Gloria Garnacho-Saucedo

Frontal fibrosing alopecia: A multicenter review of 355 patients

BACKGROUND To our knowledge, there are no large multicenter studies concerning frontal fibrosing alopecia (FFA) that could give clues about its pathogenesis and best treatment. OBJECTIVE We sought to describe the epidemiology, comorbidities, clinical presentation, diagnostic findings, and therapeutic choices in a large series of patients with FFA. METHODS This retrospective multicenter study included patients given the diagnosis of FFA. Clinical severity was classified based on the recession of the frontotemporal hairline. RESULTS In all, 355 patients (343 women [49 premenopausal] and 12 men) with a mean age of 61 years (range 23-86) were included. Early menopause was detected in 49 patients (14%), whereas 46 (13%) had undergone hysterectomy. Severe FFA was observed in 131 patients (37%). Independent factors associated with severe FFA after multivariate analysis were: eyelash loss, facial papules, and body hair involvement. Eyebrow loss as the initial clinical presentation was associated with mild forms. Antiandrogens such as finasteride and dutasteride were used in 111 patients (31%), with improvement in 52 (47%) and stabilization in 59 (53%). LIMITATIONS The retrospective design is a limitation. CONCLUSIONS Eyelash loss, facial papules, and body hair involvement were associated with severe FFA. Antiandrogens were the most useful treatment.

Trichoscopic features of frontal fibrosing alopecia: Results in 249 patients

To the Editor: Currently, dermoscopy constitutes an essential noninvasive tool for dermatologists. It helps discern between different types of alopecia, it provides a more precise follow-up, and it can be used to identify an adequate biopsy site. Frontal fibrosing alopecia (FFA) is a primary lymphocytic scarring alopecia with a distinctive clinical pattern of progressive frontotemporal hairline recession and eyebrow loss that mainly affects postmenopausal women. The main objective of our study was to describe the trichoscopic features of FFA in a large series of patients and to correlate these findings with several relevant parameters of FFA. We performed a descriptive, retrospective, observational, multicenter study of digital trichoscopic images, obtained between 1994 and 2013, of 238 women with FFA at 12 Spanish centers. Diagnostic criteria included typical clinical signs and/or histopathologic features consistent with FFA. Images were obtained with either a nonpolarizing or a polarizing dermoscope. Two dermatologists expert in dermoscopy evaluated the images if the registered trichoscopic features of FFA (cicatricial white patches, perifollicular erythema, follicular hyperkeratosis, lonely hairs, and hair diameter diversity) and yellow dots typical of androgenetic alopecia were present on the frontotemporal hairline. Both a descriptive and an analytic study to correlate these parameters with the degree of severity and other clinical variables were performed using SPSS 15.0 software. Clinical and severity variables included female pattern hair loss (FPHL), presence or absence of menopause, FFA severity (I: 1 cm, II: 1-2.99 cm, III: 3-4.99 cm, IV: 5-6.99 cm, and V: [7 cm), and years of evolution, pruritus, trichodynia, facial papules, occipital involvement, eyebrow and eyelash loss, pubis hair loss, and body hair involvement. A bivariate analysis including trichoscopic findings and the aforementioned variables was carried out, and those variables with statistical significance in X test were included in a multivariate logistic regression analysis adjusted for age and excluding lost cases. No new dermoscopic signs were found. Descriptive dermoscopic results are listed in Table I. Both the intraobserver and interobserver agreement for the assignment of a dermoscopic pattern for each lesion were excellent (! 1⁄4 0.82, P\.001; ! 1⁄4 0.80, P\.001, respectively). The trichoscopic features that were statistically significantly associated (P \ .05) with some clinical parameters in the bivariate and multivariate logistic regression analysis are listed in Table II. Dermoscopic features of FFA have previously been described in some isolated studies. Toledo-Pastrana et al retrospectively analyzed the dermoscopic images of 79 patients with FFA. They found that 100% of the patients showed no follicular openings, 72.1% showed follicular hyperkeratosis, 66.3% showed perifollicular erythema, and 44.8% showed follicular plugs. Interestingly, they also found that perifollicular erythema was statistically associated to the activity of FFA. In our study, we correlated the dermoscopic features with another outcome: the severity of the disease in terms of extension of the hairline. Remarkably, we found that the presence of cicatricial white patches was statistically associated with the severity of FFA. This dermoscopic feature correlates with the histopathologic findings of hair follicle destruction and severe tissue fibrosis. Therefore, it

