nutritional or herbal suplements were selected. This review includes 4 human and 9 animal studies that met the criteria of the search. Positive outcomes in the human studies were not significant while the nutritional supplements used in the animal studies were effective and promoted wound healing. The most notable effect of supplementation with curcumin, L-Arginine, or vitamin E have been shown in animal sudies. More human studies need to be conducted to determine the efficacy of these nutritional supplements in promoting wound healing. (SKINmed. 2013;11:217–225)


iabetic patients are particularly prone to developing foot ulcers primarily caused by neuropathy, vascular insufficiency, and diminished neutrophil function in combination with persistent opportunistic infections and poor blood glucose control.1–3 According to the Centers for Disease Control and Prevention (CDC), 15% of patients diagnosed with diabetes mellitus (DM) develop foot ulcers in their lifetime.4 Among diabetics in the US population, the incidence of new diabetic foot ulcers (DFUs) has been estimated to be about 2% to 3% per year. The treatment cost for a man (aged 40 to 65 years) with a new foot ulcer is estimated at $29,000 for the first 2 years of care following diagnosis.5–8 The CDC estimates that around 82,000 limb amputations are performed every year in patients with DM.9 DFU increases the risk for amputations, at a rate of 11% to 29% five years after diagnosis and is responsible for 50% to 70% of all nontraumatic amputations.10

Unlike decubitus ulcers, which are preceded by protein-energy malnutrition, the most common factor in the onset and progress of DFU is hyperglycemia.11 Elevated blood glucose levels impair the inflammatory process and may delay DFU healing by hyperglycemia-induced mitochondrial superoxide overproduction.12

Hyperglycemia also predisposes diabetic patients to persistent inflammation by decreasing the efficacy of leukocytes in tissue remodeling and by promoting the formation of advanced glycation end products (AGEs).13 The formation of AGE causes the production of reactive oxygen species (ROS), which contributes to oxidative stress and the activation of pro-inflammatory cytokines, further stalling the healing process. Thus, DFUs are usually chronic wounds that do not heal within 8 weeks of onset.14 Conservative and local treatments such as antibiotics and debridement have not been effective in DFUs, leaving a significant number of people with nonhealing chronic wounds.15 Advanced therapies such as systemic hyperbaric oxygen (HBO) can yield an efficacy of 76% with treatment, which still leaves 24% of patients with nonhealing wounds. Although some other new techniques are promising for the treatment of DFUs, such as growth factors (eg, epidermal growth factor) and wound healing modulators (eg, platelet releasate), none of these techniques have been validated for high-grade ulcers (Wagner grade 4 or 5).16,17 Nutrients have been classified into two major groups: anti-inflammatory (ie, omega 3 fatty acids) and antioxidative (ie, vi-

From the Department of Nutrition, Food, and Exercise Sciences, The Florida State University, Tallahassee, FL Address for Correspondence: Maria T. Spicer, PhD, Department of Nutrition, Food, and Exercise Sciences, The Florida State University, Tallahassee, FL 32306 • E-mail:

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tamins A, C, and E) based on their roles in the wound healing process.18 The nutritional impact on the different phases of wound healing, ie, homeostasis, inflammatory phase, proliferative phase, and remodeling, have been summarized.19 For example, to optimize homeostasis, nutrients such as vitamin E and drugs such as aspirin that affect blood clotting should be avoided before surgery. Vitamin A is required for epithelial formation, cellular differentiation, and immune function, while vitamin C is necessary for collagen synthesis. Zinc is important for DNA synthesis, cell division, and protein synthesis, while protein is essential for wound remodeling.19 Optimum nutrition is crucial for the healing of burn and postsurgical wounds.20,21 Balanced nutritional intake optimizes the physiological environment for normal wound healing to occur.22 Research is limited regarding the use of nutritional supplements in the healing of DFUs. Four review papers regarding nutrition and wound healing have been published on pressure ulcers,18 surgical wounds,19,20 burn wounds,21 and other chronic wounds. None of these focused on diabetic wound healing; therefore, the purpose of this article is to review the current literature on the effects of nutritional supplements on diabetic wound healing used in experimental studies and clinical trials. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method, an initial internet search through PubMed and the ISI’s Web of Science was performed using the following search terms in different combinations: “diabetes,” “diabetic,” “wound,” “healing,” “foot ulcer,” “nutrition,” “diet,” and “supplement,” and in combination with individual

nutrients. A total of 2637 Chinese and English articles were found during the initial search. Articles were limited to the evaluation of oral or injected nutrition supplementation in humans or animals, published between 1967 and 2011. For the purpose of this review, a supplement is defined as anything consumed or subcutaneously injected in addition to the usual intake of an individual including herbal products. Abstracts, case studies, prevention therapies, treatment of nondermal wounds, and studies of topical treatments were excluded, resulting in 13 articles that are discussed in this review. RESULTS

Human Studies Only one randomized clinical trial (RCT) has been conducted on the efficacy of an oral nutritional supplement on the healing of DFUs since 2004.23 A proprietary gluten-free liquid formula, Fortimel (Nutricia AB, Netherlands), was used in this RCT. It is composed of 9.7 g protein from concentrated skimmed milk, 10.4 g carbohydrate from lactose, sucrose, maltodextrin, 2.1 g vegetable fat, and unspecified amount of vitamins and minerals per 100 mL, providing 1 kcal/mL. Fifty-three patients, who were referred to a foot care center and randomized in the study, were assigned to consume 400 mL of Fortimel or 400 mL placebo daily for 6 months. The standardized medical treatment of DFUs was not described. No significant results were observed from this study. The status of malnutrition, compliance with the supplement, and the status of the ulcer in the patients were not reported. A total of 19% in the intervention group and 44% in the placebo group were classified as protein-energy–malnourished. There were a significantly higher number of patients with

Table I. Summaries of Human Studies First Author, Year

Supplements/ Application

Study Design

No. of Patients



Reference No.

Eneroth, 2004

Nutrition supplementation (protein, fat, and cholesterol)/oral


26 of 27

6 mo

No effect


Arana, 2004


Patients choice

11 of 11

14 wka

>85% healed 8 of 11 100% healed 3 of 11 >85% healed


Wong, 2001

Herbal drink/oral

Pilot study


9 wka

87.5% healed


Leung, 2008

Herbal drink/oral


40 of 40

5.9±1.4 vs 9.2±1.9 wk

100% healed, free of amputation ↓ TNF-α


Abbreviations: ↓ decreased; ↑ increased; RCT, randomized controlled trial; TNF-α, tumor necrosis factor α. a Average treatment/healing time. SKINmed. 2013;11:217–225


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critical leg ischemia and peripheral vascular disease (PVD) in the intervention group than the placebo group. When patients with ischemia and PVD were excluded, the effect of nutritional supplementation was significant. All wounds in the intervention group without ischemia and PVD patients healed, while less than half in the placebo group healed. A Chinese herbal supplement beverage composed of 12 herbs with huang-chi as the main ingredient was evaluated for its efficacy in saving limbs and preventing amputations in patients with DFUs.15,24 The herb supplement was used as an adjunct to standard treatment, which included daily debridement, diabetic control, and infection control with broad-spectrum antibiotics. The combination of the herbs was believed to be effective in the strengthening of muscle, controlling of swelling, and promoting of regeneration as traditional herbal medicine. In the pilot study, 30 patients were recruited. In addition to daily debridement, herbal drinks were given to the patients. As results, this Chinese herbal supplement drink successfully saved 35 of 40 legs in 30 DFU patients enrolled in the pilot study. Therefore, the achieved limb salvage was 85%. Among all feet saved from amputation, the longest treatment lasted 30 weeks; however, the majority (27 of 35) of feet were cured after an average of 7 weeks. Based on the results of the pilot study, an RCT was conducted with 80 DFU participants in 2008 wherein the effects of the supplement on DFU were compared with a placebo. Antidiabetic treatment and broad-spectrum antibiotics were given for all patients. Unlike the pilot study, the herbal formula was converted into user-friendly granules, which was added to a beverage and given to patients twice a day. Placebo was made with starch and food dye. The herbal supplement significantly improved wound healing in the placebo group in terms of limb salvage, appearance of granulation tissue, and overall assessment of wound healing (size of the wound and healing rate).24 In addition, tumor necrosis factor alpha (TNF-α) decreased by 42% from baseline in the herbal treatment group, while it decreased by only 10% in the placebo group. The effect of L-Arginine (L-Arg) on DFU wound healing was studied in a unique design.25 Patients were given the option to receive treatment of 10 mM L-Arg injections subcutaneously around the DFU in addition to standard DFU care. Wounds ranged in size from 0.5 cm2 to 38.5 cm2. L-Arg is a precursor of nitric oxide (NO), which is a potent vasodilator. It is also the precursor for proline, which is a major protein in collagen. After 9 to 284 days of treatment (mean of 101 days), 100% healing was achieved in 8 of the 11 patients. The remaining 3 patients achieved 85% to 95% healing within 49 to 57 days of treatment.25 SKINmed. 2013;11:217–225

Animal Studies In all the animal studies covered in this review, typical streptozotocin (STZ)-induced diabetes mellitus and wounding procedures were followed. Male or female Sprague-Dawley rats (250 g-300 g) were utilized. Diabetes was induced by an intramuscular injection of streptozotocin. Fasting blood glucose was determined to confirm diabetes 3 days after the injection. Experimental wounding was carried out 5 days after the confirmation of diabetes. Experimental wounding is usually performed by hole punch or excision at the back of the animals, at around 10 mm in diameter or length. Wound healing is usually observed for 7 to 18 days using different supplements. The procedure may vary slightly in different studies, but this is explained when applicable.

Aloe Vera Aloe vera has been used in traditional medicinal practices in many cultures to treat burns, wounds, and scars.19 Two studies used diabetic rat models26,27 and the other used spontaneous model (Goto-Kakizaki) of type 2 diabetic rats.28 In one study, 4-cm2 excision wounds were created in 18 STZinduced diabetic rats.26 Lyophilized colorless parenchyma powder from aloe vera was diluted in water (30 mg/mL) and then administered orally (30 mg per rat). After 16 days of daily treatment, higher levels of collagen, DNA, and protein content in the granulation tissue and a shorter period of epithelialization were observed in the treatment group compared with the control group (P<.05). In the same study, one group of wounded diabetic rats was treated topically with an aloe vera dressing (30 mg per rat) twice a day. Average healing times were 24±2.4, 22.2±2.3, and 20.8±3.4 days for control, topical, and oral groups, respectively (topical vs control, P<.05; oral vs control, P<.01). Rats in both treatment groups showed higher wound tensile strength than those in the control group (P<.001).26 In another study, subcutaneous injection of an aqueous solution of decolorized aloe vera was administered daily for 7 days at 3 different dosages (1 mg/kg, 10 mg/kg, and 100 mg/kg) on 6-mm Baker’s biopsy punch wounds on the backs of STZ diabetic rats.27 After 7 days of treatment, profound wound reductions of 47.00%±3.78%, 50%±2.61%, and 56%±3.50% were observed at 1 mg/kg, 10 mg/kg, and 100 mg/kg, respectively. Spontaneously diabetic rats with 1.3-cm2 full thickness skin wounds were treated with one 30-mg oral dose of lyophilized aloe vera powder solubilized in water after wound creation.28 Wound healing was observed for 8 days after wounding. Wound area was significantly smaller in the treatment group (P<.05) on days 2, 4, and 8 compared with controls. Aloe vera treatment


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Table II. Summary of Animal Studies Supplements

First Author, Year

Experimental Models



Effect on Wounds

Reference No.

Aloe vera

Davis, 1987

STZ mice/6-mm punch


Injection (1, 10, and 100 mg/kg/d)

↓ Wound area Dose responses


Chithra, 1998

STZ rats/2×2-cm full skin excision

16 d

Topical/oral (30 mg/head)

↑ Collagen content ↓ Wound area


Atiba, 2010

Spontaneous model of type 2 diabetes rats/1.5×1.5-cm open wounds


Oral (30 mg/head)

↓ Wound area



Sidhu, 1999

STZ rats and genetically diabetic mice

11 d

Oral (40 gm/kg/d)

↓ Wound area



Shi, 2003

STZ rats/7-cm dorsal skin incision

10 d

Injection (1 g/kg/d)

↑ Procollagen mRNA, citrulline, ornithine, and NOx


Witte, 2002

STZ rats/7-cm dorsal skin incision

10 d

Oral (1 g/kg/d)

↑ Wound breaking strength, OHP, and NOx


Royal jelly

Fuji, 1990

STZ rats/1×1-cm head skin

21 d

Oral (0.1 g/kg/d)

↓ Healing time, blood glucose


Vitamin E

Musalmah, 2002

STZ rats

10 d

Oral (200 mg/kg)

↑ Wound closure


Musalmah, 2005

STZ rats/6-mm round excision wounds

10 d

Oral (200 mg/kg)

↓ Wound area ↑ Protein content


Abbreviations: ↓ decreased; ↑ increased; NOx, mononitrogen oxides; OHP, hydroxyproline; STZ, streptozotocin-treated.

improved wound contraction, inflammatory cell infiltration, angiogenesis, extracellular matrix deposition, and epithelialization. Furthermore, significantly higher levels of protein synthesis, transforming growth factor (TGF) β1 and vascular endothelial growth factor (VEGF) were observed in the treatment group when compared with the control group.28 Overall, oral treatment with aloe vera promoted wound healing in the diabetic rats. Two possible mechanisms may explain why aloe vera is effective in promoting the healing of diabetic wounds: (1) its hypoglycemic effect and (2) its collagen promotion property. Aloe vera has been shown to decrease blood glucose levels in diabetic patients29 and mice.30 Since hyperglycemia is directly related to persistent inflammation and oxidation,31 reduced blood glucose levels would attenuate the persistent inflammation and oxidation caused by hyperglycemia. It is proposed that the antidiabetic effect of aloe vera is mediated through stimulating the synthesis and/or release of insulin from pancreatic β-cells. Aloe vera has been shown to significantly increase the collagen content in granulation tissue of diabetic rats26 as well as nondiabetic rats.32 SKINmed. 2013;11:217–225

Curcumin The wound healing effect of curcumin has been studied in both streptozotocin (STZ) diabetic rats and genetically diabetic mice.33 Full thickness dorsal cutaneous wounds were created using an 8-mm skin biopsy punch on diabetic rats. Curcumin was suspended in water and then given to the animals by oral gavage at a dosage of 40 mg/kg of body weight per day. Water was given to controls. The wound tissues were excised and studied for morphology and biochemical properties. Wounds from diabetic rats treated with curcumin showed early reepithelialization and neovascularization and increased dermal cells migration into the wound bed. Immunohistochemical staining of TGF-β was greater in curcumin-treated wounds compared with untreated wounds. TGF-β is a critical peptide that controls wound repair and has been called the “wound hormone” because it stimulates fibroblast division and differentiation.33 The wound healing–promoting effect of curcumin may also be explained by its antioxidative capability. Curcumin may inhibit free oxygen species production caused by hyperglycemia. This


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Table III. Summary of Wound-Related Physiological Markers in Animal Studies Aloe Vera

Supplementation First author



Curcumin Atiba






L-Arginine Shi


Royal Jelly Fujii

Vitamin E Musalmah


Glutathione peroxidase

Improve healing











Abbreviations: ↑, significant increase was observed; ↓, significant decrease was observed; FN, fibronectin; TGF-β1, transforming growth factor β1; VEGF, Vascular endothelial growth factor; Y, promoted wound healing or improved wound healing.

