Showing papers in "Journal of The American Academy of Dermatology in 1999"

Psoriasis causes as much disability as other major medical diseases.

Abstract: Background: Little is known about how the health-related quality of life (HRQL) associated with psoriasis compares with that of other patient populations. Objective: We describe HRQL associated with psoriasis and compare it with HRQL of patients with other major chronic health conditions. A second aim is to identify which specific aspects of psoriasis contribute most to HRQL. Methods: A total of 317 patients completed a non-disease-specific measure of HRQL. Responses were compared with those of patients with 10 other chronic health conditions. HRQL was regressed on ratings of 18 aspects of psoriasis. Results: Patients with psoriasis reported reduction in physical functioning and mental functioning comparable to that seen in cancer, arthritis, hypertension, heart disease, diabetes, and depression. Six aspects of psoriasis predicted physical functioning, and 5 different disease aspects predicted mental functioning. Conclusion: The impact of psoriasis on HRQL is similar to that of other major medical diseases. Different aspects of psoriasis are related to the different dimensions of HRQL supporting the need for multidimensional treatment models. (J Am Acad Dermatol 1999;41:401-7.)

Skin cancer in kidney and heart transplant recipients and different long-term immunosuppressive therapy regimens.

Abstract: Background: Nonmelanoma skin cancer occurs frequently in organ transplant recipients, but the relative importance of different immunosuppressive therapy regimens is unclear. Objective: We studied the risk of skin cancer in the complete, single-center Norwegian cohort of kidney and heart transplant recipients (n = 2561). Methods: We determined cancer risk estimation by means of standardized incidence ratios and multivariate Cox regression. Results: Transplant recipients had an increased risk of cutaneous squamous cell carcinoma (SCC) (65-fold), malignant melanoma (3-fold), and Kaposi's sarcoma (84-fold), and of lip SCC (20-fold), compared with the general population. After adjustment for age, kidney transplant recipients receiving cyclosporine, azathioprine, and prednisolone had a significantly (2.8 times) higher risk of cutaneous SCC relative to those receiving azathioprine and prednisolone. After adjustment for age and type of immunosuppressive regimen, heart transplant recipients had a significantly (2.9 times) higher risk than kidney transplant recipients. Conclusion: The risk of cutaneous SCC, malignant melanoma, Kaposi's sarcoma, and lip SCC is increased in kidney and heart transplant recipients. The risk of posttransplant cutaneous SCC is related to the degree of immunosuppression caused by long-term immunosuppressive therapy. (J Am Acad Dermatol 1999;40:177-86.)

Prevalence of facial acne in adults.

Abstract: Background: Acne is usually considered a disorder of adolescence, and a number of studies have examined the prevalence of this condition in the adolescent population. There are, however, relatively few data on the prevalence of acne in the adult population. Objective: A community-based study was carried out to investigate the current prevalence of facial acne in adults. Methods: Seven hundred forty-nine persons older than 25 years were examined for facial acne by means of the Leeds acne-grading technique. Results: A degree of facial acne was recorded in 231 women and 130 men, giving an overall prevalence of 54% (95% confidence interval [CI], 49-58) in women and 40% (95% CI, 35–45) in men ( P 0.75) was recorded in 3% (95% CI, 1.2–4.8) of men and in 12% (95% CI, 9-15) of women ( P P Conclusion: This study shows a prevalence of clinical facial acne in women of 12%, which is likely to persist into middle age.

