Natasha Atanaskova Mesinkovska

The effect of patch testing on surgical practices and outcomes in orthopedic patients with metal implants.

OBJECTIVE To determine the effect of patch testing on surgical decision making and outcomes in patients evaluated for suspected metal hypersensitivity related to implants in bones or joints. DESIGN Medical chart review. SETTING Tertiary care academic medical center. PARTICIPANTS All patients who had patch testing for allergic contact dermatitis related to orthopedic implants. INTERVENTION Patch testing. MAIN OUTCOME MEASURES The surgeons preoperative choice of metal implant alloy compared with patch testing results and the presence of hypersensitivity complications related to the metal implant on postsurgical follow-up. RESULTS Patients with potential metal hypersensitivity from implanted devices (N = 72) were divided into 2 groups depending on timing of their patch testing: preimplantation (n = 31) and postimplantation (n = 41). History of hypersensitivity to metals was a predictor of positive patch test results to metals in both groups. Positive patch test results indicating metal hypersensitivity influenced the decision-making process of the referring surgeon in all preimplantation cases (n = 21). Patients with metal hypersensitivity who received an allergen-free implant had surgical outcomes free of hypersensitivity complications (n = 21). In patients who had positive patch test results to a metal in their implant after implantation, removal of the device led to resolution of associated symptoms (6 of 10 patients). CONCLUSIONS The findings of this study support a role for patch testing in patients with a clinical history of metal hypersensitivity before prosthetic device implantation. The decision on whether to remove an implanted device after positive patch test results should be made on a case-by-case basis, as decided by the surgeon and patient.

Hair: What is New in Diagnosis and Management?: Female Pattern Hair Loss Update: Diagnosis and Treatment

Female pattern hair loss (FPHL) is the most common cause of alopecia in women. FPHL is characterized histologically with increased numbers of miniaturized, velluslike hair follicles. The goal of treatment of FPHL is to arrest hair loss progression and stimulate hair regrowth. The treatments for FPHL can be divided into androgen-dependent and androgen-independent. There is an important adjuvant role for nutritional supplements, light therapy, and hair transplants. All treatments work best when initiated early. Combinations of treatments tend to be more efficacious.

The use of oral pioglitazone in the treatment of lichen planopilaris

The use of oral pioglitazone in the treatment of lichen planopilaris To the Editor: Current therapies for primary cicatricial alopecia remain empirical and often ineffective. Recent experimental evidence has suggested a potential role of aberrant peroxisome-proliferator-activated receptor (PPAR)functioning in the pathogenesis of cicatricial alopecias. On the basis of this finding, Mirmirani and Karnik successfully treated a patient with therapy-resistant lichen planopilaris (LPP) with a PPARagonist. The aim of this studywas to evaluate the efficacy of pioglitazone, a synthetic PPARligand, in the treatment of LPP. We performed a retrospective case analysis of the 22 patients who were prescribed pioglitazone hydrochloride for LPP in a tertiary hair research center from 2010 through 2012. Inclusion required therapy with pioglitazone for at least 1 month, and clinical follow-up longer than 3 months. Clinical grading, including subjective measures (pain, tenderness, pruritus), objective measures (perifollicular erythema, scale), and hair loss extent, were recorded at baseline and on subsequent visits. At each visit, a hair specialist physician assigned a score to each objective and subjective end-point grade, ranging from resolution (0), improvement (1), stable (2), to worsening (3) condition. Global response to treatment was graded by the investigators, based on clinical impression, supplemented with standardizedphotographic data. Clinical impression categories included: ‘‘complete remission,’’

Clinical Efficacy of Diphenylcyclopropenone in Alopecia Areata: Retrospective Data Analysis of 50 Patients.

Diphenylcyclopropenone (DPCP) is widely considered the most effective topical immunotherapy for refractory or extensive alopecia areata (AA), but questions regarding how long to try DPCP therapy before terminating and what factors are prognostic of therapeutic success still remain unanswered. In this retrospective study of 50 AA patients, we evaluated DPCP efficacy and identified patient factors predictive of therapeutic success/failure. The median duration of DPCP treatment was 3 years, with 47% patients experiencing their first regrowth in the first 6 months of DPCP therapy, 20% between 6 months-1 year, and 8% between 1-2 years. In our study, treatment success, defined as ⩾50% terminal hair regrowth, was reached in 71% of alopecia totalis patients and in 56% of alopecia universalis patients. Three factors were statistically significant predictors of poor treatment outcome-extent of hair loss before DPCP treatment, history of thyroid disease, and extent of body hair involvement. Relapse was observed in 44% of patients and significantly associated with history of thyroid disease. Common side effects were itching, rash, and local lymphadenopathy. The results of this study support our belief that DPCP therapy is a viable treatment option, can be successfully accomplished at home, and should not be terminated before 2 years.

