Refractory Folliculitis Decalvans Treatment Success with a Novel Surgical Excision Approach Using Guarded High-Tension Sutures.

Purpose: Folliculitis decalvans (FD) is a difficult-to-treat, localized scarring alopecia characterized by an expanding area of chronically inflamed purulent plaques or masses. Current treatment modalities vary and often result in only temporary remission. There are no reports of surgical therapies for FD. Here, we describe FD treatment using surgical excision and second-intention healing aided by guarded high-tension sutures. Methods: Five patients (one woman and four men) with histologically confirmed FD were treated by surgical lesion excision. All wounds were allowed to heal via second-intention. Guarded high-tension sutures were employed to minimize tissue tears while aiding and guiding wound contraction. Results: All wounds healed with a 47-83% spatial contraction of the maximum wound diameters. Three patients healed entirely by second-intention, while two required a minor skin graft to close the wound completely. No disease recurrence was noted at 10-24 months. Conclusion: Surgical excision with second-intention healing aided by guarded high-tension sutures effectively treated small and extensive FD lesions with no recurrence at long-term follow-up. To our knowledge, this is the first report of successful surgical treatment of FD.

Unveiling a Shared Precursor Condition for Acne Keloidalis Nuchae and Primary Cicatricial Alopecias.

Purpose: Small observational studies suggest subclinical disease occurrence in the normal-appearing scalp zones of several primary cicatricial alopecias. To aid patient management, we began routinely evaluating the entire scalp of patients with acne keloidalis nuchae (AKN), including trichoscopy-guided biopsies. Patients and Methods: This retrospective study evaluated 41 patients sequentially presenting with AKN at a single clinic between June and December 2022. Primary lesions and normal-appearing scalp in the superior parietal scalp at least 5 cm away from AKN-affected zones were clinically evaluated, and areas showing perifollicular erythema or scales/casts on trichoscopy were biopsied and histologically analyzed. Results: Forty-one men with AKN, including 20 men of African descent, 17 Hispanic, and 4 European-descended Whites, were evaluated. All patients, including 22% with associated folliculitis decalvans, showed scalp-wide trichoscopy signs of perifollicular erythema or scaling in normal-appearing scalp areas. All patients showed histologic evidence of perifollicular infundibulo-isthmic lymphocytoplasmic infiltrates and fibrosis (PIILIF), with 96% showing Vellus or miniaturized hair absence. PIILIF was often clinically mistaken for seborrheic dermatitis (44-51%). All White patients had mild papular acne keloidalis nuchae lesions mistaken for seborrheic dermatitis. Conclusion: PIILIF may be a precursor to a wide spectrum of primary cicatricial alopecias, including AKN and folliculitis decalvans. This finding carries implications for the early diagnosis and management of AKN and other primary cicatricial alopecias.

Acne keloidalis nuchae (AKN) is a type of hair loss and scalp condition marked by scarring and inflammation. This condition falls under a group of chronic hair and scalp issues known as primary cicatricial alopecia (PCA). Current treatments for AKN and similar PCAs often do not work well, and the condition tends to return. We have found a hidden scalp condition that could be causing AKN and other PCAs. It's a subtle disease that affects the entire scalp, even though it might not show noticeable symptoms. We have observed this condition in all 41 AKN patients in our study, and it's characterized by certain changes in the hair and scalp's structure and immune system response. Other studies have linked this condition to various other PCAs. We believe this hidden condition could be causing AKN and making it come back after treatment. This study suggests that treating AKN might require a broader approach beyond just treating the visible symptoms. Since this hidden condition exists in other PCAs, it might be a common cause.

Acne Keloidalis Nuchae is Associated with Cutis Verticis Gyrata.