The clinical phenotype of pemphigus is defined by the anti-desmoglein autoantibody profile

Abstract: Background: Some patients with pemphigus vulgaris (PV) have mucous membrane erosions with minimal skin involvement (mucosal dominant type), and others show extensive skin blisters and erosions in addition to mucous membrane involvement (mucocutaneous type). Patients with pemphigus foliaceus (PF) show only skin involvement. Objective: The purpose of this study is to determine whether there is a difference in autoantibody profile among mucosal dominant PV, mucocutaneous PV, and PF. Methods: Antibody titer against desmoglein 1 (Dsg1) and desmoglein 3 (Dsg3) were measured with enzyme-linked immunosorbent assay using recombinant Dsg1 and Dsg3. Sera were obtained during clinically active disease from 24 patients with mucosal dominant PV, 20 with mucocutaneous PV, and 23 with PF. Results: All sera samples from patients with mucosal dominant PV sera were negative against Dsg1 but positive against Dsg3. All sera samples from those with mucocutaneous PV were positive against both Dsg1 and Dsg3. All sera samples from patients with PF were positive against Dsg1, but negative against Dsg3. Conclusion: Each subtype has its own anti-Dsg autoantibody profile, indicating that the clinical phenotype of pemphigus is defined by the autoantibody profile. (J Am Acad Dermatol 1999;40:167-70.)

Therapeutic response of basal cell carcinoma to the immune response modifier imiquimod 5% cream

Abstract: Background: Basal cell carcinoma (BCC) responds to interferon therapy. Imiquimod is a cytokine and interferon inducer. Objective: This randomized, double-blind pilot trial evaluated the safety and efficacy of imiquimod 5% cream versus vehicle in the treatment of BCC. Methods: In this population of 35 patients with BCC, 24 received imiquimod 5% cream and 11 received vehicle cream in 1 of 5 dosing regimens for up to 16 weeks. Six weeks after treatment, an excisional biopsy of the target site was performed. Results: BCC cleared (on the basis of histologic examination) in all 15 patients (100%) dosed twice daily, once daily, and 3 times weekly; in 3 of 5 (60%) patients dosed twice weekly; 2 of 4 (50%) dosed once weekly; and in 1 of 11 (9%) treated with vehicle. Adverse events were predominantly local reactions at the target tumor site, with the incidence and severity of local skin reactions declining in groups dosed less frequently. Conclusion: Imiquimod 5% cream shows clinical efficacy in the treatment of BCC. (J Am Acad Dermatol 1999;41:1002-7.)

Mucocutaneous reactions to chemotherapy

Abstract: Chemotherapeutic agents are a widely used treatment modality. Side effects range from common to unusual and may be confused with other cutaneous sequelae of oncologic treatment. The goal of this communication is to elaborate on previous descriptions of the cutaneous manifestations of chemotherapeutic treatment and to discuss more recent findings. (J Am Acad Dermatol 1999;40:367-98.) Learning objective: At the conclusion of this learning activity, participants should be able to generate a differential diagnosis of possible etiologies for varying patterns of cutaneous involvement in patients receiving chemotherapy and identify the various cutaneous side effects of chemotherapeutic treatment. In addition, they should be able to distinguish life-threatening side effects that require immediate management from more benign manifestations of chemotherapeutic treatment.

Update on the incidence and mortality from melanoma in the United States.

Abstract: Background: Increases in the incidence of malignant melanoma have been among the largest of all cancers in the United States. Objective: We report updated trends in melanoma rates among the US white population. Methods: Incidence and mortality rates were calculated for 1973 to 1994. Trends were examined with stratification by state, age, and sex, and by anatomic site, stage, and melanoma thickness at diagnosis. Results: Melanoma incidence and mortality rates increased dramatically from 1973 to 1994, rising 120.5% and 38.9%, respectively. In recent years, however, rates for most age-sex groups appeared to stabilize or even decline. Male patients continued to have higher incidence and mortality rates than female patients, but for both male and female patients the largest increases by site were for the trunk. A large proportion of melanomas were detected in the local stage and with a thickness less than 0.75 mm. Conclusion: Prevention of sun exposure is recommended to reverse the high incidence rates of melanoma.(J Am Acad Dermatol 1999;40:35-42.)