Prevalence of Comorbid Conditions and Sun-Induced Skin Cancers in Patients with Alopecia Areata

Alopecia areata is a multifactorial autoimmune disease causing non-scarring hair loss. Recent genome-wide association studies have pointed to connections between alopecia areata and other autoimmune disorders. Research of clinical conditions positively and negatively associated with alopecia areata is crucial for discovering the pathological mechanisms of disease and further treatment options.

Association of lichen planopilaris with thyroid disease: A retrospective case-control study

BACKGROUND Studies on the precise causes and comorbidities seen with lichen planopilaris (LPP) are limited. OBJECTIVE We sought to determine the prevalence of thyroid diseases in patients with LPP. METHODS Medical records of 166 patients with LPP and 81 age- and gender-matched control subjects seen in the Department of Dermatology at the Cleveland Clinic Foundation in Ohio between 2000 and 2013 were reviewed. RESULTS A diagnosis of thyroid disease was present in 34% (n = 57) of the 166 patients with LPP, and in 11% (n = 9) of the control subjects (P = .0001). When confined to hypothyroidism only, this disease was found in 29% (n = 48) of the patients with LPP and 9% (n = 7) of the control subjects (P = .0003). LIMITATIONS This study was limited by being retrospective. CONCLUSION In our patients, LPP was associated with thyroid disease, especially hypothyroidism.

Ossifying fibromyxoid tumor: a clinicopathologic analysis of 26 subcutaneous tumors with emphasis on differential diagnosis and prognostic factors

Ossifying fibromyxoid tumor (OFMT) is rare and may present diagnostic difficulty. We describe 26 subcutaneous examples of OFMT emphasizing differential diagnosis and prognostic features.

Colocalization of vitiligo and alopecia areata presenting as poliosis

Vitiligo and alopecia areata are two cutaneous diseases believed to be primarily autoimmune in pathogenesis. While the coexistence of the two conditions in the same patient has been well‐described, reports of the two disease processes occurring in the same location are rare. We report the case of a 10‐year‐old male with an unremarkable past medical history who presented with a single localized area of poliosis with depigmented underlying skin on the frontal scalp. The hair in the affected area was relatively decreased in density. A punch biopsy of the depigmented patch demonstrated features consistent with both vitiligo and alopecia areata. The decreased number of large hair follicles and a focal peribulbar lymphocytic infiltrate around an anagen follicle were suggestive of alopecia areata. A panel of melanocyte‐specific stains revealed absent melanocytes in the epidermis, consistent with vitiligo. Loss of microphthalmia‐associated transcription factor‐positive root sheath cells was seen, suggestive of loss of melanocyte stem cells. The combination of clinical and histopathologic findings supports the theory of a common pathogenesis of alopecia areata and vitiligo.

Comorbidities in patients with alopecia areata

REFERENCES 1. Xing L, Dai Z, Jabbari A, et al. Alopecia areata is driven by cytotoxic T lymphocytes and is reversed by JAK inhibitors. Nat Med. 2014;20:1043-1049. 2. Gilhar A, Schrum AG, Etzioni A, et al. Alopecia areata: animal model illuminates autoimmune pathogenesis and novel immunotherapeutic strategies. Autoimmune Rev. 2016;15:726-735. 3. Jabbari A, Nguyen N, Cerise JE, et al. Treatment of an alopecia areata patient with tofacitinib results in regrowth of hair and changes in serum and skin biomarkers. Exp Dermatol. 2016;25: 642-643. 4. Craiglow BG, King BA. Killing two birds with one stone: oral tofacitinib reverses alopecia universalis in a patient with plaque psoriasis. J Invest Dermatol. 2014;134:2988-2990. 5. Liu LY, Craiglow BG, Dai F, et al. Tofacitinib for the treatment of severe alopecia areata and variants: a study of 90 patients. J Am Acad Dermatol. 2017;76:22-28. 6. Craiglow BG, Liu LY, King BA. Tofacitinib for the treatment of alopecia areata and variants in adolescents. J Am Acad Dermatol. 2017;76:29-32. 7. US National Institutes of Health ClinicalTrials.gov website. Efficacy study of tofacitinib in pediatric JIA population. Available at: http://clinicaltrials.gov/show/NCT02592434. Accessed December 23, 2016.

Periocular Granuloma Annulare: A Case Report and Review of Literature

Granuloma annulare (GA) is a granulomatous dermatosis that rarely presents on the face and is extremely uncommon in the periocular region. We report our experience with the presentation and management of GA lesions on the eyelids of a 17‐year‐old girl. We performed a review of published literature and identified 13 cases of pediatric periocular GA. One additional case was identified upon review of all pediatric GA cases at the Cleveland Clinic Foundation. Review of these cases suggests that periocular GA is a benign condition that spontaneously regresses within a few months. GA nodules have a predilection for the upper eyelids. A greater incidence is noted in African American children. Awareness of the self‐resolving nature of this condition can prevent unnecessary surgical excisions in affected children.