Purpose: Both acne keloidalis nuchae (AKN) and cutis verticis gyrata (CVG) are scalp conditions predominantly affecting men. Both are characterized by dermal thickening and fibroblast hyperactivity. AKN typically occurs in the nuchal area, often involving the naturally occurring folds in the occipital region. The aim of this study was to determine the relationship between excessive scalp folding (CVG) and AKN. Patients and methods: A total of 108 patients with AKN seen over 11 years from July 2009 and November 2020 were retrospectively evaluated. Patients with AKN concomitant with CVG were selected for analysis. Results: Seven of the 108 AKN patients had scalp-wide (widespread) AKN lesions, including 4 with CVG. In 3 of the 4 patients with concomitant AKN and CVG, the AKN was widespread, and its onset had preceded CVG by 1-2 years. In the fourth CVG patient, AKN lesions were confined to the nuchal area, and the CVG preceded AKN onset by several years. All patients were male, with a mean age of 35.8 years (overall) and 38.0 years (CVG group). Conclusion: We describe a previously unreported relationship between widespread AKN and CVG, with the development of AKN preceding CVG formation.

A New Universal Follicular Unit Excision Classification System for Hair Transplantation Difficulty and Patient Outcome.

Introduction: The difficulty of the follicular unit excision (FUE) hair transplantation procedure is currently attributed to hair curliness and subsurface angulation. Patients possessing the curliest hair shafts are considered the most challenging. Consequently, patients with these features are often denied FUE. However, this practice does not consider intrapatient variation in the graft attrition rate and the rates themselves, which are frequently low in very curly hair where the skin firmness/thickness is average. To better aid practitioners in predicting FUE performance, we have developed a new scoring system (the Sanusi FUE Score Scale [SFS Scale]) based on two major donor variables (hair and skin characteristics). Material and Method: The scale assigns scores to each of three hair subtypes (straight-wavy, curly, and coily-kinky) and each of three skin subtypes (thick/firm, soft/thin, and medium thickness/firmness). The scores were weighted based on the assessment of 13 experienced FUE practitioners from around the globe, who were asked to score each of the three skin and hair characteristics for their contribution to FUE difficulty. Results: On the contribution of skin characteristics to FUE difficulty, 12/13 (92%) practitioners assigned the highest (most difficult) score to thick/firm skin, with medium skin thickness/firmness being the least challenging. The same percentage of practitioners gave the highest difficulty score to coiled-kinky hair subtypes regarding the contribution of hair characteristics to FUE difficulty. All agreed that straight-wavy hair presents the least challenge to FUE performance. Tallying the scores of the skin and hair variables generates a final score range of 2-9, which is associated with five grades/classes of challenge in the FUE procedure, influencing the need for a specialized skill/nuanced approach or equipment. Conclusion: We developed a universal FUE donor scoring scale that accounts for the diversity of human hair and skin types. Further evaluation to determine the validity of this new classification system in predicting and grading FUE difficulty and patient outcomes is warranted.

Lichen Planopilaris Responsive to a Novel Phytoactive Botanical Treatment: A Case Series.

INTRODUCTION: Lichen planopilaris (LPP) is characterized by chronic scarring alopecia that is progressive and typically refractory to therapy. Current drug treatments are suboptimal and not applicable for long-term use because of the high potential for adverse effects, warranting safer and more effective treatment alternatives. METHODS: Based on our previous success in treating a patient with central centrifugal cicatricial alopecia using a topical botanical formulation (Gashee), we reviewed records of four patients with biopsy-proven LPP treated with the topical formulation alone or in combination with its oral preparation. Three patients had failed previous treatment with intralesional steroid injections, topical minoxidil, tacrolimus, and clobetasol. Physical examination and photographic documentation were also used as outcome measures. Treatment duration with the botanical formulations ranged from 6 weeks to 9.5 months. RESULTS: All patients showed overall improvement in surrogate indicators of LPP activity as evidenced by the disappearance of symptoms (pruritus, tenderness, scalp irritation, and hair shedding), improvement in hair growth, and reduction in redness. All reported a high satisfaction level and no adverse effects. CONCLUSIONS: Patients with treatment-refractory LPP responded to a novel botanical treatment. To the best of our knowledge, this is the first published report of LPP responding to a plant-based natural treatment. Further evaluation of this treatment in a controlled trial with a larger number of patients is warranted.

