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Showing papers in "Archives of Dermatology in 1999"


Journal ArticleDOI
TL;DR: Birt-Hogg-Dubé syndrome may be associated with familial renal tumors and patients with BHD and their relatives should undergo abdominal computed tomography and renal ultrasound screening for renal tumors.
Abstract: Background Birt-Hogg-Dube syndrome (BHD) is a dominantly inherited predisposition for development of fibrofolliculomas, trichodiscomas, and acrochordons. Concurrent internal tumors, such as colonic polyps and renal carcinoma, have been described in patients with BHD. Objective To evaluate kindreds with familial renal tumors for cutaneous manifestations of BHD. Design One hundred fifty-two patients from 49 families underwent complete oral and skin examination. Skin lesions were identified by their clinical appearance, and the diagnosis was confirmed by results of histologic examination. Individuals underwent screening for familial renal neoplasms. Setting A tertiary referral research hospital. Patients Individuals with familial renal tumors and their asymptomatic at-risk relatives. Main Outcome Measure We determined whether any form of renal cancer is associated BHD. Results We identified 3 extended kindreds in whom renal neoplasms and BHD appeared to segregate together. Two kindreds had renal oncocytomas and a third had a variant of papillary renal cell carcinoma. Thirteen patients exhibited BHD. Seven individuals, including a set of identical twins, had renal neoplasms and BHD. An additional 4 patients (3 deceased and not examined) in these families had renal neoplasms but not BHD. Birt-Hogg-Dube syndrome without renal neoplasms was present in 6 individuals. Thirteen patients with fibrofolliculomas and trichodiscomas presented clinically with multiple smooth skin-colored to grayish-white papules located on the face, auricles, neck, and upper trunk. Oral papules were present in 9 of 28 and achrochordons in 11 of 28 patients. Features of BHD not previously appreciated included deforming lipomas in 5, collagenomas in 4, and pulmonary cysts in 4 of 28 patients. Families with BHD did not display germline mutations in the von Hippel-Lindau gene or in the tyrosine kinase domain of theMETproto-oncogene. Conclusions Birt-Hogg-Dube syndrome may be associated with familial renal tumors. Birt-Hogg-Dube and renal tumors segregate together in an autosomal dominant fashion. Patients with BHD and their relatives are at risk for development of renal tumors. Therefore, patients with BHD and their relatives should undergo abdominal computed tomography and renal ultrasound screening for renal tumors.

367 citations


Journal ArticleDOI
TL;DR: It is surmised that Mohs micrographic surgery should be used mainly for larger, morphea-type BCCs located in danger zones, followed in order by those treated with surgical excision, cryosurgery, and curettage and electrodesiccation.
Abstract: Objective To systematically review the literature for studies reporting on recurrence rates of basal cell carcinomas (BCCs) after different therapies. Design We reviewed all studies published in English, French, German, Dutch, Spanish, or Italian between 1970 and 1997 that prospectively examined recurrence rates for at least 50 patients with primary BCCs observed for at least 5 years after treatment with Mohs micrographic surgery, surgical excision, curettage and electrodesiccation, cryosurgery, radiotherapy, immunotherapy with interferon or fluorouracil, or photodynamic therapy. Setting Department of Dermatology, University Hospital Maastricht, Maastricht, the reference center for dermatologic oncology and Mohs micrographic surgery in the Netherlands. Main Outcome Measures The recurrence rates after different therapies for BCCs, resulting in the development of guidelines for the treatment of these disorders. Results Of 298 studies found in several electronic databases, only 18 met the requirements and could be used for analysis. Tumors treated with Mohs micrographic surgery show the lowest recurrence rates after 5 years, followed in order by those treated with surgical excision, cryosurgery, and curettage and electrodesiccation. Conclusions Recurrence rates for different therapies could not be compared because of a lack of uniformity in the method of reporting, so evidence-based guidelines could not be developed. We surmise that Mohs micrographic surgery should be used mainly for larger, morphea-type BCCs located in danger zones. For smaller BCCs of the nodular and superficial types, surgical excision remains the first treatment of choice. Other treatment modalities can be used in patients in whom surgery is contraindicated. Immunotherapy and photodynamic therapy are still investigative.

336 citations


Journal ArticleDOI
TL;DR: Little objective evidence exists to demonstrate relief of pruritus in patients with atopic dermatitis, and the majority of trials are flawed in terms of the sample size or study design.
Abstract: Objective: To critically review the body of clinical trials that refute or support the efficacy of antihistamines in relieving pruritus in patients with atopic dermatitis. Design: Review of MEDLINE from 1966 through March 1999, the Cochrane Database of Systematic Reviews, and Best Evidence to identify therapeutic trials of antihistamines in patients with atopic dermatitis. Main Outcome Measures: All randomized controlled trials or clinical trials of antihistamines used in the treatment of atopic dermatitis. We found 16 studies throughout the literature. Results: Large, randomized, double-blind, placebocontrolled clinical trials with definitive conclusions (grade A trials) have not been performed. Two grade B trials (small, rigorous, randomized trials with uncertain results due to moderate to high a or b error) refuted the use of antihistamines in relieving pruritus. One grade B trial supported the efficacy of antihistamines in relieving pruritus. All remaining trials (grade C) lacked placebo controls or randomization, or contained fewer than 20 patients in each treatment group. Conclusions: Although antihistamines are often used in the treatment of atopic dermatitis, little objective evidence exists to demonstrate relief of pruritus. The majority of trials are flawed in terms of the sample size or study design. Based on the literature alone, the efficacy of antihistamines remains to be adequately investigated. Anecdotally, sedating antihistamines have sometimes been useful by virtue of their soporific effect and bedtime use may be warranted. There is no evidence to support the effectiveness of expensive nonsedating agents.