Laser-assisted hair removal: Side effects of Q-switched Nd:YAG, long-pulsed ruby, and alexandrite lasers

Abstract: Background: Laser-assisted hair removal has become popularized using wavelengths in both the red and infrared regions of the electromagnetic spectrum. These photoepilation devices target follicular melanin or an exogenous pigment placed within the follicle resulting in thermal damage to the hair follicle and shaft. However, melanocytes and keratinocytes located within the superficial layers of the skin also absorb red and infrared laser radiation. This may result in unwanted epidermal injury during the hair removal process. Objective: The purpose of this study was to examine a large patient population to determine the frequency of side effects using 3 different hair removal laser systems with various wavelengths, pulse durations, and treatment protocols. Methods: A retrospective chart review and digital photographic analysis of the side effects resulting from 900 consecutive laser-assisted hair removal treatments delivered over a 24-month study period, by means of either a Q-switched Nd:YAG laser with pretreatment wax-epilation and topical carbon solution, a long-pulse ruby laser with a contact cooling tip, or a long-pulse alexandrite laser are reported. Results: Treatment pain, erythema, edema, hypopigmentation and hyperpigmentation, blistering, crusting, erosions, purpura, and folliculitis were observed. The majority of undesirable tissue effects occurred on tanned skin or in Fitzpatrick skin phototypes III and higher. The ruby and alexandrite laser systems resulted in the majority of side effects seen. The effects of seasonal variations, anatomic treatment location, and sun exposure were striking within the ruby and alexandrite laser groups. No infections, scarring, or long-term complications occurred. Conclusion: Laser-assisted hair removal is a safe procedure when patient characteristics such as skin type, anatomic location, and sun-exposed or tanned skin are considered during selection of laser treatment parameters. Lasers emitting wavelengths with high melanin absorption capabilities should be used in a conservative manner when treating patients with dark skin phototypes or suntans. No long-term complications, infections, or scarring occurred in this study population. (J Am Acad Dermatol 1999;41:165-71.)

Prognosis in cutaneous T-cell lymphoma by skin stage: long-term survival in 489 patients.

Abstract: Background: Although a number of studies have documented the long-term survival of patients with cutaneous T-cell lymphoma (CTCL), none have provided data as to the relative survival of all 4 skin stages. Objective: We document survival of CTCL patients by T stage relative to that of an age-, sex-, and race-matched population. Methods: The survival of 489 patients with CTCL registered since 1957 was compared with that of a California control population. Results: For stage T1 ( P = .002). At 10 years the relative survivals were: T2 (10% or more skin involved) 67.4%, T3 (tumor stage) 39.2%, T4 (generalized erythroderma) 41.0%. T2 plaque stage patients had an inferior relative survival ( P = .001), whereas T2 patch stage patients did not. Lymphadenopathy had an unfavorable impact on prognosis. There was a strong trend toward diagnosing CTCL at an earlier stage in more recent years. We estimate that from 15% to 20% of our patients died of CTCL or related complications. Conclusion: The relative survival of CTCL patients worsens with increasing skin stage, although stages T3 and T4 had closely similar survivals. The great majority of patients with CTCL do not die of their disease. (J Am Acad Dermatol 1999;40:418-25.)

Patients with psoriasis and their compliance with medication

Abstract: Background: Poor compliance with treatment advice in chronic conditions, such as psoriasis, represents a major challenge to health care professionals. Previous research suggests that the rate of noncompliance in chronic conditions may be as high as 40%. Objective: This study was designed to examine self-reported compliance in patients with psoriasis. Methods: We undertook an anonymous postal survey sent to consecutive patients with psoriasis attending a tertiary psoriasis specialty clinic. Results: Thirty-nine percent of participants reported that they did not comply with the treatment regimen recommended. The noncompliant group had a higher self-rated severity of psoriasis ( t =−2.16, P =.03), were younger ( t =3.28, P =.001), and had a younger age at onset ( t =2.35, P =.02) than those who were compliant. The noncompliant group reported that psoriasis had a greater impact on daily life ( t =−2.23, P =.028), but general well-being was not significantly different from those who complied ( t =.47, P =not significant). Conclusion: Patients who reported intentional noncompliance with treatment advice were more likely to believe that both psoriasis and its treatment interfered with their quality of life but not overall well-being. The impact of treatment on daily life highlights the importance of joint decision making in planning treatment.