Figure. Structure of curcumin and its reaction with free radicals.35

was demonstrated in an in vitro study in which curcumin lowered the percentage of hemoglobin glycation, levels of ROS, and malondialdehyde (MDA) generation in human red blood cells. In the experiments, red blood cells were preincubated with curcumin (10 µM) for 30 minutes before exposure to glucose for 24 hours.34 Curcumin is a phenolic compound that reacts with free radicals by direct hydrogen abstraction from the phenolic OH group, as illustrated in the Figure.35

L-Arginine In addition to being the precursor of NO and proline, L-Arg plays vital roles in the synthesis of phosphocreatine and in the urea cycle. L-Arg degradation occurs via multiple pathways such as the production of NO via the catalytic reaction of NO synthase, the production of L-ornithine and urea via arginase, and the production of agmatine via arginine decarboxylase.36 The efficacy of L-Arg supplementation in diabetic wound healing was studied by two groups using STZ diabetic rats.37,38 In one study, 7-cm longitudinal dorsal skin incisions were created in diabetic rats. The treatment group received intraperitioneal injections of 1 g/kg/d of L-Arg in saline solution, while an equal amount of saline was used for the control animals. After 10 SKINmed. 2013;11:217–225

days of treatment, the researchers found that L-Arg significantly enhanced wound breaking strengths and increased wound hydroxyproline content by 40% compared with the saline-treated counterparts.38 In another study, oral treatments of 1 g/kg L-Arg twice daily significantly increased wound breaking strength and hydroxyproline content in the treated group compared with the control group given water.37 L-Arg forms polyamines in reactions mediated by arginase. Polyamines including putrescine, spermidine, and spermine are involved in insulin biosynthesis in vitro.39 In alloxan-induced diabetic rats, the reduction of polyamine concentrations in the pancreas was accompanied by loss of pancreatic arginase activity. Exogenous L-Arg reverses enzyme activity and increases polyamine concentration.25 L-Arg is also the precursor of endothelium-derived NO, a potent endogenous vasodilator, which plays a major role in regulating systemic and pulmonary vascular reactivity and hemodynamics,36,40 improving blood supply to the wound.

Royal Jelly Royal jelly (RJ), a secretion of the hypopharyngeal and mandibular glands of worker honey bees, is the exclusive food of the queen honeybee starting at the larva stage. RJ is 50% to 60%


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water, 18% protein, 15% carbohydrate, 3% to 6% lipid, 1.5% minerals and vitamins, and phenolic compounds collected by bees from plants.41 The principle phenolic compounds in RJ are flavonoids, such as quercetin, apigenin, and acacetin.42,43 RJ has been demonstrated to possess several pharmacologic activities in experimental animals such as vasodilation,44 wound healing,45 and reduction of hypercholesterolemia.46 STZ diabetic rats treated with RJ at 3 different dosages (10 mg/ kg/d, 100 mg/kg/d, and 1000 mg/kg/d) had improved wound healing with significantly shorter healing time (14%) and reduced inflammation with decreased exudation.45 In addition, RJ reduced blood glucose levels in STZ diabetic rats by 10.3 % at week 4.45 In an in vitro wound model, human dermal fibroblasts cell migration was accelerated by RJ treatment. Wound coverage was significantly higher after incubation47 with RJ compared with control. Fibroblast migration is a major step in wound healing, which happens after the initial inflammatory response. It facilitates new tissue formation, cell migration, and proliferation.

Vitamins Vitamin E, as a membrane-protective antioxidant, interacts with selenium-dependent glutathione peroxidase in inhibiting the degradation of fatty acids in the cell membrane. Vitamin E encompasses both tocopherol and tocotrienol isomorphes.48 Two studies49,50 investigated the efficacy of vitamin E (α-tocopherols) on diabetic wound healing using STZ diabetic rats. In both studies, vitamin E (200 mg/kg) was administrated to rats daily by oral gavage. In the first study, the researchers observed that the α-tocopherols supplementation significantly reduced oxidative stress markers, which include MDA, superoxide dismutase (SOD), catalase, and glutathione peroxidase (GPx) and improved rates of wound closure when compared with the control group (treated with an equivalent volume of olive oil).49 The second study50 compared the efficacy of palm-derived vitamin E and purified α-tocopherol on diabetic wound healing. Both palm vitamin E and α-tocopherol decreased the wound area significantly greater and faster than the control treatment (olive oil).50 Vitamin E (α-tocopherol) protects lipid or other biological compounds from being oxidized. It plays a major role in the inhibition of lipid peroxidation, quenching of free radicals, and reduction of low-density lipoprotein oxidation.51 The likely mechanism by which vitamin E is beneficial for wound healing is in its action as an antioxidant. Vitamin E is oxidized during the process by providing hydrogen from its C-6 hydroxyl group. Oxidized vitamin E can be regenerated by vitamin C, glutathione, and nicotinamide adenine dinucleotide phosphate. SKINmed. 2013;11:217–225

The effect of vitamin A, in the form of β-carotene, on diabetic wound healing has also been studied. β-carotene (50 mg/kg) was administered to STZ rats for 28 days before wounding.52 Fourteen days after wounding, the hydroxyproline production and wound breaking strength were significantly improved in the vitamin A pretreated group compared with the nontreated controls.52 DISCUSSION The studies reviewed suggest that nutritional supplementations used in the treatment of wounds in diabetic animal models can significantly promote healing. STZ-induced diabetic rats were used as animal models for most wound healing studies. Aloe vera, curcumin, L-Arg, RJ, and vitamin E all enhanced the healing of created wounds. Wound-related physiological markers, such as TGF-β1, VEGF, MDA, and GPx were investigated in the studies. L-Arg and RJ were able to significantly reduce blood glucose levels when compared with untreated controls. Aloe vera,29,30 curcumin,8,53 and vitamin E54,55 were shown to have anti-inflammatory and/or antioxidative effects. These are candidate supplements that can be studied in the treatment of chronic DFUs. Wound healing research in humans with DM is limited. Among all the nutrients tested in animals, only L-Arg has been examined in human patients. Subcutaneous injection of L-Arg can improve wound healing in diabetes.25 Supplementation with a high protein energy drink successfully reversed malnutrition and improved wound healing in elderly people with diabetes but without ischemia.23 A clinical trial controlling for physiological variations while focusing on the efficacy of the oral nutritional supplement being studied is a justifiable approach for a human study. Chinese herbs have been used for thousands of years to maintain well-being, improve health, and treat diseases . The efficacy of a proprietary formula of Chinese herbs on diabetic wound healing has been demonstrated24 but warrants further controlled study. Providing the formula in tablets or capsule form would be more practical for a large study population in a clinical trial. CONCLUSIONS Impaired wound healing in diabetes is caused by the abnormal physiological environment that prevents tissue regeneration and repair. The nutritional status of patients with DFUs influences the biochemical processes necessary for the phases of normal healing to occur. Compared with other types of treatment procedures, such as HBO, gene therapy, and growth factor therapy, studies on oral nutrition supplementation to promote the healing of diabetic wounds are limited. More studies of supplementation in human patients with DFUs are warranted.


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17 Eldor R, Raz I, Ben Yehuda A, Boulton AJ. New and experimental approaches to treatment of diabetic foot ulcers: a comprehensive review of emerging treatment strategies. Diabet Med. 2004;21:1161–1173.

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36 Wu G, Bazer FW, Davis TA, et al. Arginine metabolism and nutrition in growth, health and disease. Amino Acids. 2009;37:153–168.

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37 Witte MB, Thornton FJ, Tantry U, Barbul A. L-Arginine supplementation enhances diabetic wound healing: involvement of the nitric oxide synthase and arginase pathways. Metabolism. 2002;51:1269–1273.

47 Kim J, Kim Y, Yun H, et al. Royal jelly enhances migration of human dermal fibroblasts and alters the levels of cholesterol and sphinganine in an in vitro wound healing model. Nutr Res Pract. 2010;4:362–368.

38 Shi HP, Most D, Efron DT, Witte MB, Barbul A. Supplemental L-arginine enhances wound healing in diabetic rats. Wound Repair Regen. 2003;11:198–203.

48 Lansdown AB. Nutrition 2: a vital consideration in the management of skin wounds. Br J Nurs. 2004;13:1199– 1210.

39 Goova MT, Li J, Kislinger T, et al. Blockade of receptor for advanced glycation end-products restores effective wound healing in diabetic mice. Am J Pathol. 2001;159:513–525.

49 Musalmah M, Fairuz AH, Gapor MT, Ngah WZ. Effect of vitamin E on plasma malondialdehyde, antioxidant enzyme levels and the rates of wound closures during wound healing in normal and diabetic rats. Asia Pac J Clin Nutr. 2002;11 suppl 7:S448–451.

40 Moncada S, Higgs A. The L-arginine-nitric oxide pathway. N Engl J Med. 1993;329:2002–2012.

50 Musalmah M, Nizrana MY, Fairuz AH, et al. Comparative effects of palm vitamin E and alpha-tocopherol on healing and wound tissue antioxidant enzyme levels in diabetic rats. Lipids. 2005;40:575–580.

41 Neeper M, Schmidt AM, Brett J, et al. Cloning and expression of a cell surface receptor for advanced glycosylation end products of proteins. J Biological Chem. 1992;267:14998–15004.

51 Dickinson PJ, Carrington AL, Frost GS, Boulton AJ. Neurovascular disease, antioxidants and glycation in diabetes. Diabetes Metab Res Rev. 2002;18:260–272.

42 Cushnie TP, Lamb AJ. Antimicrobial activity of flavonoids. Int J Antimicrob Agents. 2005;26:343–356.

52 Seifter E, Rettura G, Padawer J, et al. Impaired wound healing in streptozotocin diabetes. Prevention by supplemental vitamin A. Ann Surg. 1981;194:42–50.

43 Fiorani M, Accorsi A, Blasa M, Diamantini G, Piatti E. Flavonoids from italian multifloral honeys reduce the extracellular ferricyanide in human red blood cells. Journal of agricultural and food chemistry. J Agric Food Chem. 2006;54:8328–8334.

53 Seo KI, Choi MS, Jung UJ, et al. Effect of curcumin supplementation on blood glucose, plasma insulin, and glucose homeostasis related enzyme activities in diabetic db/db mice. Mol Nutr Food Res. 2008;52:995-1004.

44 Shinoda M, Nakajin S, Oikawa T, et al. Biochemical studies on vasodilative factor in royal jelly. Yakugaku Zasshi. 1978;98:139–145.

54 Guney M, Erdemoglu E, Mungan T. Selenium-vitamin E combination and melatonin modulates diabetes-induced blood oxidative damage and fetal outcomes in pregnant rats. Biol Trace Elem Res. 2011;143:1091–1102.

45 Fujii A, Kobayashi S, Kuboyama N, et al. Augmentation of wound healing by royal jelly (RJ) in streptozotocindiabetic rats. Jpn J Pharmacol. 1990;53:331–337.

55 Mayer-Davis EJ, Costacou T, King I, Zaccaro DJ, Bell RA. Plasma and dietary vitamin E in relation to incidence of type 2 diabetes: The Insulin Resistance and Atherosclerosis Study (IRAS). Diabetes Care. 2002;25:2172–2177.

46 Vittek J. Effect of royal jelly on serum lipids in experimental animals and humans with atherosclerosis. Experientia. 1995;51:927–935.

SELF ASSESSMENT EXAMINATION W. Clark Lambert, MD, PhD Instructions for Questions 1-4: For each numbered question, select the single best lettered response from the choices provided. 1. Which of the following is known as the “wound hormone” because it stimulates fibroblast division and differentiation? a. TGF α (Tissue Growth Factor α). b. TGF β (Tissue Growth Factor β). c. TNF α (Tumor Necrosis Factor α). d. TNF β (Tumor Necrosis Factor β). e. VEGF (Vascular Endothelial Growth Factor). f. FN (Fibronectin).

2. Which of the following is a precursor of nitric oxide (NO) and proline? a. α Tocopherol. b. β Carotene. c. Curcumin. d. L-argenine. e. Zinc.

From the Departments of Dermatology, Medicine, and Pathology and Laboratory Medicine, Rutgers University–New Jersey Medical School, Newark, NJ Address for Correspondence: W. Clark Lambert, MD, PhD, Professor of Dermatology and Pathology, Rutgers University–New Jersey Medical School, Newark, NJ• E-mail:

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5. Which of the following has (have) been shown to enhance the healing of created wounds in diabetic animals? a. Aloe vera. b. Curcumin. c. L-argenine. d. Royal jelly. e. Vitamin E. ANSWERS TO SELF ASSESSMENT EXAMINATION b. d. d. a. a, b, c, d, e.