332 citations


Journal ArticleDOI
TL;DR: In the United States, an estimated 21,909 HIV-infected persons died with AIDS, nearly all as a result of opportunistic illnesses (OIs) as mentioned in this paper, and the number of persons living with AIDS is increasing, and the incidence of AIDS is decreasing.
Abstract: Problem/Condition: Acquired immunodeficiency syndrome (AIDS)defining opportunistic illnesses (OIs) are the major cause of morbidity and mortality among persons infected with human immunodeficiency virus (HIV). As a result of new treatments that reduce mortality for persons with AIDS, the number of persons living with AIDS is increasing, and the incidence of AIDS is decreasing. In 1997, an estimated 271,245 persons were living with AIDS in the United States and thus were at high risk for OIs. In 1997, an estimated 21,909 HIV-infected persons died with AIDS, nearly all as a result of OIs.

266 citations


Journal ArticleDOI
TL;DR: Evidence is found suggesting that patients are trying to use information on the Internet as a supplement for physicians and that teleadvice might be overused by chronically ill and frustrated patients looking desperately for additional information.
Abstract: Objectives To analyze the motivation, expectations, and misconceptions of patients seeking teleadvice or medical information on the Internet. To explore the possible economics and problems of direct physician-to-patient teleadvice via electronic mails (e-mail). Design Exploratory survey of 209 unsolicited e-mails mostly sent to physicians by individuals seeking teleadvice. Setting University dermatology hospital with a major Web site on the World Wide Web. Patients Two hundred nine patients and information-seeking individuals, mainly with dermatologic problems. Main Outcome Measures Previous contacts with live physicians, disease duration, level of frustration expressed in the e-mails, and type of information sought. Results Many dermatologic patients who request teleadvice have a chronic disease (81%) and seek a second opinion. Seventeen percent express frustration about previous encounters with live physicians. Forty percent of all e-mails could have been answered by a librarian, 28% of all e-mails were suitable to be answered by a physician via e-mail alone, and in 27% of the cases any kind of consultation would not have been possible without seeing the patient. In at least 5 instances patients attempt self-diagnosis. Conclusions We found examples for the beneficial effects of the provision of medical information on the World Wide Web but also evidence suggesting that patients are trying to use information on the Internet as a supplement for physicians and that teleadvice might be overused by chronically ill and frustrated patients looking desperately for additional information. Telemedicine via e-mail could substitute a physician visit or telephone call in some cases, but many principal problems must be solved beforehand.

229 citations


Journal ArticleDOI
TL;DR: Ebium:YAG laser is safe and effective in removing facial rhytides and subjects treated with Er:Y AG laser recover more quickly from the procedure than those receiving CO2 laser treatment.
Abstract: Objective To compare the efficacy, adverse effects, and histological findings of erbium:YAG (Er:YAG) and carbon dioxide (CO 2 ) laser treatment in removing facial rhytides. Design An intervention study of 21 subjects with facial rhytides. All participants were followed up for 6 months. The end points of the study were wrinkle improvement and duration of adverse effects. Setting Academic referral center. Subjects Nineteen female and 2 male volunteers with skin type I to III and wrinkle class I to III participated in the study. Intervention In all subjects, 1 side of the face was treated with a CO 2 laser and other side with an Er:YAG laser. Skin biopsies were performed in 6 subjects before treatment and immediately, 1 day, 2 days, and 6 months after treatment. Observations were recorded by subjects, investigators, and a blinded panel of experts. Main Outcome Measures Improvement in wrinkles and severity and duration of adverse effects. Results The CO 2 laser–treated side had relatively better wrinkle improvement when evaluating all subjects ( P 2 laser treatment. Posttreatment erythema was noted at 2 weeks in 14 subjects (67%) on the Er:YAG laser–treated side and 20 subjects (95%) on the CO 2 laser–treated side. The frequency of erythema was significantly less after Er:YAG laser treatment at 2 ( P =.001) and 8 ( P =.03) weeks. Hypopigmentation was seen in 1 Er:YAG-treated (5%) and 9 CO 2 -treated (43%) sides (χ 2 , P 2 -treated side. Conclusions Erbium:YAG laser is safe and effective in removing facial rhytides. Subjects treated with Er:YAG laser recover more quickly from the procedure than those receiving CO 2 laser treament.

227 citations


Journal ArticleDOI
TL;DR: Several risk factors are associated with the failure of a patient's venous leg ulcer to heal while using limb-compression therapy, and it is prudent to consider these factors when referring a patient to a wound care subspecialists or for alternative therapies.
Abstract: Background Venous leg ulcers afflict a significant portion of the population. The most popular form of therapy for venous leg ulcers is a compression bandage (eg, Unna boot), a therapy that is frequently unsuccessful. Objective To describe risk factors associated with the failure of a wound to heal when treated with a limb-compression bandage for 24 weeks. Design A retrospective cohort study. Setting Single-center outpatient specialty clinic at an academic medical center. Participants Two hundred sixty consecutive patients with chronic venous leg ulcers. Main Outcome Measure The magnitude of the effect of a given risk factor on the probability that a wound will heal within 24 weeks of care. Results Based on an assessment of leg wounds during initial office visits, we observed that the failure of a wound to heal within 24 weeks was significantly associated with larger wound area, measured in square centimeters (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.11-1.27), duration of the wound in months (OR, 1.09; 95% CI, 1.04-1.16), history of venous ligation or venous stripping (OR, 4.58; 95% CI, 1.84-11.36), history of hip or knee replacement surgery (OR, 3.52; 95% CI, 1.12-11.08), ankle brachial index of less than 0.80 (OR, 3.52; 95% CI, 1.12-11.08), and the presence of fibrin on more than 50% of the wound surface (OR, 3.42; 95% CI, 1.38-8.45). Conclusions Several risk factors are associated with the failure of a patient's venous leg ulcer to heal while using limb-compression therapy. It is prudent to consider these factors when referring a patient to a wound care subspecialists or for alternative therapies.