Neoadjuvant Intralesional Methotrexate Before Surgical Treatment of Invasive Squamous Cell Carcinoma of the Lower Lip

A 51-year-old Spanish man with no relevant medical history was referred for assessment of a 1-month-old rapidly growing keratotic tumor on his lower lip. Clinical examination revealed an exophytic, sharply demarcated crateriform nodule with central keratotic plug 2.5 by 2.3 cm in size (Figure 1A). A 4-mm punch biopsy specimen was taken from the lesion for histopathologic examination. Complete blood cell count and renal and liver function tests were normal. No suspicious lymphadenopathies were detected using palpation or regional ultrasound. With a clinical diagnosis of

Subcutaneous phaeohyphomycosis due to Alternaria infectoria in a renal transplant patient: Surgical treatment with no long-term relapse

BACKGROUND Phaeohyphomycosis can be caused by a number of different species, being the most common Alternaria alternata and Alternaria infectoria. The biggest risk factor for the development of the infection is immunosuppression. AIMS We present the case of a 64-year-old male renal transplant patient who came to hospital for presenting a tumour in the Achilles region which had been gradually growing in size. METHODS A skin biopsy was taken for histological study and culture of fungi and mycobacteria. Blood tests and imaging studies were performed. RESULTS Histopathology study and cultures identified A. infectoria as the causal agent. Imaging studies ruled out internal foci of infection. The lesion was surgically removed with no signs of recurrence after 24 months of follow-up. CONCLUSIONS There are no treatment guidelines at present for cutaneous and subcutaneous Alternaria spp. infections. Various systemic antifungals have been used, either in combination with surgical removal or alone, with varying results. Surgery alone could be useful in the treatment of solitary, localised lesions in transplant patients in whom there are difficulties in controlling immunosuppression.

Beard involvement in a man with frontal fibrosing alopecia.

Indian Journal of Dermatology, Venereology, and Leprology | November-December 2014 | Vol 80 | Issue 6 542 Figure 2: Non-inflammatory bald patches in the beard 3. Paul TV, Spurgeon R, Jebasingh F. Visual vignette. Postherpetic neuralgia and galactorrhea. Endocr Pract 2008;14:392. 4. Bateganya MH, Muhwezi J, Mugyenyi P, Kityo C, Lynen L, Zolfo M, Colebenders R. Persistent galactorrhea in a post menopausal woman with Herpes zosterand HIV‐1 infection. Malawi Med J 2005;17:101‐3.

Classic Kaposi's sarcoma treated with topical 0.5% timolol gel.

To the editor, Kaposi’s sarcoma (KS) is an angioproliferative disorder closely associated with human herpesvirus type 8. Classic KS is found mainly in elderly males, with lesions beginning slowly and insidiously on the distal lower extremities and occasionally on the hands. Although the disease is very rarely responsible for the death of the patient, there might be complications such as ulceration, bleeding and pain in nodules on pressure areas requiring treatment (1). To date, a uniformly effective and low-risk treatment for KS has not been found, so therapeutic recommendations must be individualized. Topical treatment would be ideal for patients with limited disease confined to the skin, since it may satisfactorily slow progression of classic KS for several years with lower risks of systemic side effects. In this way, some topical agents have been used with various results, including 5% imiquimod cream (2), 0.5% rapamycin ointment (3), 0.1% alitretinoin gel (4) and very recently, 0.5% timolol maleate solution (5). We report here two cases of classic KS successfully treated with topical timolol. We used 0.5% timolol gel, applied twice daily. To our knowledge, this is the second report of classic KS treated with topical timolol.

Imatinib treatment of therapy resistant generalized deep morphea

Morphea, or localized scleroderma, is a distinctive inflammatory disease that leads to sclerosis of the skin and subcutaneous tissue (1). It is distinguished from systemic sclerosis by the absence of sclerodactyly, Raynaud’s phenomenon, nail fold capillary changes, and organ involvement (2). The term deep morphea describes the microscopic changes affecting mainly the superficial muscle, fascia, subcutis and deep dermis. One of the more severe forms of localized scleroderma is generalized morphea, which is characterized by extensive cutaneous involvement, a persistent behavior, and poor response to therapy (2,3). We describe a case report of a patient with therapy resistant generalized deep morphea who responded to imatinib with improvement not only in her skin manifestations but her mobility and quality of life as well.