Chronic idiopathic urticaria: Comparison of the clinical features of patients with and without anti-FcϵRI or anti-IgE autoantibodies

Abstract: Background: Previous studies defining the clinical features of patients with chronic idiopathic urticaria (CIU) were performed before the identification of functional autoantibodies against FcϵRI and/or IgE, now known to be present in approximately 30% of patients with CIU. Objective: Our purpose was to determine whether there are differences between patients with and those without autoantibodies in the clinical features or severity of CIU. Methods: The clinical features of 107 patients with CIU were evaluated prospectively. Patients were identified as having functional autoantibodies on the basis of the serum-evoked histamine release in vitro from the basophils of 2 healthy donors. Results: Patients with autoantibodies (31%) had more wheals ( P = .005), a wider distribution of wheals ( P = .009), higher itch scores for the most severe episodes of itching ( P = .002), more systemic symptoms ( P = .03), and lower serum IgE levels ( P Conclusion: The presence of autoantibodies indicates a subset of patients with more severe CIU. (J Am Acad Dermatol 1999;40:443-50.)

Skin cancer in Australian heart transplant recipients

Abstract: Background: Cutaneous malignancy is a major cause of morbidity in organ transplant recipients. Objective: Our purpose was to report on skin cancer in Australian heart transplant recipients with analysis of HLA factors. Methods: We reviewed histologically proven skin cancers in the first 455 patients undergoing organ transplantation in Sydney, Australia. Results: The cumulative incidence of skin cancer was 31% at 5 years and 43% at 10 years with a squamous cell carcinoma/basal cell carcinoma ratio of 3:1. Caucasian origin, increasing age at transplantation, and duration of follow-up were significantly associated with skin cancer. Skin cancer accounted for 27% of 41 deaths occurring after the fourth year. Recipient HLA-DR homozygosity was associated with skin cancer overall, whereas HLA-DR7 was a protective factor in skin cancer overall, squamous cell carcinoma, and Bowen's disease. HLA-A1 and HLA-A11 were significant protective factors in Bowen's disease. Conclusion: Skin cancer is a major cause of morbidity and long-term mortality in heart transplant patients. (J Am Acad Dermatol 1999;40:27-34.)

The new pemphigus variants

Abstract: Pemphigus describes a group of autoimmune diseases characterized by blisters and erosions of the skin and mucous membranes, acantholysis by histology, and autoantibodies directed against epidermal cell surface components. Since the early 1970s, the following new clinical variants of pemphigus have been reported: pemphigus herpetiformis, IgA pemphigus, and paraneoplastic pemphigus. In recent years, significant data have been obtained from laboratory investigation on these rare and atypical variants, especially regarding their specific target antigens. We review these variants, their clinical presentations, histologic findings, immunopathology, target antigens, theories of pathogenesis, treatment modalities, and clinical courses.

