Massimiliano Pazzaglia

The role of scalp dermoscopy in the diagnosis of alopecia areata incognita

BACKGROUND Alopecia areata incognita is a variety of alopecia areata characterized by acute diffuse shedding of telogen hairs without typical patches. OBJECTIVE We sought to report the clinical, pathological, and dermoscopic features of alopecia areata incognita. METHODS Seventy patients with alopecia areata incognita were evaluated clinically and with videodermoscopy during the period of 2002 to 2006. Pathology was performed in 50 patients. RESULTS The presence of numerous, diffuse, round or polycyclic yellow dots, different in size and uniform in color and distribution, was a typical dermoscopic feature in all patients. Short regrowing hairs were also present. The dermoscopic findings were correlated and supported by the histologic features of the scalp specimens. LIMITATIONS Scalp biopsy was performed only in 50 patients. CONCLUSION Videodermoscopy is a first step before performing a biopsy. It can help the clinician to find the right place to take the sample, but can also avoid unnecessary biopsies.

Photocontact dermatitis from UV filters

UV filters are currently the most common photoallergens (1, 2), particularly the benzophenones (2–7). Recently, the concentration of UV filters in the GIRDCA photopatch test series has been increased from 2% to 10% pet.

Contact sensitization to 5-chloro-2-methyl-4-isothiazolin-3-one and 2-methyl-4-isothiazolin-3-one in children

The frequency of positive reactions to 5-chloro-2-methyl-4-isothiazolin-3-one (MCI/MI) were studied at 22 European cntact dermatitis clinics over a period of 1 year. A total of 4713 patients participated. All the patients were patch tested with nickel sulphate, formaldehyde, paraben-mix, and MCI/MI 19.4% of the patients had positive patch tests to nickel, making this the most common allergen, 3% of the patients reacted to 100 ppm MCI/MI, while 2.6% reacted to formaldchyde and 1.1% to parabens. There was great variation in the frequency of MCI/MI sensitivity among the 22 centres. MCI/MI contact allergy was most common among women and in patients with facial dermatitis, while it was rarely seen in patients with dermatitis on the lower legs. There were no fluctuations in the number of positive patch tests to MCI/MI on a monthly basis when the results from all centres were combined. 117 of the 141 MCI/MI sensitized patients included in the study were retested 88% had positive patch tests when retested. 101 of the MCI/MI-sensitive patients participated in a double -blind, placebo-controlled product use test. This test showed that 31% of the MCI/MI-sensitive patients had a positive reaction to a MCI/MI-preserved product. Only a few patients reacted to a control product. It is concluded that the preservative MCI/MI is an important new contact allergen.

Videodermoscopy: A Useful Tool for Diagnosing Congenital Triangular Alopecia

Abstract:  Congenital triangular alopecia, despite its name, usually presents in children between 3 and 6 years of age, but adult patients have been reported. It is not uncommon for triangular alopecia to be misdiagnosed as alopecia areata and treated for such. This is especially true when a lesion of triangular alopecia presents in an area of the scalp other than the typical fronto‐temporal hairline or later in adulthood. Videodermoscopy may serve as a useful tool to perform the right diagnosis as it can highlight signs not seen by the unaided eye and may be able to spare the patient from a biopsy.

Periocular pigmentation associated with use of travoprost for the treatment of alopecia areata of the eyelashes

JEADV 2007, 21, 392–435

Xanthelasma palpebrarum: a new adverse reaction to intradermal fillers?