221 citations


Journal ArticleDOI
TL;DR: In this review, 3 major topics will be addressed regarding the critical role for pathogenic T cells as causing this common and enigmatic skin disease.
Abstract: In 1991, a comprehensive review was published highlighting the importance of cytokines in the immunopathogenesis of psoriasis. 1 Since then, many advances have been made regarding the critical role for pathogenic T cells as causing this common and enigmatic skin disease. While epidermal keratinocytes are clearly involved as participants in establishment of the appropriate cytokine milieu as presented earlier, more recent data point to T lymphocytes as triggering the chain reaction of cellular and molecular networks that culminate in the formation of a psoriatic plaque. In this review, 3 major topics will be addressed.

220 citations


Journal ArticleDOI
TL;DR: The incidence of NMSC is fairly low in Finland, accounting for 3.5% of all new cancer cases, whereas BCC is the most common cancer type, and the mortality trend was decreasing for both cancer types.
Abstract: Objective To study trends of nonmelanoma skin cancer in Finland. Design Descriptive analysis of incidence and mortality rates for basal cell skin carcinoma (BCC) and other nonmelanoma skin cancers (NMSCs) from 1966 and 1956, respectively, through 1995 in relation to sex, age, anatomical distribution, place of residence, and occupation. Setting Data were obtained from the nationwide Finnish Cancer Registry, to which reporting of skin cancer is compulsory. Patients Inhabitants of Finland (5.1 million in 1998). Main Outcome Measures Age- and sex-specific incidence and mortality rates and overall rates adjusted for age to the world standard population; occupation-specific standardized incidence ratios, with the total Finnish population as reference. Results The age-adjusted incidence rate in 1991 through 1995 for BCC was 49 per 100,000 person-years in men and 45 in women. For NMSC it was 8.7 in men and 5.3 in women. Both cancer types showed an increasing trend in incidence rates. The proportion of tumors in the face, scalp, and neck was 59% for BCC and 67% for NMSC. The incidence rate of NMSC increased from north to south, while there was no great urban-rural or occupational variation in the occurrence of NMSC. The incidence rate for BCC was higher in urban than in rural regions. Farmers, forestry workers, and fishermen showed low incidence of BCC, whereas occupations with a high level of education or compulsory health checkups and medical care occupations appeared to have an increased incidence of BCC. The mortality rate for BCC in 1991 through 1995 was 0.08 per 100,000 person-years in men and 0.05 in women, and for NMSC, it was 0.38 in men and 0.23 in women. The mortality trend was decreasing for both cancer types. Conclusions The incidence of NMSC is fairly low in Finland, accounting for 3.5% of all new cancer cases. Conversely, BCC is the most common cancer type. The incidence trend is increasing for both skin cancer types, but mortality remains low.

205 citations


Journal ArticleDOI
TL;DR: Cryogen spray cooling is a safe and effective method for protecting the epidermis during nonablative laser treatment of facial rhytides thereby avoiding much of the morbidity associated with other resurfacing procedures.
Abstract: Background Cryogen spray cooling can be used to provide epidermal protection while still achieving spatially selective photocoagulation in the upper dermis. The objective of this study is to determine the efficacy and safety of cryogen spray cooling in combination with a nonablative Nd:YAG (λ=1320 nm) laser treatment of facial rhytides in human volunteers. Observations Thirty-five adults with bilateral periorbital rhytides were treated with cryogen spray cooling in combination with 3 nonablative laser treatments performed sequentially at intervals of 2 weeks. Small but statistically significant improvements were noted in the mild, moderate, and severe rhytid groups 12 weeks after the final laser treatment. A final assessment performed 24 weeks after the last treatment showed statistically significant improvement only in the severe rhytid group. The procedure was found to be safe; 4 sites (5.6%) developed transient hyperpigmentation. Two sites (2.8%) subsequently developed barely perceptible pinpoint pitted scars. Conclusions Cryogen spray cooling is a safe and effective method for protecting the epidermis during nonablative laser treatment of facial rhytides thereby avoiding much of the morbidity associated with other resurfacing procedures. Minor improvements in rhytides can be achieved with the current technology. Optimization of treatment parameters may further improve these results.

196 citations


Journal ArticleDOI
TL;DR: Examination of changes in melanoma rates by several measures of severity of disease indicates that the increasing incidence rates are not solely caused by increased early detection and diagnosis of clinically insignificant melanomas, but may also represent a true increase in cancer rates.
Abstract: Background: The incidence of melanoma has been increasing faster than that of any other cancer in the United States. It is unclear whether the increase is related to increased surveillance or other changes in the disease. Objective: To examine changes in melanoma rates by several measures of severity of disease and to review the ways in which increased surveillance may cause leadtime bias through early detection or length bias through detection of clinically insignificant lesions as a basis for interpreting these changing rates. Design: Population-based incidence rates for 1973 through 1994.