4. Which of the following protects lipids and other biological compounds from being oxidized? a. α Tocopherol. b. β Carotene. c. Aloe vera. d. Curcumin. e. L-argenine. f. Zinc.

Instructions for Question 5: For this numbered item, choose as many responses as apply. All, some, one, or none of the responses may be appropriate.

Wax Moulage

“Calcinosis and Sklerodermie”, Moulage No. 170, made by Lotte Volger in 1926 in the Clinic for Dermatology Zurich. Demonstrating a calcified plaque by pressing with a finger on the patiens left temple. Museum of Wax Moulages Zurich. Courtesy of Michael Geiges, MD

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1. 2. 3. 4. 5.

3. Which of the following reacts with free radicals by direct hydrogen abstraction from its phenolic hydroxyl (OH) group? a. α Tocopherol. b. β Carotene. c. Aloe vera. d. Curcumin. e. L-argenine.


July 18 - 20, 2014 SulAmĂŠrica Convention Center Rio de Janeiro Brazil


July/August 2013

Volume 11 • Issue 4

Core curriculum Virendra N. Sehgal, MD, Section Editor

Hair Biology and Its Comprehensive Sequence in Female Pattern Baldness: Clinical Connotation Diagnosis and Differential Diagnosis—Part II Virendra N. Sehgal, MD; Govind Srivastava, MD; Ashok K. Aggarwal, MD; Rashmi Midha, MBBS

Hair can become a source of concern when there is a change in its texture, number, and thinning. Although female pattern baldness is common, it has received little attention compared with male pattern baldness. Thinning that affects the vertex is insidious and progressive. Hair loss in women has accordingly been interpreted and classified differently than that in men. The Ludwig scale is the most accepted classification. The gross anatomy and the general microanatomy of the hair follicle, including that of the anagen, catagen, and telogen phase, are presented. The hair growth cycle, encompassing anagen, catagen, telogen, exogen, and kenogen, is also discussed to address pattern hair loss in women and provide therapeutic options that are currently available.


it only by the preserved frontal fringe, a characteristic of FPB. With advancing age, the rarefaction on the crown within the aforementioned area may become more pronounced, and the number of thinner and shorter hairs may increase (Figures 2–4).

Clinical Connotation

The “Christmas-tree pattern,” with widening of the central parting line and prominently noticeable in the mid-frontal scalp, was described by Olsen3 (Figure 5).

emale pattern baldness (FPB) is a common condition that is the subject of continuing debate. In part I of this review,1 hair biology was discussed to describe the physiopathology of FPB and to define its clinical overtones, comprising non-/semi-invasive and invasive methods for its differential diagnosis.

FPB may either begin post-menarche or adrenarche. Women typically complain of hair loss around the age of 40 to 50 years. Whether it is an exacerbation of undiagnosed long-standing existing FPB or truly late-onset FPB is not yet clear.2 Usually, the balding process starts with a uniform thinning of the hair on the crown. A circular band of normally dense hair of variable breadth surrounds the resulting oval-shaped area. Frontally, the fringe is narrow, ranging from 1 to 3 cm, while laterally in the temperoparietal (Figure 1) region it is about 4- to 5-cm wide. On the back of the head, the fully haired occiput is separated from the area of rarefaction by a semicircular line between the vertex and the occipital protuberance. The shape of the area closely resembles that of advanced male pattern baldness, differing from

Fronto-temporal deep M-shaped recession is a third, uncommon pattern.4 This pattern, when present in women (Figure 6), is associated with abnormally high testosterone levels, comparable to that seen among healthy men. Although male pattern baldness (Hamilton type) is uncommon in women, when present, it may serve as a marker for an underlying virilizing syndrome. This loss of the frontal hairline is remarkable, and in 468 women studied by Ludwig, only 3 patients showed patterning, which was a marker of virilization. Moderately high levels of circulating androgens may be associated with a Ludwig type of hair loss, while grossly elevated testosterone levels might produce “male-patterning.”5

From the DermatoVenereology (Skin/VD) Center, Sehgal Nursing Home, Panchwati-Delhi, Skin Institute, School of Dermatology, Greater Kailash New-Delhi Address for Correspondence: Virendra N. Sehgal, MD, DermatoVenerology (Skin/VD) Center, Sehgal Nursing Home, A/6 Panchwati, Delhi-110 033, India • E-mail:

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Figure 1. Tempro-parietal pattern baldness in a 49-year-old woman (left). Thinning of the ponytail in the same patient (right).

Figure 2. Progressive thinning/rarefaction of hair on the crown of the head in a 23-year-old woman (left) and 16-yearold girl (right) conforming to Ludwig’s grade I.

Figure 3. Progressive thinning/rarefaction of hair depicted as frontal parting in a 24-year-old woman (Left). Sparing/ occipital parting of the hair in the same patient (middle). Pronounced frontal parting in a 34-year-old woman with Ludwig’s grade II (right). SKINmed. 2013;11:227–236


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Figure 4. Pronounced thinning/rarefaction of the crown of the head, with the preservation of the frontal fringe in a 27-year-old woman (left). Sparing of occipital parting in the same patient with Ludwigâ&#x20AC;&#x2122;s grade III (right).

Figure 5. Christmas tree pattern in a 30-year-old (left) and a 31-year-old (right) woman.

Figure 6. Fronto-temporal deep recession similar to that in male pattern baldness. SKINmed. 2013;11:227â&#x20AC;&#x201C;236


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FPB can also be classified into either early (premenopausal) or late-onset (postmenopausal) disease.4 Androgen excess or normal levels6 may also be complimentary in the understanding of FPB. An objective clinical technique for establishing an early diagnosis consists of comparing “part width” on the crown with “part width” on the occipital scalp. The part width on the crown of the scalp is wider than that of the occiput in female pattern hair loss (FPHL). This patterned change, one of the earliest clinical signs of FPB, is caused by preferential miniaturization of hairs on the crown of the scalp.7 FPHL involves the same general areas of the scalp as that in male pattern hair loss (MPHL); however, the final extent of hair loss in the various regions of the scalp is less in the former. Mild bi-temporal recession in women implies finer and shorter hair vs balding as in MPHL, and has been recorded in 60% to 64% of aging women. Although it may be associated with other areas of hair loss seen with FPHL, bi-temporal recession may occur alone or in association with chronic telogen effluvium (CTE).8 The age of onset of FPHL may range from the immediate postpuberty period to the 3rd decade of life, similar to that of MPHL, or the 2nd peak in the 5th and early 6th decade.4 Women with early-onset FPHL are much more likely to have an associated hyperandrogenism and clear-cut androgenic alopecia (AGA) than those with late-onset FPHL. Late-onset FPHL often corresponds temporally to peri-menopause, but hormone replacement therapy with estrogen does not reverse this process. There is an age-related decrease in hair density, which is always greater on the central scalp, and the overlap undoubtedly contributes to the hair loss of late-onset FPHL.5,9 The hallmark of FPHL, as in MPHL, is an increase in miniaturized hair in the affected scalp. Two factors have been proposed to cause this miniaturization of terminal hairs: a shortening of anagen (which leads to shorter hairs and an increased percentage of hairs in telogen) and a smaller dermal papillae/hair matrix, which leads to a transformation from terminal to vellus hair diameter. This is mirrored in the typical histopathological findings on scalp biopsies of an increase in telogen hairs and vellus-like hair. The accompanying age-related decrease in hair diameter is not race-specific.10,11 In general, just as in MPHL, the primacy of miniaturization of the hair follicle and a decrease in the percentage of hairs in anagen in affected areas are accepted as constant features. Unlike in men, the degree of miniaturization of hair in a given area of the scalp in women is neither as uniform or as potentially extreme as seen in some men.12 This miniaturization process does not progress to baldness, because all hairs in the afSKINmed. 2013;11:227–236

fected areas of the central scalp are not equally affected and the miniaturization is not as profound.13 Although variation in hair diameter is typical of FPHL, it is not pathogonomic, having been reported in (or superimposed on) telogen effluvium secondary to hypothyroidism. A progressive fineness of the hair is a common feature of women with pattern hair loss, but it is generally regarded as a diagnostic feature, probably because of the large inherent inter-individual variability of hair shaft diameter. Early in the process of FPHL, there may be an increase in hair shedding, which, on clinical examination, is manifested as a positive telogen hair pull in affected areas. Over a period of time, this hair shedding tends to stabilize, and a hair pull may not be positive even in the most severe cases of FPHL. This lack of shedding may be the result of two factors: (1) A lag phase at the end of telogen that delays the onset of the new anagen phase in both MPHL and FPHL. This lag phase would account for the affected follicles remaining empty for much longer than in the usual telogen phase.14 (2) The decreased shedding could result from the overall decreased density of terminal hairs, as it is only shedding of terminal hair that causes patient consternation and/ or assessed on the hair pull evaluation. The lag phase may be associated with a specific clinical clue to the diagnosis of pattern hair loss (PHL), that is the presence of what Olsen5 termed “focal atrichia,”14–16 or small eraser-sized areas of baldness. Olsen and Whiting found this focal atrichia to be a relatively specific clinical finding in late vs early FPHL and to be histologically characterized by a decrease in density of both terminal hair and follicular units. A brown halo at the base of affected follicles has been noted as a clinical clue to PHL (peripilar sign) in both men and women.17 This may relate to common histopathological findings of chronic inflammation in PHL and could represent post-inflammatory hyperpigmentation. Histopathology Miniaturization/diminution of follicular size is the hallmark of AGA.18 It is characterized by a decrease in terminal hair in favor of vellus-like hair, a decrease in anagen hairs in favor of telogen hairs, and an increase in follicular stelae, the residual fibrous tract marking where former terminal hairs resided and ending in the superficially located miniaturized follicle that is from the reticular dermis to the papillary dermis.13 It is along this area that this small vellus-like hair cycles up and down through anagen and telogen. If this hair is re-stimulated by treatment to transform again into terminal hair, it travels back down that streamer and generates terminal hair again.19


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core currculum Diagnosis The primary reason for the appraisal of women with the typical clinical picture of FPHL is to rule out close mimickers of FPB not otherwise possible by clinical examination alone. It is worthwhile to determine whether there are treatable factors that may negatively impact the therapeutic interventions for FPB or in themselves are causing hair loss or determine the potential reversibility of the hair loss process.5,24 A history should include the time of onset of hair loss, the location of hair loss, whether increased shedding was present at onset and continues, and the relationship of hair loss to significant life events, illness, surgery, changes in diet, or weight loss or new medications within 6 months prior to the onset hair loss.25 It should be precisely determined what the patient means when there are complaints of hair loss. If the patient has noticed an increased number of hairs falling out daily but no bald areas are seen, an irregularity in the hair cycle (telogen or anagen effluvium) may be the cause.

Figure 7. Photomicrograph of the section prepared from the skin of the scalp showing a telogen hair and part of another telogen pilo-sebaceous unit ending in middermis. There is mild perivascular and periappendageal mononuclear inflammatory infiltrate (hematoxylin and eosin stain, original magnification ×40).

To fully appreciate the number of miniaturized hair follicles, horizontal sections at the level of lower infundibulum of terminal hair follicles should be examined, because sections below this may miss the vellus hairs whose bulbs are situated in the upper dermis. Cursory inspection at low power reveals random variations in the caliber of hair follicles; for this variation in histological size of hair diameter, the term anisotrichosis has been introduced.20–22 A mild peri-follicular lympho-histiocytic infiltrate primarily around the upper follicle is common even in patients without hair loss but is increased in extent and degree in those with PHL (Figure 7). Concentric peri-follicular fibrosis may be present and sebaceous glands remain intact. Although vellus hairs can be quickly identified by the fact that their shaft diameter is equal to or greater than the thickness of their inner root sheath, they are quantitatively defined as having a shaft diameter of ≤0.03 mm. Although the histopathology of PHL is indistinguishable between the sexes, there is some evidence that more hairs are miniaturized in men than either in premenopausal or postmenopausal women.23 SKINmed. 2013;11:227–236

A patient who has not noticed excessive hair loss but complains of having less hair may be experiencing a diffuse loss from genetic FPB or normal senescent thinning. Other causes of hair loss should also be ruled out, such as thyroid diseases or other endocrine disorders, poor nutritional status, iron deficiency,26 drugs, severe infection, and systemic diseases (particularly secondary syphilis and systemic lupus erythematosus. Questions should include whether the menses in the 3rd to 4th decades are regular or require oral contraceptive agents for regulation, whether the patient was able to conceive without artificial stimulation, whether hirsutism is present and being treated and if so when it started, and whether a family history of the same is present. It is important to know whether the menses are now regular, changing, or absent or whether any supplemental hormones have been stopped or started in the recent past. A history of thinning or balding on both sides of the family is important. AGA is multigenetic. It is autosomal-dominant in men, while recessive in women. The latter may express either in the maternal or the paternal side of patients, including aunts, uncles, and grandparents. The patient’s hairstyle history can also be revealing. She will know whether she has had to use smaller hair clips, to style her hair shorter, or to arrange it to hide her thinning towards the top. These are all signs that FPHL is implicated in a gradual transition to shorter, fine hair.27 The physician should then explore the possibility that chronic tension on the hair shaft has led to follicular damage and hair loss. It can also result from tight chignons, ponytails, braiding, or other forceful hair pulling in patients.


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Drugs, particularly anticancer agents, anticonvulsants, anticoagulants, thyroid drugs, β-blockers, and tricyclic antidepressants, can cause diffuse thinning. Although pesticides are not a usual cause, one should determine whether the patient has been exposed to these toxins. If a drug or chemical exposure is the cause, discontinuing the offending agent is usually followed by hair regrowth.28

been used, the commonly used scores include modified Norwood scale for men (the Ludwig scale for women), and the Savin scale, which can be used for both men and women. Another simple way of describing the regional pattern of hair loss is to divide the scalp in sections such as vertex, mid-scalp, frontal, and bi-temporal regions. Each of these regions can be further divided into zones.