Eslicarbazepine-induced toxic epidermal necrolysis.

To the Editor: Eslicarbazepine acetate (ESL), member of the dibenzazepine family—which also includes carbamazepine (CBZ) and oxcarbazepine (OXC)—is a new antiepileptic drug approved in 2009 by the European Medicines Agency and in 2013 by the U.S. Food and Drug Administration as adjunctive therapy in adults with partial-onset seizures with or without secondary generalization. The incidence of rash, which is the most common idiosyncratic reaction with all antiepileptic drugs, seems to be lower in patients treated with ESL relative to CBZ and OXC. In fact, since ESL was approved, reports on severe cutaneous adverse drug reactions (cADRs) with this antiepileptic have not been accumulating, with only one case of eslicarbazepineinduced erythema multiforme major reported to date. To our knowledge, we report the first case of toxic epidermal necrolysis (TEN) following treatment with ESL. An 85year-old man with a longstanding history of hypertension treated with captopril, was admitted with fever (38.8°C), stinging eyes, pain upon swallowing, and painful cutaneous lesions on day 19 after taking ESL at doses of 800 mg/day for partial-onset seizures. On physical examination, we observed coalescing dusky red macules over >30% of the body surface, with blisters and detachment of large sheets of necrolytic epidermis all over his chest (Fig. 1A), back (Fig. 1B), and face. The conjunctiva and oral (Fig. 2) and genital mucosa were also involved, and tense blisters were seen in the palmoplantar surfaces. The diagnosis of TEN was confirmed by histopathologic examination of lesional skin. Laboratory examination showed markedly elevated C-reactive protein levels, with renal and hepatic enzymes within normal limits. ESL was withdrawn. The patient was treated with intravenous immunoglobulin at a dose of 2 g/kg/day for 3 days, intravenous corticosteroids (tapered methylprednisolone starting with 125 mg daily), and cyclosporine at a dose of 4 mg/kg for 10 days, and then tapered over another 10 days; He showed a slow but progressive improvement both in symptoms and cutaneous manifestations. Reepithelization of the skin was achieved in 4 weeks. Stevens-Johnson syndrome (SJS) and TEN are rare, acute, and life-threatening mucocutaneous diseases that are nearly always drug-related. Compelling evidence suggests that SJS/TEN is associated with an impaired capacity to A

Topical Amphotericin B for the treatment of localized cutaneous leishmaniasis

Cutaneous leishmaniasis (CL) is a chronic disease caused by protozoan parasites of the genus Leishmania. In Spain, L. infantum is the only endemic species causing CL, although other species have been identified in travelers and immigrants (Herv as et al., 2012). To date, no general consensus on optimal treatment for CL has been achieved. The clinical manifestations can vary widely depending on the host’s cellmediated immune response and the species of Leishmania involved, so therapeutic recommendations must be individualized. Topical treatment is an attractive alternative for patients with limited disease confined to the skin. In this way, topical liposomal Amphotericin B (AmB) formulations have been used in the treatment of CL (Layegh et al., 2011; Vardy et al., 1999; Zvulunov, Cagnano, Frankenburg, Barenholz, & Vardy, 2003) with promising results. We report two cases of localized CL successfully treated with topical AmB. We used a preparation containing 2% AmB in petrolatum, applied twice daily for 12 weeks.

Asymptomatic angiomatous lesions on the face and limbs of an adult woman.

356 A 73-year-old woman presented with an acute-onset, asymptomatic eruption for 2 days. There was no history of fever or other prodromal symptoms. There was no relevant medical history other than a hepatitis C positivity detected 10 years back for which no treatment was taken. Physical examination revealed erythematous, bright red maculopapular lesions measuring 3–4 mm in diameter on her face [Figure 1] and limbs. The lesions were blanchable and those on the arms and legs [Figure 2] were surrounded by pale haloes. Routine laboratory tests including liver function tests were normal. A skin biopsy showed dilated capillaries with plump endothelial cells and a mild lymphocytic infiltrate surrounding the affected vessels in the dermis. The epidermis was unaffected and there was no vascular proliferation [Figure 3a and b].