Crystal Aguh

A new drug with a nasty bite: A case of krokodil-induced skin necrosis in an intravenous drug user

Krokodil is a commonly used street name for desomorphine, an injectable opioid derivative that is associated with severe dermatologic effects. We report a case of a woman who had extensive ulcerations after a single use of this narcotic. To our knowledge, this is the first case report of the cutaneous manifestations of krokodil use in the dermatologic literature.

Understanding patient experiences with scarring alopecia: a qualitative study with management implications

Abstract Introduction: Alopecia can have a significant negative impact on patient’s lives. The objective of this study is to describe some of the emotional and psychological challenges that affect women with scarring alopecia (SA). Methods: A qualitative study design was used with open-ended, individual interviews with 10 women with biopsy-proven SA. Interviews were audio-taped, transcribed verbatim and analyzed thematically using ATLAS.ti analysis software. Results: Four overarching major themes (with several subthemes) emerged including the following: the negative emotional impact of SA, difficulties with concealing hair loss, negative experiences with diagnosis/management, and the importance of support from others. Patients reported that many of these issues were under-emphasized during doctor visits. Conclusion: Analysis of patient responses indicated that patients with SA contend with significant emotional and psychological sequelae of their diagnosis.

Madura foot caused by Gordonia terrae misdiagnosed as Nocardia

Actinomycetomas are soft tissue bacterial infections that are in the differential for unusual masses of the extremities. Typical infectious agents include Actinomyces and Nocardia and are treated with long‐term antibiotics. We report a rare case of Gordonia actinomycetoma that was misdiagnosed as Nocardia and subsequently required surgical excision in addition to antibiotic therapy.

Fibroproliferative Genes are Preferentially Expressed in Central Centrifugal Cicatricial Alopecia

Background Central centrifugal cicatricial alopecia (CCCA) is a primary cicatricial alopecia that most commonly affects women of African descent. Like CCCA, fibroproliferative disorders (FPDs) such as keloids, atherosclerosis, and fibroids are characterized by low‐grade inflammation and irritation, resulting in end‐stage fibrosis. Objective We sought to determine whether fibroproliferative genes were up‐regulated in patients with CCCA. Methods A total of 5 patients with biopsy‐proven CCCA were recruited for this study. Two scalp biopsy specimens were obtained from each patient; 1 from CCCA‐affected vertex scalp and 1 from the unaffected occipital scalp. Microarray analysis was performed to determine the differential gene expression patterns. Results There was an upregulation of genes implicated in FPDs in patients with CCCA. Specifically, we noted increased expression of platelet derived growth factor gene (PDGF), collagen I gene (COL I), collagen III gene (COL III), matrix metallopeptidase 1 gene (MMP1), matrix metallopeptidase 2 gene (MMP2), matrix metallopeptidase 7 gene (MMP7), and matrix metallopeptidase 9 gene (MMP9) in affected scalp compared with in unaffected scalp. Significant overlap in the canonic pathways was noted between patients with CCCA and patients with both atherosclerosis and hepatic fibrosis (P < .001). Limitations Small sample size and the use of whole skin tissue for analysis. Conclusion We have identified the upregulation of critical genes implicated in FPDs in the gene expression profile of patients with CCCA. These findings may help identify future therapeutic targets for this otherwise difficult‐to‐treat condition.

Breaking the cycle of hair breakage: pearls for the management of acquired trichorrhexis nodosa

Abstract Acquired trichorrhexis nodosa (TN) is a common cause of hair loss for patients of all ethnicities. It is especially prevalent in black patients with tightly curled hair types and can present unique diagnostic and therapeutic challenges due to structural differences in these hair types and the combination of various hair care and styling practices that contribute to hair damage. While scalp biopsies can help rule out other etiologies of hair loss, there is a paucity of histologic findings in acquired TN, making this primarily a clinical diagnosis. Instead of more traditional prescription based therapies, the management of this form of hair loss emphasizes protecting the hair shaft and minimizing further damage through the development of a healthy hair care regimen. This involves appropriate selection and use of cleansing products and conditioning agents that help protect the hair from the insults of daily grooming. This paper will review the current literature on acquired TN and will provide guidelines and recommendations for management by reviewing the different types of cleansing and conditioning products that can be used to prevent and/or halt the progression of hair breakage.

Reply to: “Commentary on ‘A new drug with a nasty bite: A case of krokodil-induced skin necrosis in an intravenous drug user’”

To the Editor: I thank the authors for their reply to our article. Levamisole, an adulterant most commonly found in cocaine, can be associated with skin vasculitis resulting in ulcerating lesions.1, 2 The most common cutaneous findings are characteristic purpuric lesions, including retiform purpura or palpable purpura, which often occur in conjunction with leukocytoclastic vasculitis. These lesions favor acral surfaces such as the helical rim or fingertips and are often antineutrophil cytoplasmic antibody positive.1, 2 On the contrary, large ulcerations on the forearms would be an unusual presentation for levamisole toxicity, especially in the absence of more classic findings as noted above. In cases such as these, physical examination is important, and cutaneous findings must be emphasized. The patient only had involvement where she directly injected the substance, another finding that is unusual for levamisole, which often affects areas distal to areas of injection owing to systemic activity without antineutrophil cytoplasmic antibody positivity. Finally, the patient voluntarily reported purchasing krokodil immediately before the ulcerations occurred. I caution against the authors sentiment of completely excluding patient history, especially when clinical findings support the history provided. We believe that doctors should continue to exercise vigilance and keep krokodil on their differential of possibilities in cases of large ulcerations in patients with a history of intravenous drug use.