Noninvasive Methods of Evaluating Hair Growth

Contrasting Felt Examination

Physical Examination Examination should include the scalp with attention particularly to whether hair loss excludes the occiput, which is typical of FPB, and can be ascertained by comparing the part width in the occiput with that on the top of the scalp.29 Notation should be made as to any patches of hair loss, focal atrichia, broken hairs, general scalp erythema or atrophy, or peri-follicular erythema. Hair pull should be performed on the top, sides and occiput, and the proximal ends of any hair and should be evaluated microscopically to ensure the presence of any telogen hairs. Signs of hirsuitism should be looked for, and nails should be evaluated for pits. A scalp biopsy should be performed from the involved areas when the diagnosis is in doubt or to determine the potential reversibility of the hair loss. Various techniques have been used in diagnosing the type of alopecia.30–32

Scalp Scores Scalp scores nclude validated questionnaires that address the patient’s perception of hair growth and satisfaction with hair appearance. Photographs are taken a short distance away from the patient who is seated in front of a plain cloth or any nonreflecting surface. The head of the patient is kept at an angle of 30 degrees with the long axis. Additional photographs with a vertical partition over the parieto-occipital region can also be taken.33 This helps in comparing between the frontal and occipital parting. Additionally, macrophotographs using 4 times the magnification, if available, can be used to assess hair density and diameter. If an area measuring 14 ×13 mm is evaluated, then grade I density is <4 hairs and grade 6 is >40 hairs. Diameter can be graded as 1 (thin), 2 (medium), or 3 (thick). A separate hair diameter diversity scale can be graded as 0 (<20% in hair diameter diversity) or 1 (>20% in hair diameter diversity). The latter is indicative of miniaturization.5

Regional Hair Pattern This pattern of gradual hair loss in AGA is well defined and distinct in both men and women. Although several grades have SKINmed. 2013;11:227–236

This test is used to see the short, miniature hairs of the scalp. An index card with black felt glued on one side and white felt on the opposite side is used. After making a parting in the hair, the index card is held along the scalp. Fine short hairs with broken or tapered distal tips project up along the edge of the felt. These miniature hairs can be seen in the androgen-dependent areas of both men and women presenting with AGA. In a regrowing telogen effluvium, a classical short frontal fringe is seen.31

Daily Hair Counts Daily hair counts are useful for quantitative assessment of the actual number of hairs shed daily in patients with complaints of excessive shedding. The patient is instructed to collect all the hairs that have been shed every morning including those shed during shampooing in the sink/shower, on the pillow, in the comb, and on the shoulders. These are to be collected for 14 consecutive days and counted. The average daily loss is about 30 to 70 hairs per day. If more than 70 hairs are shed every day, then shaft abnormalities and the appearance of hair bulb should be looked into to distinguish between telogen effluvium, anagen effluvium, and the like.30

Dermatoscopy Dermatoscopy is an accepted novel device for diagnosing pigmented skin lesions. Its use has recently been extended to evaluate AGA and female AGA (FAGA) in Asian individuals,34 where >20% hair diameter diversity (HDD) has been reported as an early sign of AGA. It corresponds with hair follicle miniaturization in the affected area, suggesting that HDD is an essential feature to diagnose AGA and FAGA. Semi-invasive Methods of Evaluating Hair Growth

Rate of Hair Growth The hair in a given target area are shaven and a fixed time allowed to lapse. The area is re-shaved, and the hairs in the target area collected. Hair growth is calculated as the mean length of the collected hairs divided by number of days.


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Hair Pull Test Another simple clinical test, which should ideally be performed on each patient with a complaint of hair loss, is the hair pull test. At times, the pull is not sufficient to pull out the hairs. This technique involves gentle traction from the base to the terminal ends of a group of 25 to 50 scalp hairs. Shedding of 2 to 3 hairs on each hair pull is pathologic. Intact hair shafts and bulbs on microscopic evaluation in patients with increased hair shedding suggest an effluvium or hair breakage. Normal telogen indicates a physiologic aberration, vs dystrophic tellogen or anagen hair, which suggests a pathologic process.33

Hair Feathering Test The hair feathering test is useful in patients with complaints of decreased hair growth or easily broken hair, as it can help in detecting abnormal hair fragility and hair shaft breakage.

Trichogram (Hair Pluck Test) Trichography mainly involves study of the hair cycle. About 50 hairs are evaluated after being cut 0.5 cm above the surface of the scalp. They are rapidly pulled out with epilating forceps or artery forceps in groups of 5 to 10 hairs, in the direction of hair growth.5 The roots are then classified as anagen, telogen, catagen, and dystrophic. A total of 80% to 95% of hair is in the anagen phase. It has a thick, dark base with preserved inner and outer sheaths. The bulb is at an angle of 20 degree with the shaft. Telogen hair constitutes 10% to 20% of plucked hair. It is thin and club-shaped with a smooth contour. The bulb is nonpigmented. Telogen counts >25% are considered abnormal. A total of 1% to 2% of hair is in the catagen phase. The hair is similar to telogen hairs, except that the bulb is rough and covered by a loose and thick outer and inner sheath. Dystrophic/splastic hair/traumatized anagen hair lacks an outer and inner sheath and has an angulated bulb. Disadvantages of trichography include pre-sampling errors, which are difficult to standardize. Ideally, the patient should not shampoo for at least 3 months before sampling. As this is nearly impossible for most patients, uniformity is to be maintained by either shampooing daily or on alternate days. Sampling should be performed within 3 hours of shampooing. It is also a painful procedure and can modify bulb characteristics if improperly performed, thus producing errors in counting anagen and telogen hairs.

Unit Area Rrichogram In this method, the proportion of various hair types is counted after epilating all the hairs marked in a unit area. It is more sensitive than trichography, although more time-consuming. It also SKINmed. 2013;11:227â&#x20AC;&#x201C;236

allows measurement of hair density and shaft diameters. If the hair is predominantly telogen-type, it is known as telogen effluvium. Excessive dystrophic hair is indicative of anagen effluvium. Mixed dominance of telogen hair and dystrophic hair is indicative of alopecia areata.31

Photo-Trichogram and Video-Trichogram After clipping the hair short (1 mm) in a marked area, it is photographed using high magnification at baseline and after a few days. At 2 to 3 days, the number of anagen hairs can be determined, because only the anagen hairs will have gained length. This allows calculation of total number of hair per unit area, differentiation of the hair follicles into terminal, non-vellus, and indeterminate (on the basis of hair diameter), and the A/T ratio. It is less sensitive than a unit area trichogram in assessment of light-colored or grey hair. The advantages are that it is a noninvasive, painless method that is easy to perform, and the patient tolerates it well. The total hair density can be evaluated, and unlike with the trichogram, this examination can be repeated every month on the same area. Digital enlargement of photographs up to 50 to 200 times helps in the estimation of morphologic parameters, such as microvascular status of the scalp, presence of empty follicles, peri-pilar atrophy, scales, and seborrhea.15,35

Digital Epiluminescence Microscopy Digital epiluminescence microscopy is also known as the trichoscan.36 For this method, a region of 1.8 cm2 is marked over the scalp and the hair is clipped. The shaved area is dyed after 3 days. Digital images with epiluminescence microscopy system are taken at 20- to 40-fold magnification on day 0, immediately after clipping, 2 to 3 days after clipping, and 3 and 6 months after the initial visit. Special software is used to analyze the biologic parameters of hair growth, such as hair density, diameter, growth rate, and anagen/telogen ratio.

Global Photographs in Phototrichogram The phototrichogram is used along with global photographs and headshots taken a short distance away from the patient. The patient is usually photographed from the front with the head down to show the frontal hair line and crown, and also from the back to show the vertex.32,37,38 Invasive Methods of Evaluating Hair Growth

Scalp Biopsy Scalp biopsy is performed if the diagnosis of FPB is questionable. It helps in distinguishing androgenetic alopecia from telogen ef-


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fluvium, alopecia areata, and a concomitant primary scarring alopecia.12 In the past, only vertical sectioning was performed, which showed 6 to 8 follicles and delineated the distribution of inflammatory infiltrate and fibrosis. Currently, horizontal sectioning is also recommended, which shows around 20 to 60 follicles (an average of 40 follicles) in a 4-mm punch biopsy.39 This is helpful in showing miniaturization of hair follicles and sparse follicles in scarring alopecia (vide supra).40,41 Screening blood work should always include at least a thyroidstimulating hormone and a free thyroid level (T4) test. Any telogen effluvium related to thyroid deficiency or excess is imminently treatable, and the related hair loss is reversible. It is always wise to assess the patient’s iron status, given that there is some question about the relationship between iron deficiency and FPHL and a suggestion that a response to cyproterone acetate and ethinyl estradiol for FPHL is diminished in the face of uncorrected iron deficiency.42 In addition, iron deficiency anemia can be a sign of a serious underlying medical problem. To screen for iron deficiency, a serum ferritin is a reasonable test of iron stores, but because it is an acute-phase reactant and will be elevated in the face of acute inflammation, an erythrocyte sedimentation rate should be performed along with the ferritin.28 If the ferritin is normal in the face of an elevated sedimentation rate, additional tests should be performed (iron and total iron-binding capacity) to confirm that iron stores are normal.26 A complete blood cell count should also be performed to rule out anemia, including iron deficiency anemia.43 Although there are some data to support that male pattern baldness, especially vertex hair loss, is related to coronary artery disease in men, the data regarding this with FPB in women are insufficient.5 In a study of 106 women younger than 55 years who underwent angiography for symptoms or tests suggestive of coronary artery disease, 29% of women with AGA vs 11% of women without AGA were noted to have angiographically diagnosed coronary disease.28 Differential Diagnosis

Chronic Telogen Effluvium CTE is characterized by chronic, diffuse scalp hair shedding of more than 6 months’ duration, often accompanied by bi-temporal recession. Hair loss is usually not obvious to the physician, but the hair pull test is positive for telogen effluvium in multiple areas of the scalp including the occiput, as opposed to FPHL in which there should never be a positive hair pull from the occiput unless there is a superimposed telogen effluvium.44 The hair pull also excludes loose anagen syndrome, in which multiple loose SKINmed. 2013;11:227–236

anagen hairs are generally seen, a finding corroborated on microscopic examination. Screening by history and relevant laboratory tests for other specific cause(s) of hair loss are prerequisites. Hair loss in patients with known thyroid disease, connective tissue disease, obvious nutritional deficiencies, or use of drugs known or suspected to cause hair loss should be excluded. CTE can be definitely discriminated from FPHL by biopsy of the scalp, where there is a higher terminal/vellus hair ratio in CTE (>11:1) vs FPHL (2.2:1).12 In early FPHL and in elderly woman who naturally have an increased percentage of age-related miniaturized hairs, the distinction may be difficult to make. Performing more than one scalp biopsy will increase the reliability of discriminating between FPHL and CTE.45

Alopecia Areata Occasionally, alopecia areata46 can present with diffuse scalp hair loss instead of patches of hair loss.47 The hair loss is not usually limited to the top of the scalp, and the hair pull is quite different from that seen in FPHL, because both telogen and dystrophic anagen hairs are found in alopecia areata in contrast to only telogen hairs in FPHL.

Trichotillomania Occasionally, trichotillomania48 can mimic FPHL, because some women or girls with this psychological disorder may preferentially choose to pull out the hair on the top of the scalp. Even if the plucked hairs in the affected area have been allowed to partially regrow, the exceptionally short length of all hairs in the involved area, the normal diameter of the involved hairs, and the high proportion of tapered tips of the short hairs signifying new synchronous anagen growth clinically distinguish this from FPHL. Trichotillomania can also be definitely discriminated from FPHL by a scalp biopsy.

Cicatritial Alopecia Cicatritial alopecia49 should also be differentiated from FPHL. Ten men and women with AGA were studied who had “follicular keratosis,” peri-follicular erythema, and obliteration of follicles in the distribution of hair loss.50 On biopsy, there were typical histopathological features of AGA, characterized by miniaturization, replacement of terminal hair by fibrous tracts, along with a lichenoid and an isthmus/infundibullar lymphohistiocytic infiltrate and follicular loss. The condition was called fibrosing alopecia in a pattern distribution (FAPD).51 There is a later presentation of another cicatritial pattern of hair loss, frontal fibrosing alopecia, occurring primarily in the same age group of Caucasian women, with the same perifollicular erythema and with the same histological findings of lichen plano-pilaris, but with the hair


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loss limited to the frontal hairline. Although frontal fibrosing alopecia has since been reported to occur in some cases with FAPD, clearly these conditions may occur independently and only FAPD presents any difficulties in distinguishing from FPB. The clinical presentation of FAPD is very similar to that previously described45 as cicatricial pattern hair loss (CPHL). In CPHL, also seen primarily in middle-aged to older Caucasian women, there is a decrease in density in the top of the scalp in the distribution pattern of a Ludwig pattern of FPHL plus/minus erythema but without any perifollicular papules or follicular accentuation as with FAPD. The histopathology in CPHL is different from that of FAPD. It shows the typical miniaturization findings of FPHL, but with an increase in fibrosis and a marked decrease in expected number of hair follicles (with normal being approximately 35 per 4-mm punch biopsy).52 It is likely that CPHL represents an end stage of FPHL much like a Hamilton pattern VII, which represents an end stage of earlier patterns of MPHL.53,54 It is unclear why this degree of follicular dropout should occur in only a subset of women with FPHL and how CPHL is related to FAPD.

3 Olsen EA. The midline part: an important physical clue to the clinical diagnosis of androgenetic alopecia in women. J Am Acad Dermatol. 1999;40:106–109. 4 Olsen EA. Female pattern hair loss. J Am Acad Dermatol. 2001;45:S70–S80. 5 Olsen EA, Messenger AG, Shapiro J, et al. Evaluation and treatment of male and female pattern hair loss. J Am Acad Dermatol. 2005;52:301–311. 6 Ludwig E. Classification of types of androgenetic alopecia (common baldness) occurring in female sex. Br J Dermatol. 1977;97:247–254. 7 Miller JJ. Medical Pearl: Comparing crown part width to occipital part width to diagnose female pattern hair loss. J Am Acad Dermatol. 2005;53:331–332.

Venning VA, Dawber RP. Patterned androgenetic alopecia in women. J Am Acad Dermatol. 1988;18:1073–1077.