Lichen planopilaris is a chronic and progressive condition, most commonly affecting middle-aged women. It results in scalp inflammation, scarring, and ultimately permanent hair loss. Treatments are typically ineffective in the long term and are associated with side effects that limit their use. We report success in treating four patients using a new botanical formulation called Dr. UGro Gashee as the sole therapy for a duration ranging from 6 weeks to 9.5 months. The treatment was administered topically or in combination with its oral formulation. All the patients showed cessation of disease progression with significant hair regrowth. They also reported complete resolution of scalp itch, tenderness, and irritation, with no adverse effects. Our report is the first published study of lichen planopilaris responding to a plant-based natural treatment and warrants further evaluation in larger controlled trials.

Treatment-Refractory Central Centrifugal Cicatricial Alopecia Responsive to a Novel Botanical Treatment.

Purpose: Central centrifugal cicatricial alopecia (CCCA) is the most common cause of scarring alopecia in women of African descent. However, current treatments for CCCA, such as immunosuppressants and immunomodulatory pharmaceutical agents, have suboptimal efficacy and undesirable side effects. This case series reports the therapeutic effect of a new botanical formulation (Dr. UGro Gashee) in four patients with histologically supported diagnoses of CCCA. The formulations contain at least three phytoactive ingredients that affect multiple targets in the cascade of pathophysiologic events contributing to CCCA. Possible mechanisms of action include anti-inflammatory effects, inhibiting proinflammatory cytokines, and the net antifibrotic effect of inhibiting transforming growth factor-beta while upregulating AMP-activated protein kinase and peroxisome proliferator-associated receptor-gamma activity. Patients and Methods: Four African American women with treatment-refractory CCCA were treated with a new topical botanical formula (cosmeceutical) alone or in combination with its oral formulation (nutraceutical) for 8 weeks to 1 year. The cosmeceutical and nutraceutical treatments contain similar phytoactive ingredient profiles. Treatment outcomes were collected using documented patient reports and images and by direct observation. Results: In all patients, scalp pruritus cessation occurred within 2 weeks of treatment, and significant hair regrowth was observed within 2 months. All patients reported a high satisfaction level without adverse effects. Conclusion: Patients with treatment-refractory CCCA responded to the novel botanical treatment reported in this study. Further evaluations in a controlled trial with more patients are warranted.

Trends in Cancers of the Skin: Insights from a Three-year Observational Cohort in Manhattan Beach, California.

Background: There exists significant heterogeneity in the presentation of "common" skin cancers such as cutaneous melanoma (CM), cutaneous squamous cell carcinoma (cSCC) and basal cell carcinoma (BCC). Meaningful differences are often observed among the trio concerning age, sex, site at presentation and laterality. Objective: In this paper, we endeavor to elucidate such heterogeneity, reaffirm burgeoning trends in skin cancer incidence, and offer new insights in the presentation of common skin cancers. Results: While agreement with current consensus was achieved with regard to various aspects of sex, age, and site-specific findings, several novel results emerged: (1) the percentage of subjects presenting with CM was demonstrably higher than population averages would estimate; (2) melanoma exhibited a pronounced right-side bias; (3) cSCC was not head and neck preferring as other reviews have documented (4) cSCC exhibited greater female bias. Conclusion: In this study, we documented insights from 663 cases (397 unique subjects) across a range of factors including age, laterality, site of presentation, and sex specific differences in incidence. The results of our analysis generally accord well with previous findings, replicating several of the most prominent results.

Chromate-Induced Allergic Contact Dermatitis Treated With Dupilumab.

Chromate causes persistent, difficult to treat irritant and allergic contact dermatitis in cement-handling occupational workers. When therapeutics such as topical corticosteroids, topical calcineurin inhibitors, phototherapy and immune-modulating treatments like methotrexate fail, many patients are advised that avoidance may be the only remaining option – an option that may be particularly challenging if the patient’s occupation necessitates chromate exposure. We report a case of severe chromate-induced allergic contact dermatitis in a 55-year-old cement mason that presented to the outpatient dermatology clinic with multiple scaly, erythematous, >5 cm plaques scattered over the skin of his hands, head and neck. After a prior failed course of treatment with high potency topical corticosteroid, this patient was successfully treated with dupilumab. Given the success of dupilumab in our patient, we propose the consideration of dupilumab as an alternative treatment option for those suffering from chromate-induced allergic contact dermatitis that is refractory to ultra-high potency topical corticosteroids. J Drugs Dermatol. 2021;20(12):1340-1342. doi:10.36849/JDD.6246.

