Ncoza C. Dlova

Disseminated cutaneous histoplasmosis in patients infected with human immunodeficiency virus

Background: In the pre‐AIDS era disseminated histoplasmosis was rare and the cutaneous manifestations thereof were reported infrequently. A range of unusual clinical manifestations of disseminated cutaneous histoplasmosis (DCH) in AIDS patients has been documented, but the cutaneous histopathological descriptions are short and incomplete. In addition, the histopathological spectrum of AIDS‐associated DCH is poorly recognized.

Once weekly fluconazole is effective in children in the treatment of tinea capitis: a prospective, multicentre study.

In an open, multicentre evaluation carried out in Brazil, Canada and South Africa we have demonstrated that fluconazole 8 mg kg−1 once weekly is effective in tinea capitis caused by Trichophyton and Microsporum species. There were 61 children, aged (mean ± SE) 5·0 ± 0·3 years; weight (mean ± 5·6) 20·0 ± 0·9 kg; 41 males, 20 females; one Asian, 57 Black, one Caucasian and two Hispanic. The organisms were Trichophyton violaceum (33 patients), T. tonsurans (11) and Microsporum canis (17). The extent of tinea capitis at pretherapy was: mild (18 patients), moderate (30) and severe (13). Patients with tinea capitis due to Trichophyton species were initially treated for 8 weeks with an extra 4 weeks of fluconazole if clinically indicated. All 44 patients with tinea capitis due to Trichophyton species were completely cured (clinically and mycologically) when evaluated 8 weeks after completion of active treatment, following 8 weeks of once weekly dosing in 35 patients and 12 weeks of once weekly dosing in nine patients. In Microsporum canis tinea capitis, an extra 4 weeks was administered at week 12 in patients where it was clinically indicated at the time. Sixteen of 17 patients with M. canis tinea capitis were completely cured (clinically and mycologically) when evaluated 8 weeks following the end of treatment when given for 8, 12 and 16 weeks in 12, one and three patients, respectively. Overall, complete cure (clinical and mycological) occurred in 60 of 61 patients at follow‐up 8 weeks from the end of therapy. The duration of once weekly fluconazole in the 60 patients was 8 weeks (47 patients), 12 weeks (10 patients) and 16 weeks (three patients), respectively. Clinical adverse effects consisted of a mild, reversible gastrointestinal complaint in three (4·9%) of 61 children. A laboratory abnormality with elevated liver function tests was observed in one (5·9%) of 17 patients; this was asymptomatic, and reversible. No patient discontinued therapy. The data suggest that once weekly fluconazole dosing is effective, safe and associated with high compliance when used to treat tinea capitis.

Familial frontal fibrosing alopecia

to be expressed and to be a critical tumour-modulating gene. It may significantly affect lymphoma progression in the clinical setting. Using an approach based on genomic analysis of an aggressive lymphoma variant and its nonaggressive parental cells, the most prominent change was the strong upregulation of galectin-7. Galectin-7, a member of the galectin family, designated as the product of the p53-induced gene 1 (PIG1, now known as LGALS7), is a regulator of apoptosis and contributes to different events associated with the differentiation and development of pluristratified epithelia. Galectin-7 is thought to function in stratified epithelial tissue in response to environmental injuries, such as wound healing or UV radiation. UV radiation exposure has been shown to induce skin keratinocytes to express rapidly galectin-7 mRNA and protein, and galectin-7 has been reported to take part in UV-induced apoptosis. Microarray analysis revealed that galectin-7-transfected cells expressed approximately nine times more HMG-CoA synthase (HMGCS1) mRNA than untreated cells. HMGCS1 is a key ratelimiting enzyme, preceding HMG-CoA reductase, in the pathway for endogenous cholesterol synthesis. Recently, we discovered that galectin-7 interacts with HMGCS1 while inducing its expression (Norihiro Fujimoto, Hideki Mieno, Ryoko Hosokawa, Eita Fujimoto, Shingo Tajima. unpublished data). We present here two women with normolipaemic PX coinciding with tumour-stage MF treated with PUVA. MF, a cutaneous T-cell lymphoma, is considered to express galectin-7 even without PUVA treatment. Galectin-7 expression in MF lesions plays at least a partial role in generating PXs via inducing and holding HMGCS1. In our cases, UV irradiation (PUVA) might have accelerated galectin-7 expression and rendered the lesions ready to generate PXs. Overexpression of galectin-7 contributed to induction of epidermal apoptosis, cholesterol synthesis and subsequent lipid incontinence. This theory is supported by the result that lipid-laden macrophages in the upper dermis as well as epidermis were positively stained with antibodies against AE1 ⁄AE3 and galectin-7 (Fig. 2c, d). This explains well the possible aetiological process of DPXs in MF treated with PUVA.