9 Olsen EA. Current and novel methods for assessing efficacy of hair growth promoters in pattern hair loss. J Am Acad Dermatol. 2003;48:253–262. 10 Birch MP, Messenger JF, Messenger AG. Hair density, hair diameter and prevalence of female pattern hair loss. Br J Dermatol. 2001;144:297–304. 11 Jackson D, Church RE, Ebling FJ. Hair diameter in female baldness. Br J Dermatol. 1972;87:361–367.

Central Centrifugal Cicatricial Alopecia This is an extremely common type of hair loss in African American women. The hair loss in central centrifugal cicatricial alopecia (CCCA) initially presents in the central portion of the scalp, spreads centrifugally, and may potentially involve all but the “Hippocratic wreath” of hair always spared in MPHL. The hair loss in well-developed CCCA is accompanied by clinically obvious atrophy and baldness in contrast to the hair loss in FPHL, which may never lead to baldness, even with CPHL, and does not have an atrophic scalp.23 FPHL may be seen in African American women but, when present, is usually mild in degree. Whether CCCA represents the end result of severe FPHL in African American women, perhaps related to hair care practices unique to this population, remains to be explored. If that is the case, it would explain the much less common occurrence of typical FPHL in African American women of European descent.55,56 Conclusions Although female pattern is a common entity, it has received little attention in the literature, perhaps as a result of a lack of awareness among patients and physicians alike. References 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. 2013;11:39–45.

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2 Maguire HC, Kligman AM. Common baldness in women. Geriatrics. 1963;18:329–333.


12 Whiting DA Scalp biopsy as a diagnostic and prognostic tool in androgenetic alopecia. Dermatol Ther. 1998;8:24– 33. 13 Whiting DA. Possible mechanisms of miniaturization during androgenetic alopecia or pattern hair loss. J Am Acad Dermatol. 2001;45:S81–S86. 14 Guerrera M, Rebora A. Anagen hairs may fail to replace telogen hairs in early androgenic female alopecia. Dermatology. 1996;192:28–31. 15 Guerrera M, Ciulla MP. A quantitative evaluation of hair loss: the phototrichogram. J Appl Cosmetol. 1986;4:61– 66. 16 Unger WP, Unger RF. Hair transplanting an important but often forgotten treatment for female pattern hair loss. J Am Acad Dermatol. 2003:49:853–860. 17 Deloche C, de Lacharriere O, Miscialis C, et al. Hf peripilar signs associated with androgentic alopecia. Arch Dermatol Res. 2004;295:422–428. 18 Murphy GF. Histology of the skin. In: Elder DE, ed. Lever’s Histopathology of the Skin. 8th ed. Philadelphia, Pa: Lippincott-Raven; 1997:5–50. 19 Whiting DA, Waldstreicher J, Sanchez M, Kaufman KD. Measuring reversal of hair miniaturization in androgenetic alopecia by follicular counts in horizonal sections of serial scalp biopsies: results of finasteride 1 mg treatment of men and postmenopausal women. J Investig Dermatol Symp Proc. 1999;4:282– 284. 20 Sperling LC, Winton GB. The transverse anatomy of androgenetic alopecia. J Dermatol Surg Oncol. 1990;16:1127–1133.

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21 de Lacharriere O, Deloche C, Misciali C, et al. Hair diameter diversity: a clinical sign reflecting the follicle miniaturisation. Arch Dermatol. 2001;137:641–646. 22 Sewell LD, Elston DM, Dorion P. “Anisotrichosis”: a novel term to describe pattern alopecia. J Am Acad Dermatol. 2007;56:856. 23 Whiting DA. Diagnostic and predictive value of horizontal sections of scalp biopsies in male pattern androgenetic alopecia. J Am Acad Dermatol. 1993:28:755–763. 24 Sperling LC. Evaluation of hair loss. Curr Probl Dermatol. 1996;8:97. 25 Olsen EA. The diagnosis of androgenetic alopecia. Dermatol Ther. 1998;8:18–23. 26 Dloche C, Bastien P, Chadoutand S, et al. Low iron stores: a risk factor for excessive hair loss in non menopausal women. Eur J Dermatol. 2007;17:507–512. 27 Suzberger MB, Witten VH, Kopf AW. Diffuse alopecia in women. Its unexplained apparent increase in inside. Arch Dermatol. 1960;81:556–560. 28 Mansori P, Mortazvi M, Eslami M, Mazinani M. Androgenetic alopecia and coronary artery disease in women. Dermatol Online. 2005;11:2. 29 Trost LB, Bergfeld WF, Calgeras E. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss. J Am Acad Dermatol. 2006;54:824– 844. 30 Olsen EA. Clinical tools for assessing hair loss. In: Disorders of Hair Growth: Diagnosis and Treatment. New York, NY: McGraw-Hill; 1994:59–69. 31 Pierard GE, Piérard-Franchimont C, Marks R, Elsnerc P; for the EEMCO group. EEMCO guidance for the assessment of hair shedding and alopecia. Skin Pharmacol Physiol. 2004;17:98–110. 32 Ratner D, Thomas CO, Bickers D. The use of digital photography in dermatology. J Am Acad Dermatol. 1999;41:749–756. 33 Olsen EA, Bettencourt MS, Cote N. The presence of loose anagen hairs obtained by hair pull in the normal population. J Invest Dermatol Symp Proc. 1999;4:258–260.

40 Solomon AR. The transversely sectioned scalp biopsy specimen: the technique and algorithm for its use in the diagnosis of alopecia. Adv Dermatol. 1994:9:127–157. 41 Sinclair R, Jolley D, Mallari R, Magee J. The reliability of horizontally sanctioned scalp biopsies in the diagnosis of chronic diffuse telogen hair loss in women. J Am Acad Dermatol. 2004;51:189–199. 42 Rushton DH, Ramsay ID. The importance of adequate serum ferritin levels during oral cyproterone acetate and ethinyl oestradiol treatment of diffuse androgen dependent alopecia in women. Clin Endocrinol (Oxf). 1992;36;421–427. 43 Simpson N. The management of androgenetic alopecia in women. J Dermatol. 1989;1:107–111. 44 Whiting DA. Chronic telogen effluvium. Dermatol Clin. 1996;14:723–731. 45 Olsen EA. Female pattern hair loss and its relationship to permanent/cicatricial alopecia: a new perspective. J Investig dermatol Symp Proc. 2005;10:217–221. 46 Sehgal VN, Jain S. Alopecia areata: clinical perspective and an insight into pathogenesis. J Dermatol. 2003;30:271–289. 47 Smith MA, Wells RS. Male type alopecia, alopecia areata and normal hair in women: family histories. Arch Dermatol. 1964;89:95–98. 48 Sehgal VN, Srivastava G. Trichotillomania +/- trichobezoar: revisited. J Eur Acad Dermatol Venereol. 2006;20:911–915. 49 Sehgal VN, Srivastva G, Bajaj P. Cicatricial (scarring) alopecia. Int J Dermatol. 2001;40:241–248. 50 Zinkernagel MS, Trueb RN. Fibrosing alopecia in a pattern distribution: patterned lichenplanopilaris or androgenetic alopecia with lichenoid tissue reaction pattern? Arch Dermatol. 2002;135:205–211.

34 Inui S, Nakajima T, Itami S. Scalp dermoscopy of androgenetic alopecia in Asian people. J Dermatol. 2009;36:82–85.

51 Kossard S. Postmenopausal frontal fibrosing alopecia. Scarring alopecia in a pattern distribution. Arch Dermatol. 1994;130:770–774.

35 D’amico D, Vaccaro M, Guarneiri F, et al. Phototrichogram using vediomicroscopy: a useful technique in the evaluation of scalp hair. Eur J Dermatol. 2001;11:17–20.

52 Hamilton JB. Patterned loss of hair in man: types and incidence. Ann N Y Acad Sci. 1951;53:708–728.

36 Hoffmann R. Trichoscan: a novel tool for the analysis of hair growth in vivo. J Investig Dermatol Symp Proc. 2003;8:109–115. 37 Canfield D. Photographic documentation of hair growth in androgenetic alopecia. Dermatol Clin. 1996;14:713– 721. 38 Di Bernardo BE, Giampapa VC, Vogel J. Standardized hair photography. Dermatol Surg. 1996;22:945–952. 39 Headington JT. Transverse microscopic anatomy of the human scalp. A basis for a morphometric approach to disorders of the hair follicle. Arch Dermatol. 1984;120:449–456.

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53 Sehgal VN, Aggarwal AK, Srivastava G, Rajput P. Male pattern androgenetic alopecia. Skinmed. 2006;5:128–135. 54 Sehgal VN, Kak R, Aggarwal A, Srivastava G, Rajput P. Male pattern androgenetic alopecia in an Indian context: a perspective study. J Eur Acad Dermatol Venereol. 2007;21:473–479. 55 Whiting DA, Olsen EA. Central centrifugal cicatricial alopecia. Dermatol Ther. 2008;21:268–278. 56 Gathers RC, Lim HW. Central centrifugal cicatricial alopecia: past, present, and future. J Am Acad Dermatol. 2009;60:660–668.

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Volume 11 • Issue 4

Perils of Dermatopathology W. Clark Lambert, MD, PhD, Section Editor

Dendritic Melanocytic Pseudomelanomas James Rankin, MBS;1 Claude E. Gagna, PhD;2 Muriel W. Lambert, PhD;3 W. Clark Lambert, MD, PhD3 When I see a bird that walks like a duck and swims like a duck and quacks like a duck, I call that bird a duck.”—James Whitcomb Riley “On the other hand, it might be a teal.”—Ogden Nash


endritic atypical melanocytes, which may be quite subtle histopathologically, are a common, sometimes characteristic feature of the acral-mucosal-lentiginous melanoma and thus may alarm the dermatopathologist, especially if not initially recognized. There are a number of settings, however, in which such melanocytes may occur as an integral part of very different lesions, some benign, others not.1,2 Several of these often challenging entities are reviewed here.

plasm4,5 (Figure 1). These cells are otherwise typical of cells of the tumor, and their presence does not alter the prognosis or the biological behavior of the tumor. Aside from stimulating academic debate regarding the etiopathogensis of DFSP, these cells have no special significance. DFSPs (whether or not they contain dendritic pigmented cells) are locally very aggressive neoplasms with low metastatic potential and low-grade nuclear atypia within the tumor.

Acral Nevocellular Nevi

Melanocytic Colonization of Nonmelanocytic Lesions

Junctional nevocellular nevi occurring in and around acral sites, especially the foot and ankle, tend to show a phenomenon known as the melanocytic acral nevi with intraepidermal ascent of cells (MANIAC) phenomenon.3 MANIAC nevi show intraepidermal dendritic melanocytes that may indeed mimic melanoma. Distinguishing features histopathologically include relatively even spacing of the dendritic melanocytes, symmetry of the lesion, and low degree of cytological atypia, especially nuclear atypia. Important clinical distinguishing features exist as well, and include symmetry, diameter <6 mm, and homogeneous pigmentation. As in all pigmented lesions, a small amount of pigmentation seen histopathologically produces a much greater clinical effect. It is important that clinical details be provided to the dermatopathologist, especially since secondary factors, such as intraepidermal hemorrhage or other pigments, may complicate diagnosis. Bednar Tumor The Bednar tumor, described by B. Bednar in 1957,4 is a rare variant of dermatofibrosarcoma protuberans (DFSP) in which darkly pigmented dendritic cells are present within the neo-

Occasionally, nonmelanocytic intraepidermal lesions may be colonized by dendritic melanocytes that are found superficially and deep within the lesion1,2,6–8 (Figure 2). The term melanoacanthoma has been applied to some of these lesions, particularly seborrheic keratoses that are secondarily colonized by melanocytes.6,7 Such secondary colonization can also occur in malignant epidermal nonmelanocytic lesions, such as basal or squamous cell carcinomas, in which cases the presence of atypical nuclei may make the differential diagnosis from malignant melanocytic lesions more difficult. As for other nonmelanocytic dendritic lesions containing dendritic melanocytes, it is important that these lesions not be mistaken for the acral-mucosal-lentiginous melanoma. Other Conditions Dendritic melanocytes may also be found in other settings, including a number of genetically transmitted conditions.9 Together with the subtlety of recognizing dendritic melanocytes to begin with, this fact may make recognition and correct diagnosis of these lesions challenging.

From the New Jersey Medical School, class of 2013;1 the Department of Life Sciences, New York Institute of Technology, Old Westbury, NY;2 and the Department of Pathology and Laboratory Medicine, Rutgers University–New Jersey Medical School, Newark, NJ3 Address for Correspondence: W. Clark Lambert, MD, PhD, Professor of Dermatology and Pathology, Rutgers University–New Jersey Medical School, Newark, NJ • E-mail:

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Figure 1. Bednar tumor (variant of dermatofibrosarcoma protuberans) showing prominent pigmented dendritic cells (hematoxylin and eosin stain, original magnification ×261).

Figure 2. Melanoacanthoma (variant of seborrheic keratosis) showing dendritic melanocytes throughout the lesion (Melan-A stain, original magnification ×220).

Conclusions Increased awareness of lesions that may contain dendritic melanocytes is necessary in order to prevent misinterpretation of such lesions, avoiding “the psychosocial and medical sequelae of overdiagnosing melanoma in such patients.”8 The above lesions may all fall within the differential diagnosis of malignant melanoma and may create diagnostic uncertainty. It is critical for the dermatopathologist to realize that such entities exist and to differentiate them from melanoma. It is also important for the dermatologist, especially should he/she read their own slides, to be aware that such lesions may be difficult to distinguish from melanomas comprised of dendritic melanocytes, particularly acral lentiginous melanomas. References 1 Lambert MW, Lambert WC, Schwartz RA, et al. Colonization of non-melanocytic cutaneous lesions by dendritic melanocytic cells: a stimulant of acrolentiginous (P-P-S-M) melanoma. J Surg Oncol. 1985;28:12–18. 2 Lambert WC, Lambert MW, Mesa ML, et al. Melanoacanthoma and related disorders: simulants of acrolentiginous (P-P-S-M) melanoma. Int J Dermatol. 1987;26:508–510.