Ketogenic Diet-induced Prurigo Pigmentosa (the "Keto Rash"): A Case Report and Literature Review.

Prurigo pigmentosa (PP) is a rare inflammatory dermatosis of unknown etiology that primarily affects adolescents and young adults. It is typically characterized by a pruritic eruption of erythematous papules on the trunk and neck that evolves into reticulate hyperpigmentation upon resolution of the inflammatory phase of the rash. It has been associated with various triggers, including the metabolic state of ketosis. Interestingly, the recent increase in popularity of the ketogenic diet for weight loss has led to an increased number of PP cases reported in the literature. We present a case of PP in a 21-year-old Hispanic man, which erupted during strict adherence to a ketogenic diet. We conducted a literature review and identified 19 other cases of PP related to ketogenic diet. While PP has historically been reported primarily in Asia, we found cases occurring in patients of Middle Eastern, Caucasian, Hispanic, Asian, and African descent. On average, the rash presented 31 days after initiating the diet and subsided 18 days after diet cessation. Most cases were treated with an oral tetracycline and resolved with residual hyperpigmentation. We present this information to highlight the increasing association of PP with the ketogenic diet so that early diagnosis and treatment and optimal patient outcomes may be achieved. Dermatologists should be aware of the timing of rash onset and resolution in relation to the diet.

Ice pack-induced perniosis: a rare and underrecognized association.

Perniosis, or chilblain, is characterized by skin lesions that occur as an abnormal reaction to exposure to cold and damp conditions. It can present as an idiopathic dermatosis or in association with an underlying connective tissue or autoimmune disease. Differentiation by histopathologic examination is controversial. Herein, we report a unique case of a 73-year-old woman who developed acquired perniosis on the buttocks from the use of ice packs to treat chronic low back pain.

Concomitant fibrofolliculoma and trichodiscoma on the abdomen.

Fibrofolliculoma and trichodiscoma are adnexal tumors that arise from or around hair follicles and are two of the many characteristic features of Birt-Hogg-Dubé (BHD) syndrome. Fibrofolliculoma and other hair follicle hamartomas can be differentiated from their clinically indistinct counterparts (eg, trichodiscomas, trichoadenomas) by histologic and staining comparison. We report a rare case of a 54-year-old man who presented with a subcutaneous papule on the abdomen that was histologically proven to have features of both a solitary fibrofolliculoma and trichodiscoma.

A rare case of primary cutaneous diffuse large B-cell lymphoma, leg type.

Primary cutaneous diffuse large B-cell lymphoma, leg type (DLBCLLT) is a rare, intermediately aggressive form of primary cutaneous B-cell lymphoma (CBCL) that is characterized by the presence of large round cells on histopathology. Clinically, patients present with red-brown nodules on the distal legs. The prognosis is less favorable than other types of CBCLs, with a 5-year survival rate of 50%. We present a case of primary cutaneous DLBCLLT in a 74-year-old woman. A comprehensive review of cutaneous T-cell lymphoma and CBCL also is provided, along with a discussion of the T-cell and B-cell forms of pseudolymphoma.

Practical and Sustainable Teledermatology and Teledermatopathology: Specialty Care in Cameroon Africa.

Teledermatology is a rapidly expanding niche within telemedicine still in its infancy. It has become increasingly more feasible in recent years with the expansion of information and communication technologies. Here, the authors present the details of their collaboration and propose a model for constructing a teledermatology network. In the year 2014, the authors' Dermatopathology institute in Torrance, California, partnered with Mbingo Baptist Hospital, a tertiary referral center in Cameroon, Africa. During this time, 145 cases were received. The authors present highlights of specific cases as well as the strengths and challenges encountered. They have found the use of the store and forward method to be an effective tool with an acceptable concordance rate. With basic bandwidth speeds and images taken with smart devices shared via email, providers are given the unique opportunity to provide specialty care and alleviate disease burden where dermatology and dermatopathology resources are scarce.