Tinea Capitis in Kwa‐Zulu Natal, South Africa

Abstract:  Tinea capitis is the most common dermatophyte infection in children. The hair involvement can be classified as endothrix, ectothrix, or favus, and the clinical appearance is variable. The goal of this study was to determine the demography, etiology, and clinical patterns of tinea capitis in South Africa. A prospective, cross‐sectional study was conducted over a 1‐year period. All cases were classified clinically and subject to Wood light examination, microscopy, and culture. One hundred patients were studied. The male:female ratio was 1.4:1. The mean age was 4.6 years (range 1–11 years). Trichophyton violaceum was isolated in 90% of positive cultures. Wood light was positive in one patient with Microsporum gypseum. The most common clinical variety was the “black dot” type, seen in 50% of patients. Twenty percent of the children presented with more than one clinical type simultaneously. We concluded that the most common cause of tinea capitis in South Africa is T. violaceum. The presentation is variable.

Frontal fibrosing alopecia and lichen planus pigmentosus: is there a link?

ler and the appearance of xanthelasma, much more likely than a casual association between the spontaneous start of xanthelasma and the filler injection. We suppose that the hyaluronic acid, injected to reduce the wrinkles of the lower eyelids, may have produced an inflammatory reaction with oedema resulting in an increase of vascular permeability. It is important to remember that, normally, LDL has a low percentage of capillary leakage but local trauma increases this rate. The extravasated LDL may have formed complexes with the injected hyaluronic acid, which were internalized by histiocytes. Furthermore, hyaluronic acid favours the oxidation of LDL, increasing the formation of foam cells. Our cases suggest that special attention should be paid while performing infiltration of hyaluronic acid in the periorbital region.

Updating the diagnosis, classification and assessment of rosacea: Recommendations from the global ROSacea COnsensus (ROSCO) panel

Rosacea is currently diagnosed by consensus‐defined primary and secondary features and managed by subtype. However, individual features (phenotypes) can span multiple subtypes, which has implications for clinical practice and research. Adopting a phenotype‐led approach may facilitate patient‐centred management.

Frontal fibrosing alopecia: a clinical review of 20 black patients from South Africa