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3 McCalmont T, Brinsko R, LeBoit P. Melanocytic Acral Nevi with Intraepidermal Ascent of Cells (MANIACs): a reappraisal of melanocytic lesions from acral sites. J Cutan Pathol. 1991;18:378. 4 Bednar B. Storiform neurofibromas of the skin, pigmented and nonpigmented. Cancer. 1957;10:368– 376. 5 Mendenhall W, Scarborough M, Flowers F. Dermatofibrosarcoma protuberans. In: Maki R, Robinson J, eds. UpToDate. Waltham, MA, 2012. 6 Vion B, Mérot Y. Melanoacanthoma of the penis shaft. Report of a case. Dermatologica. 1989;179:87–89. 7 Shankar V, Nandi J, Ghosh K, Ghosh S. Giant melanoacanthoma mimicking malignant melanoma. Indian J Dermatol. 2011;56:79–81. 8 Kerl K, Kempf W, Kamarashev J, et al. Constitutional intraepidermal ascent of melanocytes: a potential pitfall in the diagnosis of melanocytic lesions. Arch Dermatol. 2012;148:235–238. 9 Schwartz RA, Cohen-Addad N, Lambert MW, Lambert WC. Diffuse dendritic epidermal and dermal melanocytosis with congenital neuroskeletal defects: a new syndrome. Cutis. 1985;37:37–41.

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Volume 11 • Issue 4

New Therapy Update William Abramovits, MD; Aditya K. Gupta, MD, PhD, Section Editors

Efinaconazole 10% Nail Solution Aditya K. Gupta, MD, PhD, FRCPC;1,2 Fiona C. Simpson, HBSc;2 William Abramovits, MD3,4,5


nychomycosis is a fungal infection of the nail apparatus of the fingers and toenails.1 It is primarily caused by dermatophytes, yeasts, and nondermatophyte molds. The global prevalence of onychomycosis is believed to be between 2% and 8%,2 and its prevalence increases with age3 and systemic comorbidities.4–8 The use of topical antifungal agents in onychomycosis has long been problematic because of poor penetrance of these drugs through the nail plate.9,10 Topical therapy is preferable in cases where oral therapy is contraindicated as a result of drug interactions; however, new entries into this class of drugs have been slow to develop. Efinaconazole (formerly IDP-108) is a new triazole antifungal developed specifically for the topical treatment of distal and lateral subungual onychomycosis (DLSO). The chemical formula for efinaconazole is 1-Piperidineethanol, α-(2,4difluorophenyl)-β-methyl-4-methylene-α-(1H-1,2,4-triazol-1ylmethyl)-, (αR,βR)-.11 Efinaconazole is formulated as a 10% solution (wt/wt). Clinical Studies Efinaconazole 10% solution has just completed two identical phase III multicenter, randomized, double-blind studies (NCT01008033 and NCT01007708).12 These studies compared efinaconazole 10% solution with vehicle in 1655 participants. The inclusion criteria for the study were age 18 to 70 years, a clinical diagnosis of DLSO affecting at least one great toenail, target nail uninfected length ≥3 mm from the proximal nail fold with thickness of ≤3 mm, evidence of toenail growth, positive potassium hydroxide (KOH) microscopy result for a dermatophyte, and positive culture alone or with Candida. Participants were randomized in a 3:1 ratio to receive efinaconazole or vehicle. The solution was applied once daily for 48 weeks,

followed by a 4-week washout period. Participants were assessed for safety at baseline and weeks 12, 24, 36, 48, and 52. The primary outcome measure for the study was complete cure at week 52 (0% nail involvement and mycological cure). There were 4 secondary endpoints assessed at week 52. Mycological cure was defined as negative results on KOH and culture. Complete or almost complete cure was considered ≤5% nail involvement and mycological cure. Treatment success was defined as <10% nail involvement, but was also assessed as ≤10%, ≤5%, and 0% nail involvement. Unaffected toenail growth was assessed as linear change from baseline. Efficacy The first study enrolled 870 participants as the intent-to-treat (ITT) population. Efinaconazole 10% solution resulted in a 17.8% complete cure rate compared with 3.3% for vehicle (P<.001). Selected results from the primary and secondary endpoints are shown in the Table. In addition to these endpoints, the treatment success rate for nail involvement in the efinaconazole group was 45% for ≤10%, 35% for ≤5%, and 21% at 0%, irrespective of mycological cure. The second study enrolled 785 participants as the ITT population. The primary and secondary endpoints were both higher for efinaconazole than vehicle, with complete cure rates of 15.2% and 5.5%, respectively (P<.001) (Table). A high proportion of participants also achieved nonmycological treatment success with 40% achieving ≤10% nail involvement. Overall, the mean complete cure rate was 16.6%±0.04% (weighted mean±standard error of the mean) for efinaconazole and 4.4%±0.05% for vehicle. The mean mycological cure rate

From the Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada;1 Mediprobe Research Inc, London, Canada;2 the Department of Medicine, Baylor University Medical Center;3 the Departments of Dermatology & Family Practice, University of Texas Southwestern Medical School;4 and the Dermatology Treatment & Research Center, Dallas, TX5 Address for Correspondence: Aditya K. Gupta, MD, PhD, FRCPC, 645 Windermere Road, London, Ontario, ON, N5X 2P1, Canada • E-mail:

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Table. Efinaconazole 10% Solution: Outcome Measures Study 1

Study 2

Efinaconazole 10% (n=656), %

Vehicle (n=214), %

Efinaconazole 10% (n=583), %

Vehicle (n=202), %

Complete cure





Mycological cure





Complete or almost complete cure





45 35.7 35 21

17 11.7 11 6

40 31.0 29 18

15 11.9 11 7

5.0 mm

1.6 mm

3.8 mm

0.9 mm

Outcome Measures

Treatment success ≤10% <10% ≤5% 0% Unaffected toenail growth

was 54.4%±0.03% and 16.9%±0.002% for efinaconazole and vehicle, respectively. Efinaconazole was significantly more effective than vehicle for all efficacy outcomes with a P value <.001. Safety The number of participants with at least one adverse event did not differ significantly in the efinaconazole and vehicle groups with 66% vs 61% in study 1 and 64.5% vs.58.5% in study 2. The main treatment-emergent adverse events leading to participant discontinuation from the study were application site dermatitis and vesicles; however, efinaconazole did not show higher rates of localized skin reactions when compared with vehicle. The rate of discontinuations related to adverse events was 3.2% and 1.9% for efinaconazole and 0.5% and 0% for vehicle. The safety of efinaconazole has not been established in individuals younger than 18 and those older than 70 years. Indications and Administration Efinaconazole is still in the regulatory approvals process, so it has not yet received an official indication from the US Food and Drug Administration or Health Canada. It is anticipated that it will be indicated for use in mild to moderate cases of DLSO. The efinaconazole 10% nail solution is applied once daily. Patients should apply the drug to a clean dry nail plate, the lateral and proximal nail folds, hyponychium, and underneath the nail plate. The recommended duration of treatment has not yet been standardized. SKINmed. 2013;11:239–241

Other possible uses for efinaconazole can be envisioned. Efinaconazole may also play a role in enhancing the efficacy of oral or device-based treatment in combined regimens. It may also be a consideration should onychomycosis begin to redevelop in one or more nails after apparent cure. The agent may also have a place in the prophylaxis against the recurrence of onychomycosis. Conclusions Efinaconazole 10% solution is a strong prospective treatment for mild to moderate onychomycosis. Its topical route of administration and low rate of treatment-emergent adverse events make it ideal for use in a broader category of patients; especially those currently contraindicated from oral medication because of drug interactions or systemic disorders. Disclosure: Dr Gupta was an advisor to and has performed clinical trials for Valeant Pharmaceuticals International Inc. References


1 Lambert MW, Lambert WC, Schwartz RA, et al. Colo1. Zaias N. Onychomycosis. Arch Dermatol. 1972;105:263– 274. 2 Gupta AK, Jain HC, Lynde CW, et al. Prevalence and epidemiology of onychomycosis in patients visiting physicians’ offices: a multicenter Canadian survey of 15,000 patients. J Am Acad Dermatol. 2000;43:244–248. 3 Baran R. The nail in the elderly. Clin Dermatol. 2011;29:54–60.

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4 Gupta AK, Taborda P, Taborda V, et al. Epidemiology and prevalence of onychomycosis in HIV-positive individuals. Int J Dermatol. 2000;39:746–753. 5 Gupta AK, Konnikov N, MacDonald P, et al. Prevalence and epidemiology of toenail onychomycosis in diabetic subjects: a multicentre survey. Br J Dermatol. 1998;139:665–671. 6 Gupta AK, Gupta MA, Summerbell RC, et al. The epidemiology of onychomycosis: possible role of smoking and peripheral arterial disease. J Eur Acad Dermatol Venereol. 2000;14:466–469. 7 Döner N, Yasar S, Ekmekçi TR. Evaluation of obesity-associated dermatoses in obese and overweight individuals. Turkderm. 2011;45:146–151. 8 Güleç AT, Demirbilek M, Seçkin D, et al. Superficial fungal infections in 102 renal transplant recipients: a

case-control study. J Am Acad Dermatol. 2003;49:187– 192. 9 Murdan S. First meeting on topical drug delivery to the nail. Expert Opin Drug Deliv. 2007;4:453–455. 10 Murdan S. Enhancing the nail permeability of topically applied drugs. Expert Opin Drug Deliv. 2008;5:1267– 1282. 11 United States Adopted Names Council. Statement on a nonproprietary name adopted by the USAN Council: Efinaconazole [Internet]. resources/doc/usan/efinaconazole.pdf. Accessed January 10, 2013. 12 Elewski BE, Rich P, Pollak R, et al. Efinaconazole 10% solution in the treatment of toenail onychomycosis: Two phase III multicenter, randomized, double-blind studies. J Am Acad Dermatol. 2012;

Historical Diagnosis and treatment Diagnosis and treatments have advanced over the past century. This feature depicts conditions from a collection of stereoscopic cards published in 1910 by The Stereoscopic Skin Clinic by, Dr S. I. Rainforth.

(Continued on page 245) SKINmed. 2013;11:239–241


Efinaconazole 10% Nail Solution

July/August 2013

Volume 11 • Issue 4

New to the Clinic Noah Scheinfeld, MD, JD, Section Editor

Imquimod 2.5% Cream Noah Scheinfeld, MD, JD


ittle has been written on imiquimod 2.5% cream, but this does not suggest that dermatologists should not be aware of its existence. After all, seldom-used compounds later find uses not anticipated in the original studies. The 2.5% concentration of imiquimod is currently only indicated for the treatment of actinic keratoses. Imiquimod 3.75% is approved for the treatment of both genital warts and actinic keratosis, while imquimod 5% has approval for use in the treatment of genital warts, actinic keratoses, and superficial basal cell cancers with a maximum tumor diameter of 2.0 cm.1 Clinical Trials Two major studies were performed for the approval of imiquimod 2.5% and 3.75% cream for the treatment of actinic keratosis. Up to two packets (0.25 mg each) were applied per dose once daily for two 2-week treatment cycles, with a 2-week, notreatment interval between cycles. Researchers assessed efficacy at 8 weeks post-treatment. The 2.5% formulation proved to be less irritating than the 3.75% formulation; however, the 3.75% preparation was more effective. In one study of 479 patients with actinic keratoses, complete and partial clearance (≥75% lesion reduction) rates were 6.3% and 22.6% for placebo, 30.6% and 48.1% for imiquimod 2.5%, and 35.6% and 59.4% for imiquimod 3.75%, respectively (P<.001 vs placebo, each; P=.047, 3.75% vs 2.5% for partial clearance). Median reductions from baseline in lesion count was 25.0% for placebo, 71.8% for imiquimod 2.5%, and 81.8% for imiquimod 3.75% (P<.001, each active vs placebo; P=.048 3.75% vs 2.5%). There were few treatment-related discontinuations. If patients experienced severe irritation, they were allowed to discontinue the medication for a week (a rest period). The patient rest period rates were 0% for placebo, 6.9% for imiquimod 2.5%, and 10.6% for imiquimod 3.75%.2,3

In another study of patients with actinic keratoses,4 490 patients were randomized to either placebo or imiquimod 2.5% or 3.75% cream. Median baseline lesion count for the treatment groups were 9 to 10. Complete and partial clearance rates were 5.5% and 12.8% for placebo, 25.0% and 42.7% for imiquimod 2.5%, and 34.0% and 53.7% for imiquimod 3.75% (P<.001, each imiquimod vs placebo; P=.034, 3.75% vs 2.5% for partial clearance). Median reductions from baseline in lesion count were 23.6%, 66.7%, and 80.0% for the placebo, imiquimod 2.5%, and imiquimod 3.75% groups, respectively (P<.001 each imiquimod vs placebo). There were few treatment-related discontinuations. Temporary treatment interruption (rest) rates were 0%, 17.1%, and 27.2% for the placebo, imiquimod 2.5%, and imiquimod 3.75%, respectively. Conclusions These studies demonstrate that 2.5% and 3.75% imiquimod are superior to placebo and that imiquimod 3.75% on a daily 2-week treatment cycle is superior to imiquimod 2.5% in treating actinic keratosis on a large surface area—the face or balding scalp. Imiquimod continues to be a promising molecule for the treatment of dermatological diseases, including superficial cancers and possibly melanoma. It is unclear where imiquimod 2.5% will find its place in dermatology in view of other stronger formulations of imiquimod and newer agents such as ingenol mebutate gel. Perhaps imiquimod 2.5% is best suited in very sensitive patients, such as those who are candidates for diclofenac sodium gel 3%, a Food and Drug Administration–approved treatment for actinic keratosis with lower irritation and efficacy rates than topical 5-Fluorouracil, imquimod 3.75% or 5%, or ingenol mebutate gel.

