Culprits of Medication-Induced Telogen Effluvium, Part 2.

Telogen effluvium (TE) is a common mechanism underlying medication-related alopecia. The inciting cause of TE may be difficult to identify due to delays in clinically apparent hair loss. Because medication-induced TE is a nonscarring alopecia that typically is reversible, appropriate management requires identification of the underlying trigger and cessation of potential culprit medications. In part 2 of this 2-part series on medication-induced TE, we focus on anticoagulant and antihypertensive medications.

Serum Ferritin Levels: A Clinical Guide in Patients With Hair Loss.

Ferritin is a key regulator of iron homeostasis that serves as an important clinical indicator of body iron status. Low serum ferritin is a highly specific and sensitive marker for diagnosing iron deficiency. In patients presenting with diffuse hair loss, serum ferritin may be a clinically useful tool for ruling out underlying iron deficiency as a cause of alopecia. As an acute-phase reactant, ferritin may be nonspecifically elevated in a wide range of inflammatory conditions; however, the role of ferritin in disorders of the skin and hair is not well understood. In this article, we review the structure and function of ferritin, and we provide a guide for clinical use.

Culprits of Medication-Induced Telogen Effluvium, Part 1.

Telogen effluvium (TE) is a common clinical consequence of medication-related alopecia. The inciting cause of TE may be difficult to identify due to delays in clinically apparent hair loss. Because medication-induced TE is a nonscarring alopecia that typically is reversible, appropriate management requires identification of the underlying triggering medication and cessation of it, if possible. In part 1 of this series, we review the existing literature on medication-induced TE with a focus on systemic retinoids, antifungal agents, and psychotropic medications.

IL-17 Expression in the Perifollicular Fibrosis in Biopsies From Lichen Planopilaris.

BACKGROUND: Lichen planopilaris (LPP) is a primary lymphocytic cicatricial alopecia for which therapy is often ineffective and there is no cure. OBJECTIVES: Looking for a new targetable molecule in the treatment of LPP, we sought to verify whether IL-17 expression is increased in scalp biopsies from patients with active scalp lesions of LPP. METHODS: Horizontal sections of hematoxylin and eosin-stained slides from 40 scalp biopsies of active LPP were retrospectively collected and stained with the monoclonal antibody against IL-17 (Abcam, Cambridge, MA; ab79056, dilution 1:100). Twenty biopsies from patients with chronic telogen effluvium served as controls because of their morphological resemblance to the normal scalp. Statistical analysis was performed using IBM SPSS Statistics for Windows (IBM Corporation, Armonk, NY). RESULTS: The main finding was the positive cytoplasmic expression of IL-17 in the perifollicular fibrosis of the affected follicles in LPP which was statistically significant compared with the controls ( P < 0.0001). The labeled cells were identified as fibroblasts based on their spindle shape and fascicular concentric arrangement in tight perifollicular distribution. Although most of the LPP specimens (n = 35; 87.5%) also revealed cytoplasmic IL-17 expression in the lichenoid inflammatory infiltrate, the results were not statistically significant ( P = 0.1351). CONCLUSION: Our immunohistochemistry results show that blocking the IL-17 inflammatory pathway may interfere with the progression of the perifollicular fibrosis and inflammation in LPP.

Primary cutaneous diffuse large B-cell lymphoma presenting as chronic non-healing ulcer.

Primary cutaneous diffuse large B-cell lymphoma is an uncommon and aggressive lymphoproliferative disorder with a rapid growth rate and dismal prognosis. We present the case of a 91-year-old female with an unusual manifestation of primary cutaneous diffuse large B-cell lymphoma, mimicking other more prevalent diseases like chronic non-healing venous ulceration. Dermatopathologic evaluation rendered the correct diagnosis. A discussion of this rare presentation is important for clinician consideration to prevent misdiagnosis and prolongation of proper management in patients with chronic non-healing leg ulcers.

Special Stains and Immunohistochemical Stains in Hair Pathology.

BACKGROUND: Patterns in scalp biopsies can overlap, and distinction may be difficult. OBJECTIVE: To review the current knowledge about the usefulness of special stains and immunohistochemical stains (IHC) for the diagnosis of hair disorders. METHODS: The authors used the search engines PubMED, MEDLINE, and MeSH to retrieve articles on the application of special stains and IHC in hair pathology. RESULTS: The authors selected 65 relevant articles discussing the use of special stains and IHC markers in scalp biopsies, including case reports and original articles. No reviews on the subject were found. Although fungal stains, such as periodic acid-Schiff, are very helpful in the diagnosis of noninflammatory tinea capitis, they may be negative in kerion. Elastic stains may help to diagnose end-stage scarring alopecia on vertical sections. Stains for mucin may help to distinguish lupus erythematosus from lichen planopilaris. Lymphocytic markers may assist in the diagnosis of lymphoma-associated alopecia. CONCLUSIONS: On a practical level, there is no evidence to recommend the routine use of a stain or a panel of stains in hair pathology. No stain can distinguish between nonscarring and early scarring alopecia. Most IHC stains are currently limited to the experimental and research setting.