Journal ArticleDOI
TL;DR: The KP-e may function well as a clinical factor to assess present disease activity and may also predict the responsiveness to fluticasone propionate plus UV-A therapy but not to UV-B (311 nm) therapy.
Abstract: Objective To investigate the association between the experimentally induced Kobner phenomenon (KP-e) and the Kobner phenomenon by history (KP-h), disease activity, and therapeutic responsiveness in vitiligo vulgaris. Design Cohort study. Setting An outpatient clinic. Patients Sixty-one consecutive patients with vitiligo vulgaris. Intervention Three months after a standardized epidermodermal injury was induced, the KP-e was evaluated. For 1 year, UV-B (311 nm) therapy or topical fluticasone propionate plus UV-A therapy was given, depending on the severity of depigmentation. Main Outcome Measures The presence or absence of the KP-e and the KP-h disease activity as scored on a 6-point scale from −1 to +4 (vitiligo disease activity [VIDA] score) and therapy-induced repigmentation grade. Results Nineteen (31%) of the patients had a positive KP-h, whereas 37 (61%) showed a positive KP-e (P Conclusion The KP-e may function well as a clinical factor to assess present disease activity and may also predict the responsiveness to fluticasone propionate plus UV-A therapy but not to UV-B (311 nm) therapy.

Journal ArticleDOI
TL;DR: Patients with moderate to severe psoriasis are at increased risk for death because of alcohol intake and smoking, and alcohol is a major cause for this excess mortality.
Abstract: Background Psoriasis is seen as a disease that does not kill. However, it is associated with alcohol intake and smoking. Thus, there could be excess mortality due to causes related to alcohol intake and smoking among patients with psoriasis. Design A cohort was identified from the nationwide Hospital Discharge Register from January 1, 1973, through December 31, 1984, and mortality was followed up for 22 years by linkage with the Cause-of-Death Register, from January 1, 1973, through December 31, 1995. Patients A cohort of 3132 men and 2555 women admitted to inpatient treatment with psoriasis as the principal diagnosis. Main Outcome Measures Date and underlying cause of death. Results We observed 1918 deaths in contrast to the 1211 deaths expected on the basis of the national mortality rates. The all-cause standardized mortality ratio (SMR) for men was 1.62 (95% confidence interval [CI], 1.52-1.71); for women, 1.54 (95% CI, 1.43-1.64). Among men, the highest SMRs were found for alcohol psychosis (8.91 [95% CI, 2.89-20.70]) and liver disease, ie, cirrhosis, fatty liver, and hepatitis (6.98 [95% CI, 5.34-8.96]). Among women, the highest SMR was found for liver disease (5.06 [95% CI, 2.70-8.65]). Excess mortality was high for all causes of death directly related to alcohol; the SMR for men was 4.46 (95% CI, 3.60-5.45); for women, 5.60 (95% CI, 2.98-8.65). Conclusions Patients with moderate to severe psoriasis are at increased risk for death. Alcohol is a major cause for this excess mortality.

Journal ArticleDOI
TL;DR: The application of an objective grading system, such as the one described herein for the first time, is the first step in providing useful information for the management of atypical Spitz tumors.
Abstract: Objective To describe a grading system for risk stratification of atypical Spitz tumors in children and adolescents. In some circumstances, unequivocal distinction between Spitz nevus and melanoma is practically impossible. It is likely that these lesions for which we lack specific diagnostic criteria represent a broad histological continuum extending from benign to malignant tumors. Therefore, we propose that Spitz tumors be categorized into low-, intermediate-, or high-risk categories based on the accumulation of abnormal features. Design Retrospective study. Settings Institutional practice. Patients We present 30 cases of atypical Spitz tumors in patients younger than 18 years evaluated for at least 3 years or in whom a metastatic event developed during this period. Intervention None. Main Outcome Measure The grading system was formulated after data collection. Results Among the parameters studied, only diagnosis at age greater than 10 years, diameter of the lesion greater than 10 mm, presence of ulceration, involvement of the subcutaneous fat (level V), and mitotic activity of at least 6/mm 2 carried a likelihood ratio greater than 1.50 and were therefore used for the grading system. Conclusion The application of an objective grading system, such as the one described herein for the first time, is the first step in providing useful information for the management of atypical Spitz tumors.

Journal ArticleDOI
TL;DR: Topical tacrolimus is a safe and effective therapeutic agent that may open a new era in the treatment of inflammatory skin diseases, particularly for patients with atopic dermatitis.
Abstract: Background Tacrolimus has been shown to be a powerful suppressor of the immune system. It was introduced into clinical use to prevent allograft rejection and is now routinely used in kidney, liver, and heart transplantation. Recently, 2 double-blind multicenter studies demonstrated the therapeutic efficacy of topical and systemic tacrolimus in the inflammatory skin diseases atopic dermatitis and psoriasis. Data Source MEDLINE was searched for relevant publications and combined with our own clinical, in vitro, and in vivo studies. Study Selection All studies dealing with tacrolimus and dermatology were reviewed. Data Extraction Publications with clinically relevant data were included in this review. Conclusions Topical tacrolimus is a safe and effective therapeutic agent that may open a new era in the treatment of inflammatory skin diseases, particularly for patients with atopic dermatitis. Before its full potential in dermatology can be assessed, more clinical experience in treating children and comparison with the criterion standard of anti-inflammatory therapy, glucocorticosteroids, are needed.

Journal ArticleDOI
TL;DR: Despite differences in freedom-from-relapse results among different treatment groups, long-term overall or disease-specific survivals were not significantly different and the concept of an adjuvant therapy after irradiation is appealing, although it may not lead to improved long- term survival.
Abstract: Objectives To study the long-term results of treatment of patients with generalized patch and/or plaque mycosis fungoides and to identify clinical characteristics predictive of survival and response to treatment. Design A single-center, 35.5-year retrospective cohort analysis. Setting Private referral medical center. Patients One hundred seventy-six patients with generalized patch and/or plaque (T2) mycosis fungoides. Main Outcome Measures Long-term actuarial survival and freedom-from-relapse results as calculated by the Kaplan-Meier method. Results The long-term (35.5-year) survival of patients with T2 mycosis fungoides is worse than the expected survival of a race-, age-, and sex-matched control population ( P P P P Conclusions A significant proportion (24%) of patients with generalized patch and/or plaque (T2) mycosis fungoides experience disease progression to a more advanced clinical stage, and nearly 20% eventually die of the disease. Younger patients have a more favorable disease-specific long-term outcome than patients who are older. Presence of lymphadenopathy (stage IIA) at diagnosis does not predict worse long-term survival outcome. Clinical features predictive of disease progression include initial lymphadenopathy (stage IIA) and lack of complete response to initial treatment. Despite superior complete response rate to a 30-Gy or higher dose of total skin electron beam therapy, topical mechlorethamine proves to be a cost-effective initial treatment for patients with T2 disease. The concept of an adjuvant therapy after irradiation is appealing, although it may not lead to improved long-term survival.