Keloidal Atypical Fibroxanthoma: Case and Review of the Literature.

Keloidal atypical fibroxanthoma (KAF) has recently been categorized as a variant of atypical fibroxanthoma. This paper will emphasize the importance of including KAF in both clinical and histological differential diagnosis of benign and malignant lesions which exhibit keloidal collagen and will also review the current literature on epidemiology, pathogenesis, histology, immunochemistry and treatments.

Congenital self-healing reticulohistiocytosis: an underreported entity.

Langerhans cell histiocytosis (LCH), also known as histiocytosis X, is a group of rare disorders characterized by the continuous replication of a particular white blood cell called Langerhans cells. These cells are derived from the bone marrow and are found in the epidermis, playing a large role in immune surveillance and the elimination of foreign substances from the body. Additionally, Langerhans cells are capable of migrating from the skin to lymph nodes, and in LCH, these cells begin to congregate on the bone, particularly in the head and neck region, causing a multitude of problems. Langerhans cell histiocytosis is classified into 4 variants: congenital self-healing reticulohistiocytosis (CSHR)(also known as Hashimoto-Pritzker disease), Letterer-Siwe disease, Hand-Schüller-Christian disease, and eosinophilic granuloma. Despite various clinical presentations and severity, all subtypes are pathologically caused by the proliferation of the Langerhans cell.

Management of Periocular Granuloma Annulare Using Topical Dapsone.

Granuloma annulare is a disease characterized by granulomatous inflammation of the dermis. Localized granuloma annulare may resolve spontaneously, while generalized granuloma annulare may persist for decades. The authors present the case of a 41-year-old Hispanic man with a two-week history of periocular granuloma annulare. Due to previously reported success in the use of systemic dapsone for the treatment of granuloma annulare, and the periocular proximity of the patient's lesion, topical dapsone was used for treatment. Various additional therapies for the management of granuloma annulare have been reported, such as topical and systemic steroids, isotretinoin, pentoxifylline, cyclosporine, Interferon gamma, potassium iodide, nicotinamide, niacinamide, salicylic acid, fumaric acid ester, etanercept, infliximab, and hydroxychloroquine. Additional clinical trials are necessary to further evaluate the effectiveness of topical dapsone in the management of granuloma annulare.

Eccrine poromatosis: case report and review of the literature.

Eccrine poroma (EP) is a benign tumor of the eccrine duct. Multiple EPs are defined as eccrine poromatosis (EPS), an uncommon phenomenon. To date there are only eight reported cases of EPS. This review exemplifies the epidemiology, pathogenesis, differential diagnosis, and histology of EP, while reviewing the eight cases of EPS. Six of the eight cases of EPS had a history of immunosuppression from either radiation or chemotherapy. This paper will also emphasize the importance of excision to avoid possible malignancy. Here we present a 73-year-old gentleman with EPS who was also treated with radiation and chemotherapy prior to the onset of the lesions.

Elastosis perforans serpiginosa in association with scabies mite.

Elastosis perforans serpiginosa is a form of perforating dermatoses, which has a characteristic clinical presentation of grouped keratotic papules coalescing into serpiginous or annular configurations. The majority of elastosis perforans serpiginosa cases are idiopathic; however, various etiologies have been postulated for the pathogenesis of this syndrome. The authors present a unique case of elastosis perforans serpiginosa that developed focally secondary to a scabies mite.

Lymphocytic thrombophilic arteritis induced by minocycline.

Lymphocytic thrombophilic arteritis is an entity only recently defined in the literature. This term describes a distinctive histopathological combination of lymphocytic vascular inflammation associated with a hyalinized fibrin ring in the vessel lumina, changes reflecting a thrombophilic endovasculitis. The authors present the case of a woman who developed lymphocytic thrombophilic arteritis coinciding with the use of minocycline. In addition to these histopathological findings, the cutaneous manifestations of this case reflect previously reported clinical findings of progressive localized livedo racemosa characterized by reticular patchy hyperpigmentation predominately affecting the lower extremities.