Alopecia areata investigational assessment guidelines

Abstract: From Duke University Medical Center, Durhama; University of Minnesota, Minneapolisb; Pontefract General Infirmaryc; University of California at San Franciscod; Northwest Cutaneous Research Specialists, Portlande; The University of British Columbia, Vancouverf; and Johnson & Johnson, Skin Biology Research Center, Skillman.g Reprint requests: Elise A. Olsen, MD, Professor of Medicine, Duke University Medical Center, Box 3294, Durham, NC 27710. J Am Acad Dermatol 1999;40:242-6. *Developed from the Alopecia Areata Consensus meeting sponsored by the National Alopecia Areata Foundation at the First Tricontinental Meeting of the Hair Research Societies, Brussels, Belgium, Oct 8, 1995. Participants are listed at the end of the guidelines. Copyright © 1999 by the American Academy of Dermatology, Inc. 0190-9622/99/$8.00 + 0 16/1/95940 I. PURPOSE To establish criteria for selecting and assessing subjects for both clinical and laboratory studies of alopecia areata, thereby facilitating collaboration, comparison of data, and the sharing of patient-derived tissue II. DEFINITION OF ALOPECIA AREATA Alopecia areata is a dermatologic disease characterized in its limited form by circumscribed round or oval patches of alopecia with well-demarcated borders between normal and affected scalp. There is no scale or induration of the scalp and no loss of follicular markings. Disease extent may progress from this limited form to complete loss of hair on the scalp and/or body. III. INCLUSION CRITERIA These guidelines apply only to terminal hair loss or growth on the scalp. These guidelines focus on the major forms of alopecia areata (patchy alopecia areata, alopecia totalis, and alopecia universalis) and their expression on the scalp. The terms alopecia totalis and alopecia universalis imply 100% scalp hair loss. Areas of hair loss other than on the scalp may be assessed and documented in the data collected on each patient. (See Section IV. B) IV. CRITERIA FOR MEASURING EXTENT OF INVOLVEMENT Those data items in boldface type should be filled out in toto. Those data items not in bold are optional and can be filled out as desired by the investigator. A. The proportion of scalp involvement is determined by dividing the scalp into 4 quadrants and estimating the percentage of the scalp surface that all the alopecic areas would occupy if placed together. The following groups will be used: S: Scalp hair loss _____S0 = No hair loss _____S4 = 76%-99% hair loss _____S1 = ≤ 25% hair loss _____a = 76%-95% hair loss _____S2 = 26%-50% hair loss _____b = 96%-99% hair loss _____S3 = 51%-75% hair loss _____S5 = 100% hair loss B. Other areas of alopecia or involvement by alopecia areata may be noted: B: Body hair loss _____B0 = No body hair loss _____B2 = 100% body (excluding scalp) hair loss _____B1 = Some body hair loss N: Nail involvement _____N0 = No nail involvement _____N1 = Some nail involvement _____a. Twenty-nail dystrophy/trachyonychia (must be all 20 nails) SPECIAL ARTICLE

Behçet's disease and complex aphthosis.

Abstract: Behcet's disease is a complex multisystem disease diagnosed by means of clinical criteria. Clinical features include oral and genital aphthae, pustular vasculitic cutaneous lesions, and ocular, gastrointestinal, and vascular manifestations. We believe that complex aphthosis, characterized by oral or oral and genital ulcers, may be a forme fruste of Behcet's disease. Although the pathogenesis of both Behcet's disease and complex aphthosis remain unknown, immune factors, infectious agents, and effector mechanisms are implicated. Treatment is based on the severity of systemic involvement and includes topical therapies as well as colchicine, dapsone, thalidomide, and immunosuppressive agents.

Acitretin in psoriasis: An overview of adverse effects

Abstract: Oral retinoids are among the drugs of choice for pustular and erythrodermic psoriasis. In addition, retinoids are effective in combination with other topical and systemic agents for the treatment of plaque-type psoriasis. Acitretin, the active retinoid metabolite, has replaced etretinate in retinoid therapy of psoriasis because of its more favorable pharmacokinetic profile, including a significantly shorter half-life. Retinoids, including acitretin, are potent teratogens, leading to strict requirements for pregnancy prevention during and after their use. Other retinoid side effects are generally preventable or manageable through proper patient selection, dose adjustments, and routine monitoring. Mucocutaneous side effects such as cheilitis and hair loss are the most common dose-dependent side effects, requiring dose reduction in some patients. Less common effects such as hepatotoxicity, serum lipid alterations, pancreatitis, and possible skeletal effects are also discussed.

Finasteride in the treatment of men with frontal male pattern hair loss.