Journal ArticleDOI
TL;DR: This article is intended to update the physician on laser skin resurfacing based on the broadest review of the current literature, and proceeds from a discussion of initial laser-tissue interactions, such as collagen denaturation, to examination of long-term biological sequelae.
Abstract: Despite the unquestionable efficacy of carbon dioxide laser skin resurfacing, mechanisms for cosmetic enhancement remain poorly characterized. Histological studies have provided some insight into the cascade of events from initial laser impact to final skin rejuvenation. However, there are few comprehensive studies of gross and microscopic wound healing. Additionally, the literature is fragmented; excellent individual articles appear in journals from widely disparate disciplines. For example, some reports relevant to laser skin resurfacing are "sequestered" in the engineering literature. This article is intended to update the physician on laser skin resurfacing based on the broadest review of the current literature. It proceeds from a discussion of initial laser-tissue interactions, such as collagen denaturation, to examination of long-term biological sequlae. At some cost to scientific rigor, mathematical models describing laser-tissue interactions are not presented.

Journal ArticleDOI
TL;DR: The data suggest that IL-10 therapy for psoriasis is safe and possibly clinically effective, and its value in Psoriasis and similar immune diseases should be further determined.
Abstract: Objective To determine the safety and clinical effects of interleukin 10 (IL-10) treatment of psoriasis. Design and Methods In an open-label phase 2 trial, 10 patients with psoriasis subcutaneously received recombinant human IL-10 over a 7-week period in a dosage of 8 µg/kg daily (n=5) or 20 µg/kg 3 times per week (n=5). Patients were followed up for an additional 5 weeks. Results The treatment was well tolerated. Antipsoriatic effects were found in all but 1 patient. A significant decrease of the psoriasis area and severity index by 55.3% ± 11.5% (mean ± SEM) was observed ( P Conclusions Our data suggest that IL-10 therapy for psoriasis is safe and possibly clinically effective. Consequently, its value in psoriasis and similar immune diseases should be further determined. Dose-finding, placebo-controlled, double-blind trials are necessary now.

Journal ArticleDOI
TL;DR: Higher serum androgen levels are associated with the presence of acne in women and a role for locally produced androgens in this process, however, cannot be excluded.
Abstract: Objective To determine if there are differences in the activity of 17beta-hydroxysteroid dehydrogenase and 5alpha-reductase (responsible for the production of testosterone and dihydrotestosterone, respectively) in sebaceous glands obtained from men and women with and without acne. Design Single-center examination of androgen levels and sebaceous gland enzyme activity in a cohort of volunteers. Setting Academic referral center. Patients Thirty-four subjects, consisting of 8 women with acne, 10 women without acne, 8 men with acne, and 8 men without acne. Interventions Single visit for blood sampling and 2 biopsies of forehead skin. Main outcome measures Serum levels of androgens were determined and compared with the activity of 5alpha-reductase and 17beta-hydroxysteroid dehydrogenase in sebaceous glands microdissected from skin samples. Results No significant differences in the activity of 5alpha-reductase or 17beta-hydroxysteroid dehydrogenase in sebaceous glands according to the presence of acne were noted in either men or women. The activity of 5alpha-reductase and 17beta-hydroxysteroid dehydrogenase was significantly greater in sebaceous glands from men (n = 16) than women (n = 17). The oxidative activity of 17beta-hydroxysteroid dehydrogenase was 2-fold higher in men than women. Serum levels of dehydroepiandrosterone sulfate, androstenedione, testosterone, and dihydrotestosterone were significantly higher in women with acne than in women without acne. No differences in serum androgen levels were noted in men on the basis of the presence of acne. Conclusions Higher serum androgen levels are associated with the presence of acne in women. A role for locally produced androgens in this process, however, cannot be excluded.

Journal ArticleDOI
TL;DR: Teleconsultation of clinical and dermoscopic images of skin tumors via e-mail provides a similar degree of diagnostic accuracy as face-to-face diagnosis.
Abstract: Background Teledermoscopy uses telecommunication technologies to transfer images of pigmented skin lesions, including clinical and anamnestic data, via e-mail to specialized centers for teleconsultation. Design Sixty-six pigmented skin lesions examined on a face-to-face basis in a skin lesion clinic in L'Aquila, Italy, were sent via e-mail on a standard-resolution color monitor for consultation at a university dermatology department in Graz, Austria. Intervention Digital photographs of the clinical and dermoscopic images of all pigmented tumors were taken with a stereomicroscope connected to a high-resolution video camera in Truevision advanced graphic array (Targa) format file and converted successively into a Joint Photographic Expert Group (JPEG) format file. All lesions were excised surgically and diagnosed histopathologically. Main Outcome Measure Diagnostic concordance between face-to-face diagnosis and telediagnosis. Results The diagnostic concordance was 60 (91%) of 66 cases. The number of correct telediagnoses was lower, but the difference was not statistically significant (Wilcoxon test, P = .10). The accuracy of the telediagnoses was not related to the quality of the images, but highly depended on the level of diagnostic difficulty of a given pigmented skin tumor (Spearman correlation, P = .01). Conclusion Teleconsultation of clinical and dermoscopic images of skin tumors via e-mail provides a similar degree of diagnostic accuracy as face-to-face diagnosis.