From the Department of Dermatology, Weill Cornell Medical College, New York, NY Address for Correspondence: Noah Scheinfeld, MD, JD, Assistant Clinical Professor of Dermatology at Weil Cornell Medical College, 150 West 55th Street, New York, NY 10019 • E-mail:

SKINmed. 2013;11:243–245


© 2013 Pulse Marketing & Communications, LLC

July/August 2013

New to the Clinic

Table I. Select Adverse Reactions Occurring in â&#x2030;Ľ2% of Imiquimod-Treated Patients and at a Greater Frequency than With Vehicle in the Combined Studies Imiquimod Cream, 3.75% (n=160)

Imiquimod Cream, 2.5% (n=160)

Vehicle (n=159)


10 (6)

3 (2)

5 (3)

Application site pruritus

7 (4)

6 (4)

1 (<1)


7 (4)

2 (1)


Adverse Reactions


6 (4)

1 (<1)

2 (1)

Influenza-like illness

1 (<1)

6 (4)


Application site irritation

5 (3)

4 (3)



5 (3)




4 (3)




4 (3)

1 (<1)


Herpes simplex

4 (3)


1 (<1)

Application site pain

5 (3)

2 (1)



3 (2)

4 (3)



4 (3)


2 (1)

4 (3)




3 (2)



3 (2)

2 (1)


Oral herpes Arthralgia

Values are expressed as number (percentage).

Table II. Local Skin Reactions in the Treatment Area in Imiquimod-Treated Patients as Assessed by the Investigator Imiquimod Cream 3.75% (n=160)

Imiquimod Cream 2.5% (n=160)

Vehicle (n=159)





Severe erythema








Severe scabbing/crusting








Severe edema








Severe erosion/ulceration








Severe exudate








Severe flaking/scaling/dryness




All Gradesa


All grades: mild, moderate, or severe. Values are presented as percentages. SKINmed. 2013;11:243â&#x20AC;&#x201C;245


Imquimod 2.5% Cream

July/August 2013

New to the Clinic

References 1 Aldara cream 5% (imiquimod) [package insert]. Scottsdale, AZ: Medicis Pharmaceutical Corp; 2013. 2 Swanson N, Rosen T, Berman B, et al. Optimizing imiquimod for treating actinic keratosis of the full face or balding scalp: imiquimod 2.5% and 3.75% applied daily for two 2-week or 3-week cycles. Poster presented at: 12th World Congress on Cancers of the Skin; May 3–5, 2009; Tel Aviv, Israel. 3 Swanson N, Abramovits W, Berman B, et al. Imiquimod 2.5% and 3.75% for the treatment of actinic keratoses: results of two placebo-controlled studies of daily application to the face and balding scalp for two 2-week cycles. J Am Acad Dermatol. 2010;62:582–590.

4 Hanke CW, Beer KR, Stockfleth E, et al. Imiquimod 2.5% and 3.75% for the treatment of actinic keratoses: results of two placebo-controlled studies of daily application to the face and balding scalp for two 3-week cycles. J Am Acad Dermatol. 2010;62:573– 581. 5 Ellis LZ, Cohen JL, High W, Stewart L. Melanoma in situ treated successfully using imiquimod after nonclearance with surgery: review of the literature. Dermatol Surg. 201;38:937–946. 6 Rivers JK. Topical 3% diclofenac in 2.5% hyaluronan gel for the treatment of actinic keratoses. Skin Therapy Lett. 2004;9:1–3.

Historical Diagnosis and treatment: epithelioma

SKINmed. 2013;11:243–245


(Continued from page 241)

Imquimod 2.5% Cream

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July/August 2013

Volume 11 • Issue 4

COSMETIC SCIENCE Howard A. Epstein, PhD, Section Editor

A Second Look at Vitamin E Howard A. Epstein, PhD


itamin E is essential for the maintainence of skin health. It is the most abundant antioxidant recognized in the skin. Vitamin E is found in 8 major naturally occurring molecules, 4 of which are tocopherols (α, β, ϒ, and δ; Figure) and 4 tocotrienols (α, β, ϒ, and δ). All of the naturally occurring vitamin E and synthetic forms have relatively similar antioxidant effects; yet, the body prefers α tocopherol as a factor involved in the regulation of molecular biological activity. Tocopherol was discovered in 1922 as a dietary factor necessary for reproduction in rats.1 Other studies conducted after this discovery showed that the presence of rancid fat in experimental diets fed to rats and chickens caused various pathologic conditions in the animals that were corrected with wheat germ oil concentrates demonstrated to contain tocopherols.2,3 Previously, the primary function of vitamin E was considered to be as an antioxidant. Recent advances in molecular biology indicate that vitamin E–sensitive genes and vitamin E–regulated transduction pathways exist in human tissue. The antioxidant effect of vitamin E is exerted through the phenolic hydroxyl group, which donates its hydrogen to the peroxyl radical, resulting in the formation of a stable lipid species.4 The efficiency of tocopherol depends on the mobility of the molecule in the cell membrane and the number of methyl species on the chromanol ring, with each methyl group conferring additional antioxidant activity. The proximity of the methyl group to the hydroxyl group also seems to be an important factor in the antioxidant activity.4 α Homologues have the most methyl species and show the greatest antioxidant activity relative to the other homologues. In vitro studies have shown α tocopherol to have the least potency compared with δ and ϒ tocopherol.4 Other studies have shown that ϒ tocopherol is more efficient than α tocopherol in the ability to trap membrane-soluble electrophilic nitrogen oxides and other electrophilic mutagens possessing free aromatic ring positions. In this regard, ϒ tocopherol is a more efficient inhibitor of reactive nitrogen species–derived damage.4 Vitamin E

does not function in isolation from other antioxidants, it is part of an interlinking antioxidant system interacting with vitamin C, and vitamin C interacting with thiol antioxidants including glutathione and lipoic acid. Gene-Regulating Activity Tocopherol is a cell signaling molecule, interacting with the lowdensity lipoprotein receptor and transcription factors including the pregnane X receptor associated with driving redox-regulated gene expression. Glutathione protein levels and changes in enzyme activity levels when investigated in vitro and in vivo were observed. Recent data suggest that genetic polymorphisms may determine the biological and gene-regulatory activity of α tocopherol.4 Mice and rat studies have shown vitamin E to be involved in transcriptional regulation of target genes connected with antioxidant defense, inflammation, cell cycle regulation, extracellular matrix, cytoarchitecture, lipid uptake, cholesterol synthesis, and other cellular events.4 Vitamin E Homeostasis, Metabolism, and Confounding Clinical Studies Studies regarding bioavailability and biopotency in humans remain the subject of debate because of the variations of test protocol and differences in the isoform of vitamin E used in the study.4 Another factor is the large interindividual variation in response to vitamin E supplementation, representing genetic heterogeneity. Proteins involved in drug/lipid metabolism, which directly influence vitamin E status, are highly polymorphic and likely to influence interindividual variation and be responsible for confounding study results.4 During the 1960s, symptoms of human vitamin E deficiency were reported to be associated with lipoprotein abnormalities and fat malabsorption of other nutrients. In the 1980s, case studies reported vitamin E deficiency connected with gene defects for α tocopherol transfer protein (α-TPP), a protein that

From EMD Chemicals, Philadelphia, PA Address for Correspondence: Howard A. Epstein, PhD, EMD Chemicals, International Plaza Drive, Philadelphia, PA 19113 • E-mail:

SKINmed. 2013;11:247–249


© 2013 Pulse Marketing & Communications, LLC

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R1 R2 R3

α tocopherol




b tocopherol




g tocopherol




d tocopherol





Fugure. Vitamin E is a generic term for the tocopherols and tocotrienols. The four forms above are found naturally.

metabolizes ϒ tocopherol to the water-soluble metabolite. Symptoms were different in that abnormal nerve function is observed in individuals with α-TPP deficiency.5 Peroxisome proliferatoractivated receptors (PPARs) are 3 different but closely related nuclear receptors in cells: PPAR-α, PPAR-b/-δ, and PPAR-ϒ, with each encoded by separate genes. PPAR-α is found in abundance in the liver where it is responsible for regulation of energy homeostasis, heme synthesis, lipoprotein assembly, and cholesterol metabolism. PPAR-β/-δ is found predominantly in the gut and placenta and is involved in fatty acid catabolism, cell proliferation, differentiation, and survival. PPAR-ϒ regulates lipid storage and glucose metabolism. PPARs act as lipid sensors that translate changes in fatty acid concentration into metabolic activity.5 Oxidative stress is an important regulator of PPARs, but the influence of tocopherol on PPARs in association with oxidative stress is not completely understood, and it is likely involved in preventing fatty acid oxidation.5 Oxidative Stress in Human Studies The ability of vitamin E, as α tocopherol (400 IU/d) and β-carotene (15 mg/d), was evaluated to reduce markers of oxidative stress and erythema in human skin exposed to UV radiation (UVR). Skin biopsy samples were taken before and after the study. Sixteen volunteers were exposed to 120 mJ/cm² UVR for 6 hours. Vitamin E supplementation significantly reduced skin malondialdehyde concentration and neither supplement affected other measures of UVR-induced oxidative stress in human skin, suggesting no photoprotection of either supplement. Supplements did appear to prevent UVR-induced decrease in skin total SKINmed. 2013;11:247–249

glutathione content.6 In another study of runners participating in a 50-km ultramarathon, oxidative stress was measured as increased F2-isoprostane concentration. Muscle damage was characterized by measures of fatigue and increased circulating muscle damage markers. Circulating inflammatory markers elicited by the run increased in the characteristic progression of cytokine responses to tissue damage and inflammation. Supplementation with both vitamin E and C completely inhibited exercise-induced lipid peroxidation but had no effect on other parameters including inflammation, DNA damage, muscle damage markers, fatigue, or recovery.5 The Clinical Use of Antioxidants in Dermatology: Potential for Efficacy The use of antioxidants in clinical dermatology is uncommon. Epidemiologic studies have shown that diets rich in fruits and vegetables containing high amounts of antioxidants may reduce the risk of diseases associated with aging. Studies have also shown that antioxidants including carotenoids, tocopherols, and ascorbate derivative may act as antioxidants or prooxidants depending on dose and length of use. Mast cells accumulate near skin tumors including basal cell carcinoma, squamous cell carcinoma, atopic dermatitis, and contact dermatitis. They may exert a promoting or inhibitory effect on the tumors. The tumor microenvironment is altered by mast cells releasing cytokines, growth factors, proteoglycans, and proteases that can ultimately lead to local UV-B–induced immunosuppression and increased angiogenesis of the tumor. Mast cells in skin may be influenced either directly by topical application or via oral consumption of vitamin E.7,8 In a canine


A Second Look at Vitamin E

July/August 2013


atopic dermatitis model, vitamin E inhibited histamine. The signaling pathway was not identified.9 Vitamin E esters have been extensively used for many years in dermatologic preparations and cosmetics. A few cases of contact dermatitis linked to treatment tocopherol acetate, tocopherol nicotinate, and tocopherol linolate have been reported in the literature. It is hypothesized that mast cells are involved in these cases.10,11 Conclusions It appears likely that the function of vitamin E is not exclusively as an antioxidant, but rather as a modulator of receptors and signaling pathways. Vitamin E protects long-chain polyunsaturated fatty acids, which is also important in cell signaling. In the future, gene expression studies involving vitamin E genetic polymorphisms may help to determine the biological and gene-regulatory activity of tocopherol. Gene expression technology will likely be useful in identifying nutritional phenotypes for future personalized nutrition and skin health and further elucidate the biological mechanisms of vitamin E with respect to physiology and metabolism factors. Perhaps, novel mechanisms of activity will be identified. References 1 Karrer P, Fritsche H, Ringier BH, Salomon H. Synthesis of alpha-tocopherol. Helv Chim Acta. 1938;21:820–825. 2 Herting DC. Perspective on vitamin E. Am J Clin Nutr. 1966;19:210:218.

3 Dam H. Influence of antioxidants and redox substances on signs of vitamin E deficiency. Pharmacol Rev. 1957; 9:1–16. 4 Rimbach G, Moehring J, Huebbe P, Lodge JK. Gene-regulatory activity of α-tocopherol. Molecules. 2010;15:1746– 1761 5 Taber MG, Atkinson A. Vitamin E, antioxidant and nothing more. Free Radic Bio Med. 2007;43:4–15. 6 McArdle F, Rhodes LE, Parslew RA, et al. Effects of oral vitamin E and ß-carotene supplementation on ultraviolet radiation-induced oxidative stress in human skin. Am J Clin Nutr. 2004;80:1270–1275. 7 Richelle M, Sabatier M, Steiling H, Williamson G. Skin bioavailability of dietary vitamin E, carotenoids, polyphenols, vitamin C, zinc and selenium. Br J Nutr. 2006;96:227–238. 8 Theoharides TC, Bielory L. Mast cells and mast cell mediators as targets of dietary supplements. Ann Allergy Asthma Immunol. 2004;93:S24–S34. 9 Gueck T, Aschenbach JR, Fuhrmann H. Influence of vitamin E on mast cell mediator release. Vet Dermatol. 2002;13:301–305. 10 de Groot AC, Berretty PJ, van Ginkel CJ, et al. Allergic contact dermatitis from tocopherol acetate in cosmetic creams. Contact Dermatitis. 1991;25:302–304. 11 Perenoud D, Homberger HP, Auderset PC, et al. An epidemic outbreak of popular and follicular contact dermatitis to tocopherol linolate in cosmetics. Swiss Contact Dermatitis Res Group. Dermatology. 1994;189:225–233.