Psoriasis Targeted Therapy: Characterization of Interleukin 17A Expression in Subtypes of Psoriasis.

INTRODUCTION: Psoriasis is a chronic, inflammatory autoimmune disease that affects about 3% of the general population in the United States with 17% suffering from moderate to severe psoriasis. The disease process is believed to be mediated by tumor necrosis factor (TNF)-α and cytokines secreted by specialized T-cell populations including Interleukin (IL)-17, IL-22, and Interferon (IFN) γ. IL-17 plays an important role in psoriasis. In this study we evaluated the expression of IL-17A in variants of psoriasis including plaque, palmoplantar, scalp, pustular, and guttate subtypes via immunohistochemistry (IHC). METHODS AND MATERIALS: A search of the University of Miami Dermatopathology database was performed to identify all available patient specimens within the various subtypes of psoriasis. IL-17A IHC staining was performed using 4 µm paraffin skin sections. 1:25 dilution of IL-17A antibody was used. Stained slides were analyzed using a semi-quantitative scoring method ranging from negative to three plus. RESULTS: Palmoplantar and pustular psoriasis cases showed consistently strong IL-17A staining. Plaque psoriasis cases showed intermittent to strong IL-17A staining. The results in the scalp and guttate psoriasis cases showed variable results. CONCLUSION: The results of our study suggests the significant role of the cytokine IL-17A in the development of palmoplantar and pustular psoriasis. However, scalp and guttate subtypes showed variable expression from negative to strongly positive, which demonstrates a case by case basis expression of IL-17A. Therefore, exploring the IHC characterization of subtypes of psoriasis will help dermatologists better understand the pathogenesis of each subtype and help clinicians optimize treatments.

Patient considerations in the management of toe onychomycosis - role of efinaconazole.

Onychomycosis is a difficult diagnosis to manage and treatment is sometimes avoided, as this diagnosis is often wrongly perceived as a cosmetic problem. However, onychomycosis has a negative impact on patients' quality of life, affecting social interaction, psychological well-being, and physical activities. Onychomycosis is also a risk factor for patients with diabetes, with proven increased rates of cellulitis, gangrene, and foot ulcers. Treatments are only mild to moderately effective, and rates of relapse and reinfection are high. Oral treatments require laboratory monitoring due to risk of hepatotoxicity and may be contraindicated in some patients due to risk of drug-drug interactions. Topical treatments require prolonged application and are not very effective. Efinaconazole 10% solution is a new topical triazole treatment for mild to moderate distal subungual onychomycosis, with good efficacy and without the need for debridement of nails. In onychomycosis of the toenails, efinaconazole 10% solution is documented to have a statistically significant, positive impact on patient satisfaction and quality of life.

Severe Onychodystrophy due to Allergic Contact Dermatitis from Acrylic Nails.

Acrylic nails, including sculptured nails and the new ultraviolet-curable gel polish lacquers, have been associated with allergic contact dermatitis (ACD). We report 2 cases of ACD to acrylic nails with severe onychodystrophy and psoriasiform changes including onycholysis and subungual hyperkeratosis. In both cases, the patients did not realize the association between the use of acrylate-based manicures and nail changes. One patient had been previously misdiagnosed and treated unsuccessfully for nail psoriasis. The informed clinician should elicit a history of acrylic manicure in patients with these nail changes, especially in cases of suspected nail psoriasis refractory to treatment. Patch testing is a useful tool in confirming diagnosis.

Retinoblastoma treatment burden and economic cost: impact of age at diagnosis and selection of primary therapy.

PURPOSE: To follow the treatment history of patients with retinoblastoma to identify the trends in the number of hospital visits over time and the direct cost of medical care as determined by age at diagnosis and selected primary treatment modality. DESIGN: An Institutional Review Board (IRB) approved consecutive retrospective case series. MATERIALS AND METHODS: Records from the Bascom Palmer Eye Institute were reviewed to identify 115 eligible patients (176 eyes) with retinoblastoma who underwent treatment at the Ocular Oncology Service between 1995 and 2010 and were available for extended follow-up evaluation. RESULTS: Bilateral disease was present in 53% (N = 61) of all patients, and 79% (N = 90) of patients were diagnosed in the first six months of life. Chemotherapy was used to treat 75% (N = 86) of all patients and 95% (N = 36) of patients diagnosed in the first six months of life. 100% (N = 4) of patients presenting between the age of five and nine were enucleated. Per episode of care, the lowest-cost treatment strategy was enucleation, followed by focal laser therapy, systemic chemotherapy with planned enucleation, systemic chemotherapy, and lastly, intra-arterial melphalan chemotherapy. CONCLUSION: Age at diagnosis is directly associated with the type of treatment chosen for retinoblastoma. The burden of retinoblastoma treatment on children and families is significant. The direct medical cost of intra-arterial chemotherapy per episode of care is comparable to systemic chemotherapy, but current strategies utilizing multiple planned episodes of intra-arterial chemotherapy are significantly more costly and may be associated with less systemic side effects and similar favorable outcomes. At the Bascom Palmer Eye Institute, intra-arterial chemotherapy has quickly become the treatment of choice for globe conserving therapy of retinoblastoma.