Journal ArticleDOI
TL;DR: Narrowband UV-B therapy is an effective short-term treatment modality for clearing SPP and early-stage MF, however, the treatment response did not sustain long-term remission.
Abstract: Background Broadband UV-B phototherapy has been used for many years in the treatment of small plaque parapsoriasis (SPP) and early-stage mycosis fungoides (MF). Our purpose was to investigate the effect on these diseases of narrowband (311-nm) UV-B therapy, which was recently established for the treatment of psoriasis and found to be more effective than broadband UV-B therapy. Observations Twenty patients (5 women, 15 men; age range, 39-85 years) with histologically confirmed SPP or early-stage MF were enrolled. Six patients had early-stage MF (patch stage), and 14 had SPP. Treatment with 311-nm UV-B was given 3 to 4 times a week for 5 to 10 weeks. In 19 patients, lesions completely cleared after a mean number of 20 treatments (range, 14-29 treatments) and a mean cumulative UV-B dose of 16.3 J/cm 2 (range, 7.4-36.4 J/cm 2 ) within a mean time of 6 weeks (range, 5-10 weeks). Biopsy specimens taken immediately after the end of phototherapy showed only sparse inflammatory infiltrates but no signs of SPP or MF. Relapses at cutaneous sites occurred in all patients within a mean time of 6 months (range, 2-15 months). Conclusions Narrowband UV-B therapy is an effective short-term treatment modality for clearing SPP and early-stage MF. However, the treatment response did not sustain long-term remission. Further studies are necessary to examine how the clinical response to and follow-up after narrowband UV-B therapy compares with that of established phototherapy modalities in these diseases.

Journal ArticleDOI
TL;DR: It is demonstrated that psoriasis is an immunological disease in which pathogenic T cells rather than epidermal keratinocytes are of primary importance, and a novel hypothesis in which the pathogenicT cells are postulated to express an assortment of KIRs and KARs is proposed.
Abstract: Background The genetic and immunological basis for psoriasis is unknown. Through the use of a severe combined immunodeficient mouse–human skin model, T cells have been shown to induce psoriasis, which points to a pathological role for such immunocompetent cells. During ongoing studies using this model, a previously overlooked subset of immunocytes expressing receptors typically present on natural killer (NK) cells was discovered, which may shed new light on the genetic susceptibility for psoriasis. Observations Immunocytes from a psoriatic patient were injected into engrafted allogeneic normal human skin and produced a psoriatic plaque. Moreover, the disturbed epidermal environment spread to induce a greater than 20-fold increase in thickness of adjacent mouse epidermis with prominent elongation of rete pegs. Thus, rather than observing the predicted graft-vs-host reaction in the allogeneic human or xenogeneic mouse skin, injection of psoriatic immunocytes triggered psoriasis. To explore a potential mechanism to explain the lack of cytopathic effect by psoriatic T cells, immunostaining to detect inhibitory receptors normally present on NK cells was performed. These receptors include surface molecules that can inhibit NK cell proliferation, cytokine release, and/or cytotoxicity (ie, killer cell inhibitory receptors [KIRs]), as well as those that may activate NK cell cytotoxicity (ie, killer cell activating receptors [KARs]). The blood-derived psoriatic immunocytes in the skin graft expressed CD94, CD158a, CD158b, NKB1, and CD161. Furthermore, both hyperplastic human and murine keratinocytes express the major histocompatibility complex (MHC) class I–like CD1d protein, which has been shown to be a specific ligand of T cells expressing CD161 and other NK cell–associated receptors. Conclusions Since several KIRs and KARs are known to recognize various class I MHC alleles, and because psoriasis inheritance and susceptibility has been linked to various class I MHC molecules, we propose a novel hypothesis in which the pathogenic T cells are postulated to express an assortment of KIRs and KARs. These interactions may produce direct activation without any exogenous antigen, and at the same time block the cytotoxic effector function of these activated immunocytes in this allogeneic and xenogeneic experimental setting. In addition, human T cells expressing CD161 may be capable of interacting with human and murine CD1d expressed by the epidermal keratinocytes. These unexpected findings demonstrate that psoriasis is an immunological disease in which pathogenic T cells rather than epidermal keratinocytes are of primary importance. Functional studies will determine if targeting this previously overlooked population of immunocytes with blocking reagents will generate a novel immunotherapeutic strategic pathway for psoriasis, and whether disease susceptibility and/or incidence patterns can be explained by genetic abnormalities involving these ligand-receptor interactions.