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SKINmed. 2013;11:247–249


A Second Look at Vitamin E


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July/August 2013

Volume 11 • Issue 4

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

Sneddon’s Syndrome Presenting With Neuropathic Pain Ersel Dag, MD; Burcu Gokce, MD; Mukadder Kocak, MD

A 55-year-old man was admitted to us with a sense of numbness, tingling, and burning in his feet and headache, characterized as a feeling of pressure all around his head, for 1 year and aggravated in the past 3 months. The patient’s neurologic examination was normal and he had no other known diseases except for hypertension according to his medical history. During the examination, we recognized purplish lesions on the patient’s body. His kidney, liver, and thyroid function test results and vitamin B12 levels were all normal. His hematocrit level was 41.8%, platelet value was 234,000 (150,000–500,000), and sedimentation rate was 9 mm/h (0–20). Electromyography was performed and results were found to be normal. The patient was diagnosed as having small fiber neuropathy. Dermatologic examination revealed reddish blue mottling of the skin with fishnet reticular pattern on his back, on the front side of the body, and on both arms and legs, and the lesions were classified as livedo racemosa (Figure 1). Brain magnetic resonance imaging (MRI) showed subcortical hyperintense ischemic-gliotic signal changes on T2-FLAIR in the deep white matter of bilateral frontoparietal vertex, centrum semiovale, and corona radiata (Figure 2). FLAIR sequence axial MRI of the brain of our patient showed subcortical hyperintense lesions in both cerebral hemispheres. His cardiac examination was normal and minimal aortic regurgitation was seen on echocardiography. His cognitive assessment Minimental Test Score was 22, and Montreal Cognitive Assessment score was 18. Laboratory values for inflammatory markers and autoimmune antibodies including syphilis serology, lupus anticoagulants, and anticardiolipin antibodies were negative. Factor V Leiden mutation was not detected in the patient. The patient was diagnosed with Sneddon’s syndrome with the above signs and symptoms and small fiber neuropathy. Clopidogrel 75 mg and gabapentin 1200 mg was started once a day and blood pressure regulation was achieved. (SKINmed. 2013;11:251–252)


neddon’s syndrome (SS) is a condition characterized by skin lesions and ischemic cerebrovascular disease.1 It is rarely seen and the incidence of this condition is 4 in 1000000.2 The etiology of the disease has not been elucidated. It is thought to be a progressive noninflammatory thrombotic vasculopathy that affects the medium and small arteries.3 It is common in young women between the ages of 20 and 42 and rarely occurs after 65 and before 10 years of age. Typical skin lesions are livedo racemosa, and neurological symptoms such as headaches, memory problems, cognitive impairment, and cerebrovascular disease can also be seen.4 Brain lesions are usually in the form of multiple infarcts or monoinfarct.5

Neuropathic pain may be a prominent presenting symptom in peripheral neuropathies and is characterized with predominant small fiber involvement. Small fiber neuropathy is caused by damage to the small, unmyelinated fibers in the peripheral nerves. Dysfunction of the small nerve fibers may cause sensory or autonomic symptoms. Neurologic examination, electromyography, and nerve conduction studies are usually normal.6 Symptoms of sensory small fiber neuropathy include numbness, hypersensitivity,

and spontaneous painful or annoying sensations called paresthesia. The latter can present as tingling, burning, freezing, stinging, stabbing, itching, squeezing, tearing, buzzing, aching, or electric sensations that fluctuate in severity. The most common cause is diabetes mellitus or glucose intolerance.7,8 In this case report, we present a patient who complained of pain caused by neuropathy and diagnosed with antiphospholipid antibody–negative SS. SS is mostly accompanied by thrombocytopenia along with, rarely, arterial hypertension.2,9 For the diagnosis of SS, other diseases such as systemic lupus erythematosus, cryoglobulinemia, paraproteinemia, vasculitis, and atherosclerosis causing livedo racemosa, should be excluded.2 Livedo racemosa is irreversible and permanent red or purple-colored skin lesions are observed on body parts such as the arms and legs.10 In the livedo racemosa development, thrombotic or embolic process in the artery and arterioles of the skin and central nervous system are proposed to be the underlying causes.11 Livedo racemosa occurs as a result of decreased blood flow caused by local vasoconstriction and arterial occlusion of cutaneous venules. Changes in blood flow (thrombosis, increased viscosity, and embo-

From the Department of Neurology, Kırıkkale University, Kırıkkale, Turkey Address for Correspondence: Ersel DAG, MD, Department of Neurology, Kirikkale University, 71100 Kirikkale,-Turkey • E-mail:

SKINmed. 2013;11:251–252


© 2013 Pulse Marketing & Communications, LLC

July/August 2013


Figure 1. Reddish blue mottling of the skin with fishnet reticular pattern on the back of our patient.

lism), calcification on the arterial wall, vasculitis, and intimal hyperplasia play a role in arterial occlusion.12 In SS, livedo racemosa occurs before cerebrovascular symptoms. Cerebrovascular disease can be seen as monoinfarcts or multiple infarcts.13 SS can also be seen in ischemic or valvular-type cardiac diseases; therefore, electrocardiography and echocardiography should be performed in patients. Neuropsychological symptoms such as cognitive impairment, dementia, and depression are widely seen in SS.14 Conclusions SS was incidentally diagnosed in our patient, as his complaints at the time of admission were related to his neuropathic pain. In the differential diagnosis of cerebrovascular disease and livedo racemosa, SS should be always taken into consideration; in this way, early diagnosis may be possible and the treatment may be applied timely. References 1 Martínez-Valle F, Ordi-Ros J, Selva-O’Callaghan A, et al. Livedo racemosa as a marker of increased risk of recurrent thrombosis in patients with negative anti-phospholipid antibodies. Med Clin (Barc). 2009;30:767–771. 2 Zelger B, Sepp N, Stockhammer G, et al. Sneddon’s syndrome. A long-term follow-up of 21 patients. Arch Dermatol. 1993;129:437–447. 3 Hilton DA, Footitt D. Neuropathological findings in Sneddon´s syndrome. Neurology. 2003;60:1181–1182. 4 Wright RA, Kokmen E. Gradually progressive dementia without discrete cerebrovascular events in a patient with Sneddon’s syndrome. Mayo Clin Proc. 1999;74:57–61. 5 Karagülle AT, Karadag D, Erden A, et al. Sneddon’s syndrome: MR imaging findings. Eur Radiol. 2002;12:144–146. 6 Stewart JD, Low PA, Fealey RD. Distal small fiber neuropathy: results of tests of sweating and autonomic cardiovascular reflexes. Muscle Nerve. 1992;15:661–665.

SKINmed. 2013;11:251–252


Figure 2. Fronto-temporal deep recession similar to that in male pattern baldness.

7 Polydefkis M, Griffin JW, McArthur J. New insights into diabetic polyneuropathy. JAMA. 2003;290:1371–1376. 8 Walk D, Zaretskaya M, Parry GJ. Symptom duration and clinical features in painful sensory neuropathy with and without nerve conduction abnormalities. J Neurol Sci. 2003;214:3–6. 9. Francès C, Papo T, Wechsler B, et al. Sneddon syndrome with or without antiphospholipid antibodies. A comparative study in 46 patients. Medicine (Baltimore). 1999;78:209–219. 10. Francès C, Niang S, Laffitte E, et al. Dermatologic manifestations of the antiphospholipid syndrome: two hundred consecutive cases. Arthritis Rheum. 2005;52:1785– 1793. 11. Wohlrab J, Fischer M, Wolter M, et al. Diagnostic impact and sensitivity of skin biopsies in Sneddon’s syndrome. A report of 15 cases. Br J Dermatol. 2001;145:285–288. 12. Sepp N, Zelger B, Schuler G, et al. Sneddon’s syndrome—an inflammatory disorder of small arteries followed by smooth muscle proliferation. Immunohistochemical and ultrastructural evidence. Am J Surg Pathol. 1995;19:448–453. 13. Tietjen GE, Al-Qasmi MM, Gunda P, et al. Sneddon’s syndrome: another migraine–stroke association? Cephalalgia. 2006;26:225–232. 14. Kraemer M, Linden D, Berlit P. The spectrum of differential diagnosis in neurological patients with livedo reticularis and livedo racemosa. A literature review. J Neurol. 2005;252:1155–1166.

Sneddon’s Syndrome Presenting With Neuropathic Pain


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July/August 2013

Volume 11 • Issue 4


Mucinous Carcinoma: A Translucent Blue Papule on an 89-Year-Old Man Thomas J. Hagele, BS; Charles Chiang, MD; Rocco Serrao, MD; Julian J. Trevino, MD An 89-year-old man with no significant medical history presented with a slow-growing, asymptomatic translucent blue mass noticed 1 year prior to evaluation. Review of symptoms was negative for constitutional symptoms, gastrointestinal (GI) disturbance, and visual complaints. Physical evaluation revealed a 4-mm firm light blue translucent papule on the left medial canthus (Figure 1). No cervical or axillary adenopathy was present. No further lesions were identified during full body skin examination, including chest wall masses. A diagnostic study was performed and stained with hematoxylin-eosin (Figure 2) and periodic acid-Schiff (Figure 3). (SKINmed. 2013;11:254–255)


icroscopic evaluation revealed floating islands of clustered cuboidal epithelial cells with vacuolated cytoplasm and hyperchromatic nuclei within lakes of basophilic material. Results from periodic acid-Schiff staining confirmed the identity of the material as mucin (Figure 3).1 Histochemical testing demonstrated immunoreactivity for epithelial membrane antigen, estrogen receptor, and mucin 1 and mucin 2. The tumor was removed with clear margins without complications by Mohs micrograph surgery. The patient was up to date on routine cancer screening, including colonoscopy. He was referred to oncology, where imaging was not recommend. On clinical follow-up, there have been no signs of recurrence. Discussion

Primary cutaneous mucinous carcinomas are rare malignancies occurring in patients of any age and race, although most commonly in white men at an average age of 63.2 Typically these cancers are distinguished grossly as solitary, slow-growing, soft to firm papules varying in color from translucent to grayish, reddish, or bluish.2,3 They average 2 cm in diameter although a case up to 7 cm has been reported.4 The differential diagnosis of mucinous carcinoma includes hidrocystoma, basal cell carcinoma, squamous cell carcinoma, lacrimal duct tumor, pyogenic granuloma, hemangioma, and Kaposi sarcoma. Mucinous carcinomas can occur anywhere on the body but are reported most commonly on the eyelid (38%), face (20%), scalp (16%), and axilla (10%).5 Typically, these tumors are locally destructive and slow-growing; however, local metastasis may occur in as many as

10% of cases, and distant metastases, although extremely rare, have been reported.5 Mucinous carcinomas are histologically described as dermal cords of neoplastic epithelial cells within pools of extracellular mucin separated by fibrovascular septae that occasionally extend into the subcutaneous tissue.4 Distinguishing primary cutaneous from metastatic mucinous carcinoma is challenging. The most common sources for metastatic disease are the gastrointestinal tract and breast.6 Staining for cytokeratin 20 staining is helpful because gastrointestinal cancers typically stain positive while results for primary cutaneous mucinous carcinoma and metastatic breast cancer are consistently negative.7 Distinguishing primary cutaneous mucinous carcinoma from metastatic breast cancer is difficult as both are estrogen receptor–positive, produce sialomucin, and typically express similar immunohistochemical markers including low molecular weight cytokeratin 7, carcinoembryonic antigen, epithelial membrane antigen, S-100, and alpha-actalbumin.8 Recent studies have suggested that cytokeratin 5 may be a distinguishing marker because it can be present in primary mucinous carcinoma and has not been observed in metastatic breast carcinoma.7 Unfortunately, the sensitivity of this marker is poor, with only 20% of primary mucinous carcinomas staining positive.7 A detailed review of systems in addition to a comprehensive physical examination is essential to screen for a possible primary source given the pathological difficulty in distinguishing primary and metastatic tumors, despite immunohistochemical staining. Further screening tests may include mammography and colonoscopy.

From the Department of Dermatology, Boonshoft School of Medicine, Wright State University, Dayton, OH Address for Correspondence: Julian J. Trevino, MD, Department of Dermatology, Boonshoft School of Medicine, Wright State University, 725 University Boulevard, Dayton, OH 45435 • E-mail:

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Figure 1. Light blue translucent papule on the left medial canthus.

Figure 3. Pool of dermal mucin highlighted with periodic acid-Schiff stain (original magnification ×40).

that immunohistochemical staining was suggestive of primary mucinous carcinoma in this case, all patients should receive routine screening with colonoscopy and mammography to evaluate for possible GI or breast etiology. References 1 Weedon D. Tumors of cutaneous appendages. Weedon’s Skin Pathology. Churchill Livingstone; 2009. http://www. Accessed January 31, 2012. 2 Snow SN, Reizner GT. Mucinous eccrine carcinoma of the eyelid. Cancer. 1992;70:2099–2104. 3 Mendoza S, Helwig EB. Mucinous (adenocystic) carcinoma of the skin. Arch Dermatol. 1971;103:68–78. 4

Figure 2. Islands of epithelial cells surrounded by mucin (hematoxylin-eosin stain, original magnification ×20).

Because of a 28% recurrence rate subsequent to excision, Mohs micrographic surgery to ensure negative margins is the preferred treatment for primary cutaneous mucinous carcinoma.9 In cases where excision is performed, margins from 1.5 to 2 cm are recommended.2 Conclusions Primary mucinous carcinoma is a rare cutaneous malignancy that must always be considered in the differential diagnosis of a solitary translucent, grayish, reddish, or bluish papule. It is essential to identify this lesion because of the risk of metastasis in addition to local tissue destruction. In most cases, treatment with Mohs micrographic surgery is curative. Despite the fact SKINmed. 2013;11:254–255


Kazakov DV, Suster S, LeBoit PE, et al. Mucinous carcinoma of the skin, primary, and secondary: a clinicopathologic study of 63 cases with emphasis on the morphologic spectrum of primary cutaneous forms: homologies with mucinous lesions in the breast. Am J Surg Pathol. 2005;29:764–782.

5 Cabell CE, Helm KF, Sakol PJ, et al. Primary mucinous carcinoma in a 54-year-old man. J Am Acad Dermatol. 2003;49:941–943. 6 Anderson PJ, Dobson CM, Berry RB. Mucinous adenocarcinoma of the face. A case report. Int J Oral Maxillofac Surg. 2004;33:610–612. 7 Levy G, Finkelstein A, McNiff JM. Immunohistochemical techniques to compare primary vs. metastatic mucinous carcinoma of the skin. J Cutan Pathol. 2010;37:411– 415. 8 Hanby AM, McKee P, Jeffery M, et al. Primary mucinous carcinomas of the skin express TFF1, TFF3, estrogen receptor, and progesterone receptors. Am J Surg Pathol. 1998;22:1125–1131. 9 Karimipour DJ, Johnson TM, Kang S, et al. Mucinous carcinoma of the skin. J Am Acad Dermatol. 1997;36(2 pt 2):323–326.

Mucinous Carcinoma




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