DEAR EDITOR, Frontal fibrosing alopecia (FFA) is an uncommon clinical variant of lichen planopilaris (LPP), presenting with band-like scarring alopecia (SA) involving the hairline, first described by Kossard in 1994. Lately, familial cases of FFA have been reported in both white and black patients, suggesting among other factors the possibility of genetic inheritance. There is a paucity of information on the epidemiology of FFA in black patients, with only one report by Miteva et al. in Miami, wherein they reported on 11 (7 8%) of 141 African American patients having FFA, 10 female and one male. No published reports were found regarding cases from Africa. The intention of this 5-year retrospective review is to provide insight on the demographic and clinical profile of black patients with FFA in South Africa. We reviewed single-centre case notes and clinical pictures of patients presenting with a histopathologically confirmed diagnosis of FFA between 2006 and 2012, inclusive. In total 44 patients were seen; 20 had FFA only and 24 had associated lichen planus pigmentosus. This study will focus on the 20 patients with FFA only, 19 (95%) female and one (5%) male, whose clinical data are summarized in Table 1. The age of onset ranged from 27 to 66 years, with a mean of 42 years. Most were African (19, 95%), with one (5%) female Indian patient. Fourteen of the 19 women (74%) were premenopausal. Only one patient (5%) had a positive family history, citing her mother and first cousin as being affected. FFA involved the frontotemporal region in all 20 cases, while two of the patients had associated patchy LPP. Traction alopecia (TA) presented in the majority of African female patients (n = 17), of whom 14 complained of hairline loss. Seven patients in total (35%) had pruritus, one of whom also had painful, tender pustules. Histology confirmed LPP in all of the patients except one, who declined biopsy. Histology showed typical features of LPP, consisting of follicular loss with perifollicular fibrosis and lichenoid inflammation around hair follicles. Only two patients (10%) had both eyebrow and limb hair loss, while eight (40%) had eyebrow loss and none had facial papules. All 18 female African patients (90%) admitted to using chemicals or had traction-inducing hairstyles. The lonely hair sign (Figs 1, 2) described by Tosti et al. was detected in 70% of the African patients with FFA. Loss of follicular ostia as a hallmark sign of scarring alopecia may be misleading, as five patients (25%) had prominent follicular ostia despite histological confirmation of a scarring process (Figs 1, 2). Cutaneous or mucosal lesions of lichen planus were not observed. Treatment included hydroxychloroquine 200 mg twice daily for 6–12 months, clobetasol dipropionate, tacrolimus 0 1% and minoxidil 2%. Traction-inducing hairstyles and frequent use of chemical relaxers were discouraged. Wigs instead of weaving were recommended for those with extensive disease. The cases of FFA reported in the literature have been mainly in postmenopausal white women. While Miteva et al. reported the occurrence of FFA in 11 postmenopausal black patients, our patients were predominantly premenopausal (74%). Both this series and that of Miteva et al. confirm that FFA is not exclusively a disease of postmenopausal white women, but affects the black population as well. Our report is similar to that of Miteva et al. in that almost all of our patients had used traction and/or chemicals for grooming and had evidence of TA, creating difficulties in diagnosis. The lonely hair sign and loss of eyebrows are useful clinical signs in the early diagnosis of FFA. The age range of onset was much lower than in other studies, explicable by the early use of traction-inducing hairstyles, which probably aggravate the progression of FFA. Africans tend to be less hairy than their Indian and white counterparts, resulting in less noticeable body hair loss. This may explain why only one African patient showed limb hair loss, along with the Indian patient. At 2-year follow-up we were able to abort the progression of alopecia in five of the 20 patients with early disease who started on chloroquine and topical treatments. This is in line with the report of Chiang et al., wherein they reported the efficacy of hydroxychloroquine in patients with low LPP activity score. One patient followed up for 5 years defaulted treatment and presented with generalized hair loss resembling alopecia universalis. This supports the observation made by Chew et al. in which the process of scarring alopecia is somewhat generalized rather than confined to the hairline and eyebrows. We have documented the largest series of FFA in black patients to date, and the first report in Africa. Despite the limitations of a retrospective review, we have shown that FFA can be easily confused with TA, as these two conditions often coexist in Africans, supporting the assertions of Miteva et al. and Tosti et al. While other studies have shown absence of follicular ostia as a hallmark of SA, we have shown that this is not necessarily so, and can be misleading. Therapeutic options are limited, and the goal of treatment is making early diagnosis, thus aborting active disease progression to minimize SA. Long-term prospective cohort studies are needed to elucidate BJD British Journal of Dermatology

Rosacea treatment update: Recommendations from the global ROSacea COnsensus (ROSCO) panel

Rosacea is currently treated according to subtypes. As this does not adequately address the spectrum of clinical presentation (phenotypes), it has implications for patient management. The ROSacea COnsensus panel was established to address this issue.

Skin lightening practices: an epidemiological study of South African women of African and Indian ancestries

Cutaneous adverse sequelae of skin lightening creams present with myriad skin complications and affect dermatology practice, particularly in sub‐Saharan Africa where such products are widely used, with a prevalence of 25–67%.

Immediate contact reactions to fragrance mix constituents and Myroxylon pereirae resin

We have studied patients who have positive‐patch test reactions to fragrance‐allergic screening substances fragrance mix (FM) or Myroxylon pereirae resin (balsam of Peru) for immediate contact reactions to the standard FM, the constituents of the FM and Myroxylon pereirae resin. In the fragrance‐positive subjects (n = 60), there were positive immediate contact reactions to Myroxylon pereirae resin in 56.6% and to FM in 11.6%. In a control group (n = 50) of eczematous, patch test‐negative patients there were positive immediate reactions to Myroxylon pereirae resin in 58.0% subjects and to FM in 12.0%. The absence of a significant difference between the fragrance‐allergic group and control group is in keeping with a non‐immunological basis for the majority of the immediate reactions seen.