Journal ArticleDOI
TL;DR: In this paper, the authors developed and introduced evidence-based guidelines for the treatment of vitiligo in children and in adults, which were synthesized and disseminated among potential users.
Abstract: Objective To develop and introduce evidence-based guidelines for the treatment of vitiligo in children and in adults. Patients and Setting Patients, residents, and dermatologists from the Department of Dermatology, Academic Medical Center, University of Amsterdam, and the Netherlands Institute for Pigmentary Disorders in Amsterdam. Design Scientific evidence obtained from 3 systematic reviews of the literature was combined with the results of 2 questionnaires and interviews of potential users of the guidelines, 3 internal expert meetings, and 1 local expert meeting, during which preliminary guidelines were presented and commented on. A final version of the guidelines was synthesized and disseminated among potential users. Six months after the introduction of these guidelines, their use was evaluated. Results Before the development of the guidelines, there was no uniformity in treatment selection, and there was a variability in estimates of treatment outcome. The meta-analysis showed class 3 corticosteroids and narrowband UV-B to be the most effective and safest therapies for localized and for generalized vitiligo, respectively. From another systematic review, it could be concluded that patients with segmental, stable, or lip-tip vitiligo could be successfully treated with most autologous transplantation methods. For vitiligo universalis, results of the systematic review showed that depigmentation using monobenzone or a Q-switched ruby laser was equally effective. The final version of the guidelines consisted of a treatment scheme together with detailed treatment protocols. Implementation of the guidelines was evaluated in 5 physicians. After the introduction of these guidelines, they were followed in most adult cases with vitiligo (71% of patients with localized vitiligo, 82% with generalized vitiligo, 100% with stable or segmental vitiligo, and 80% with universal vitiligo). In children with vitiligo, the physicians adhered to the guidelines for 52% of the cases. Conclusions Guidelines for the treatment of vitiligo can be successfully developed and disseminated for daily clinical practice. The results of the implementation of these guidelines should be confirmed in other centers involving more clinicians.

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TL;DR: It is demonstrated that in many patients with plaque-type psoriasis, narrowband UV-B is comparably as effective as PUVA and, given the lack of photosensitizer-related adverse reactions and the possibly lower long-term cancer risk, can be considered as first-line treatment.
Abstract: Objective To compare the therapeutic efficacy of narrowband (TL-01) UV-B phototherapy vs photochemotherapy (psoralen–UV-A [PUVA]) in patients with chronic plaque-type psoriasis. Design Open, nonrandomized, intraindividually controlled paired comparison study. Setting Phototherapeutic unit in a university hospital. Patients Twenty-five patients with chronic plaque-type psoriasis. Interventions Paired irradiations with threshold erythemogenic doses of narrowband UV-B and PUVA were given to the patients' dorsal aspect including the arms and legs. Treatment was performed 3 times weekly until complete or almost complete clearing with one or both regimens or over a maximum period of 18 exposures. Main Outcome Measures Assessment of the Psoriasis Area and Severity Index (PASI) in each half of the patient's dorsal aspect before and after treatment with the 2 regimens. Results The median pretreatment PASI score of 16 (range, 6.2-23.4) was reduced by 84% to 2.5 (range, 0-12.6) by the narrowband UV-B treatment and by 89% to 1.8 (range, 0-8.2) by the PUVA treatment. Statistical analysis of these data showed a tendency for PUVA being superior to narrowband UV-B although the difference remained below the level of significance ( P =.17). However, a clear effect of the pretreatment PASI score on the therapeutic outcome was found. Patients with higher baseline PASI scores responded significantly better to PUVA than to narrowband UV-B ( P =.03). Conclusions Our data demonstrate that in many patients with plaque-type psoriasis, narrowband UV-B is comparably as effective as PUVA and, given the lack of photosensitizer-related adverse reactions and the possibly lower long-term cancer risk, can be considered as first-line treatment. Treatment with PUVA, on the other hand, remains the mainstay for patients with high PASI scores who do not respond or whose psoriasis cannot be controlled adequately by narrowband UV-B.

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TL;DR: A striking increase in incidence of thin melanomas contrasts with a stable incidence of thick melanomas is found, and the evolution of tumor thickness is studied.
Abstract: Objective The aim of this study was to analyze the temporal evolution of melanoma incidence in the department of the Bas-Rhin, France, and to study the evolution of tumor thickness. Design Retrospective study including all histologically proven melanomas recorded at the cancer registry of the department of the Bas-Rhin between January 1980 and December 1992 and at the Cutaneous Histopathology Department of the University Hospitals, Strasbourg, between January 1980 and December 1997. Setting Population-based cancer registry and academic cutaneous histopathology department. Patients A total of 1254 patients with histologically proven melanomas. Intervention None. Main Outcome Measures Temporal evolution of melanoma incidence and tumor thickness. Results The mean (SD) and median tumor thicknesses were 1.48 (1.59) mm and 0.87 mm, respectively, and they decreased during the study period. The increase in the number of melanomas was mainly related to an increase of superficial spreading melanomas in both sexes. The number of intermediate melanomas (1-2 mm) in both sexes and the number of melanomas with a Breslow index between 2 and 4 mm in women increased only slightly. The number of melanomas with a Breslow index greater than 2 mm in men and greater than 4 mm in women remained stable during the reference period. Conclusion A striking increase in incidence of thin melanomas contrasts with a stable incidence of thick melanomas.

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TL;DR: Hair density in African Americans is significantly lower than that in whites, which must be taken into consideration when evaluating a biopsy specimen from an African American patient.
Abstract: Background The meager data on normal hair density in humans have been gathered from a predominantly white population. Examination of scalp biopsy specimens from African Americans suggests that hair density in this group may be lower than in whites. This study was performed to quantify any differences between white and African American patients. Design A retrospective case series of subjects who had undergone a biopsy of clinically healthy scalp skin. The 4-mm punch biopsy specimens were sectioned, and all follicles contained within the specimens were counted at various levels (suprabulbar, isthmus, and infundibulum) to arrive at the number and type of hairs present. Setting Outpatient clinic in a tertiary care medical center. Patients A consecutive sample of 22 African American and 12 white patients with clinically healthy scalp skin specimens that were studied and compared with previously reported data. Main Outcome Measures Patients' age and total number of follicles, terminal follicles, vellus follicles, terminal anagen hairs, and terminal telogen hairs. Results Total hair density (number of follicles per 4-mm punch biopsy specimen) and total number of terminal follicles and terminal anagen hairs were significantly lower in African Americans ( P Conclusions Hair density in African Americans is significantly lower than that in whites, which must be taken into consideration when evaluating a biopsy specimen from an African American patient. Data previously collected from white patients may not provide adequate guidance when evaluating scalp biopsy specimens from African Americans and could lead to an incorrect diagnosis.