MADAM, Over the years, many different techniques have been utilized to treat age-related wrinkles. We describe here two patients with a new type of xanthelasma-like adverse reaction to a filler, which appeared after the infiltration of hyaluronic acid in the superficial dermis of the lower eyelids. Case 1 was a 49-year-old white woman who was referred to us for a lesion that resembled xanthelasma palpebrarum on her right lower eyelid. The patient reported that 1 year before, a filler had been infiltrated in the same area to reduce wrinkles. The cosmetic filler used was hyaluronic acid (16 mg g), specific for eye wrinkles. In the days after this treatment, a marked oedema with lilaceous erythema had appeared. After 2 weeks the oedema had partially regressed, but the area remained slightly red and infiltrated. In the three subsequent months the lilaceous oedema was gradually replaced by a yellow plaque which became permanent and progressive (Fig. 1). The patient was in good health and her family history was negative for dermatological diseases or hyperlipidaemia. A skin biopsy was performed. Case 2 was a 67-year-old white woman who presented with two lesions that appeared to be xanthelasma, symmetrically localized on the lower eyelids. The patient confirmed that 3 months before, she had undergone a cosmetic treatment with infiltration of hyaluronic acid (16 mg g). As in the first case, a marked lilaceous oedema had suddenly appeared and slowly regressed leaving in its place a yellow-coloured plaque. The patient refused a skin biopsy. Blood tests, and in particular the lipid profile, were normal in both cases. In case 1, haematoxylin and eosin staining revealed an accumulation of histiocytes in the dermis containing optically empty material; the epidermis showed no significant alterations. Alcian blue staining showed material positive for this staining (hyaluronic acid) in the intracellular spaces (Fig. 2a). Ultrastructurally, numerous histiocytes filled with lipid droplets were observed in the dermis, as well as macrophages containing foreign material suggestive of hyaluronic acid (Fig. 2b). To the best of our knowledge, these are the first examples of a xanthelasma-like reaction subsequent to the injection of a hyaluronic acid filler. The injection of filler agents, particularly hyaluronic acid, has proved to be very effective in obtaining cosmetic soft tissue augmentation. However, depending on the characteristics of the fillers (biocompatibility, stability, safety and risk of migration), numerous adverse reactions have been reported. A histological classification of these adverse reactions into four categories has been proposed, based on the severity of inflammation and infiltration: grade I, few inflammatory cells with slight reaction; grade II, inflammatory reaction with few giant cells; grade III, fibrous tissue and inflammatory cells, lymphocytes and giant cells; grade IV, granuloma with encapsulated implants and foreign body reaction. A recent article proposed dividing the adverse reactions into just two main categories: transitory and permanent. We are unable to frame our cases within any of these previously described reactions. In approximately 55% of patients, xanthelasma palpebrarum is associated with elevated plasma lipid levels. The pathogenesis of xanthelasma palpebrarum is not well known, but its peculiar localization on the eyelids implies a pathogenetic role for some local factors typical of this area. In fact, the constant movement with friction may promote the development of xanthelasma. Xanthelasma palpebrarum has been reported in association with allergic contact dermatitis and after treatment with trichloroacetic acid and carbon dioxide laser. The mechanism by which the hyaluronic filler led to the formation of xanthelasma palpebrarum in our patients is unclear, but the literature offers some suggestions. Seike et al. demonstrated that hyaluronic injections in the extracellular matrix are capable of binding extravasated low-density lipoprotein (LDL). The LDL–glycosaminoglycans complex is internalized by macrophages more intensely than native LDL. Furthermore, LDL is susceptible to oxidation (ox-LDL) when exposed to glycosaminoglycan, and ox-LDL promoted the formation foam cells. In our cases, the sequence of events leads Fig 1. Xanthelasma palpebrarum of the right lower eyelid in case 1.

Photo-onycholysis caused by an unusual beach game activity: A pediatric case of a side effect caused by doxycycline

Photo‐onycholysis caused by doxycycline has rarely been reported in children. We present the case of a boy who loved to play pinball while at the beach, holding tightly to the machine. He developed a photo‐onycholysis predominantly on his thumbs while he was being treated with 20 mg/day of doxycycline, a low dose but enough to trigger the photoreaction.

Severe onycholysis in a card illusionist with alopecia areata universalis

In patients with alopecia areata (AA), nail abnormalities due to nail matrix inflammation are common and usually not severe. We report the case of a 23-year-old man with AA universalis, who developed severe abnormalities of all his fingernails. Systemic steroids improved the onycholysis that had an important impact on the patients job, as he was a card illusionist.

Tendency to underestimate the severity of androgenetic alopecia.

between HPV and PPECs. Of these cases, three were found to be infected with HPV 57, while the others were infected with HPV 60. HPV 60 is a distinct skin HPV, and induces unique clinical lesions on the soles and the palms, such as epidermal cysts and ridged warts, which exhibit characteristic histological features such as intracytoplasmic eosinophilic inclusion bodies, vacuolar structures in the cavity and cyst walls, and parakeratotic nuclei. Of these histological changes, intracytoplasmic eosinophilic inclusion bodies and vacuolar structures within the cavity are known to be specific for HPV 60. Several reports have described cases of PPECs infected with HPV 60, but only two have reported HPV 60 in cutaneous lesions in a nonpalmoplantar area as a possible precursor of an NPPEC. However, in these two reports the epidermal cyst was a solitary lesion without any accompanying viral wart above it. To our knowledge, our cases are unique, with findings of a concurrent viral wart and an epidermal cyst on the face, both of which were HPV 60 positive. We report these cases as evidence to support the hypothesis that HPV 60 causes epidermal cysts in human skin.

Hair in Forensic Medicine

• Drugs, chemicals, and biological substances are stored in hair where they can be detected and measured.