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TL;DR: Treatment of pemphigus vulgaris with mycophenolate mofetil is a safe and effective treatment in patients who failed initial treatment with azathioprine and prednisone.
Abstract: Background Pemphigus vulgaris is a potentially life-threatening autoimmune disease. Although combination therapies with prednisone and azathioprine are usually effective in controlling the disease, some patients either do not respond to this treatment or show early relapses. Objective To find out whether mycophenolate mofetil would be an effective drug in controlling pemphigus vulgaris in patients who failed initial treatment with azathioprine and prednisone. Results Twelve patients who were initially diagnosed as having pemphigus vulgaris and had relapsed while undergoing treatment with azathioprine (1.5-2 mg/kg of body weight) and prednisolone (2 mg/kg of body weight) subsequently received combination therapy with mycophenolate mofetil (2 × 1 g/d) and prednisolone (2 mg/kg of body weight per day). Eleven of the 12 patients responded to therapy and showed no relapse of their disease even after tapering of the steroid dose. One patient did not respond. Toxic effects were low with only mild gastrointestinal symptoms in 5 patients and mild lymphopenia (World Health Organization grade I) in 9 patients. During the 9- to 12-month follow-up, none of the 11 patients showed reappearance of pemphigus lesions. Conclusion Treatment of pemphigus vulgaris with mycophenolate is a safe and effective treatment.

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TL;DR: Cigarette smoking and, in men, alcohol consumption are associated with psoriasis and there is a strong association between smoking and pustular lesions.
Abstract: Objective To analyze the association of psoriasis with smoking habits and alcohol consumption before first diagnosis by a dermatologist. Design A multicenter case-control study. Interviews were conducted by trained medical investigators using a structured questionnaire. Setting Outpatient services of 10 general and 10 teaching hospitals in northern and southern Italy. Subjects Patients with a first diagnosis of psoriasis made by a dermatologist and a history of skin manifestations of no longer than 2 years after the reported disease onset. Patients with new diagnoses of skin diseases other than psoriasis were selected as control subjects. A total of 404 case patients (median age, 35 years) and 616 controls (median age, 36 years) were included in the analysis. Results The risk for psoriasis was higher in ex-smokers and in current smokers than in patients who never smoked. The relation with smoking was stronger and more consistent among women than men. In men, a significant association was restricted to the ex-smoker status. Smoking was strongly associated with pustular lesions (29 patients) with an adjusted odds ratio of 10.5 (95% confidence interval, 3.3-33.5) for those smoking more than 15 cigarettes per day. No significant overall association with alcohol consumption was documented after controlling for smoking habits. However, the risk seemed to vary according to sex, with a moderate association being documented in men. Conclusions Cigarette smoking and, in men, alcohol consumption are associated with psoriasis. There is a strong association between smoking and pustular lesions.

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TL;DR: In this article, the authors used a digital dermoscopy analyzer with a series of "borderline" pigmentary skin lesions (i.e., clinically atypical nevi and early melanoma) to find correlation between the studied variables and to determine their discriminating power with respect to histological diagnosis.
Abstract: Objectives To use a digital dermoscopy analyzer with a series of "borderline" pigmentary skin lesions (ie, clinically atypical nevi and early melanoma) to find correlation between the studied variables and to determine their discriminating power with respect to histological diagnosis. Design A total of 147 pigmentary skin lesions were histologically examined by 3 experienced dermatopathologists and identified as nevi (n = 90) and melanomas (n = 57). The system evaluated 36 variables to be studied as possible discriminant variables, grouped into 4 categories: geometries, colors, textures, and islands of color. Setting University medical department. Patients A sample of patients with excised pigmentary skin lesions (nevi and melanomas). Main Outcome Measures Sensitivity, specificity, and accuracy of the model for evaluating "borderline" pigmentary skin lesions. Results After multivariate stepwise discriminant analysis, only 13 variables were selected to compute the canonical discriminant function. Conclusion The present method made it possible to determine which objective variables are important for distinguishing atypical benign pigmentary skin lesions and early melanoma.

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TL;DR: Clinical results demonstrate that the improvements in scar sections treated with silicone gel sheeting and pulsed-dye laser were no different than in control sections.
Abstract: Objective To determine the efficacy of the 585-nm flashlamp-pumped pulsed-dye laser and silicone gel sheeting in the treatment of hypertrophic scars in lighter- and darker-skinned patients. Design Prospective, single-blind, randomized, internally controlled, comparison investigation. Setting Large academic dermatology department. Patients Twenty patients with hypertrophic scars (19 completed the laser treatments and 18 completed the silicone gel sheeting treatments). Main Outcome Measures Clinical measurements included hypertrophic scar blood flow, elasticity, and volume. Patients' subjective complaints of pruritus, pain, and burning were also monitored. Histological assessment of fibrosis, number of telangiectasias, and number of mast cells was performed. Statistically significant improvements in clinical measurements and patients' subjective complaints determined treatment success. Results Mean scar duration was 32 months (range, 4 months to 20 years). There was an overall reduction in blood flow, volume, and pruritus over time ( P =.001, .02, and .005, respectively). However, no differences were detected among treatment and control groups. There was no reduction in pain or burning (0-40 weeks), elasticity (8-40 weeks), or fibrosis (0-40 weeks, n=5 biopsies) in the treated or control sections of the scars. Unlike in a previous study, the number of mast cells in the scars was similar to the number of mast cells in healthy skin. Conclusion Clinical results demonstrate that the improvements in scar sections treated with silicone gel sheeting and pulsed-dye laser were no different than in control sections.