Abstract: Background: Finasteride, a specific inhibitor of type II 5α-reductase, decreases serum and scalp dihydrotestosterone and has been shown to be effective in men with vertex male pattern hair loss. Objective: This study evaluated the efficacy of finasteride 1 mg/day in men with frontal (anterior/mid) scalp hair thinning. Methods: This was a 1-year, double-blind, placebo-controlled study followed by a 1-year open extension. Efficacy was assessed by hair counts (1 cm 2 circular area), patient and investigator assessments, and global photographic review. Results: There was a significant increase in hair count in the frontal scalp of finasteride-treated patients ( P Conclusion: In men with hair loss in the anterior/mid area of the scalp, finasteride 1 mg/day slowed hair loss and increased hair growth. (J Am Acad Dermatol 1999;40:930-7.)

Loss of heterozygosity in human skin

Abstract: Loss of heterozygosity (LOH) is a genetic mechanism by which a heterozygous somatic cell becomes either homozygous or hemizygous because the corresponding wild-type allele is lost. LOH has today been recognized as a major cause of malignant growth. This article gives a comprehensive review of skin disorders in which an origin from LOH has been either documented at the molecular level or postulated on the basis of clinical evidence. LOH has been shown to cause basal cell carcinoma, squamous cell carcinoma, and malignant melanoma, but this mechanism can likewise be taken as an important model to explain the origin of many other skin diseases such as benign hamartomas; type 2 segmental manifestation of autosomal dominant skin disorders; a pronounced segmental manifestation of acquired skin disorders with a polygenic background, superimposed on symmetric lesions of the usual type; paired mutant patches in the form of either allelic or nonallelic twin spotting; and the exceptional familial occurrence of some nevi, reflecting paradominant transmission. (J Am Acad Dermatol 1999;41:143-61.) Learning objective: At the completion of this learning activity, readers should be familiar with the mechanism of LOH and its general significance for the biology of plants, animals, and humans. Participants should understand that this mechanism plays a crucial role not only in cutaneous malignant growth but also in the development of benign skin disorders, and they should be able to examine such diseases with a prepared mind to gain a better understanding of their origin.

A randomized paired comparison of photodynamic therapy and topical 5-fluorouracil in the treatment of actinic keratoses.

Abstract: Background: Photodynamic therapy (PDT) has not been compared with topical 5-fluorouracil (5-FU) in the treatment of epidermal dysplasia. Objective: The purpose of this study was to assess the efficacy and tolerability of these two treatment modalities in 17 patients with actinic keratoses on the backs of the hands. Methods: Each patient's right and left hands were randomized to receive either a 3-week course of topical 5-FU applied twice per day or PDT using topical 5-aminolevulinic acid (5-ALA) and then, after 4 hours, irradiation with an incoherent light source consisting of a 1200 W metal halogen lamp emitting red light (580 to 740 nm). Each hand randomized for PDT received 150 J/cm 2 . The observed median fluence rate was 86 mW/cm 2 (interquartile range, 53 to 100 mW/cm 2 ). All patients were reviewed at 1, 4, and 24 weeks after starting treatment. Results: Fourteen of 17 patients (82%) completed the study. The mean lesional area treated with topical 5-FU decreased from 1390 mm 2 (standard deviation [SD], 1130) to 297 mm 2 (SD, 209). This represents a mean reduction in lesional area of 70% (confidence interval [CI], 61%-80%). The mean lesional area treated with topical PDT decreased from 1322 mm 2 (SD, 1280) to 291 mm 2 (SD, 274), representing a mean reduction in lesional area of 73% (CI, 61%-84%). The reduction in lesional area elicited by the two treatment methods was similar (CI, –25% to 17%). There was no statistically significant difference between the treatment methods in overall symptom scores for pain and redness. Conclusion: One treatment with PDT using topical 5-ALA appears to be as effective and well tolerated as 3 weeks of twice-daily topical 5-FU, a cheap and widely available alternative. (J Am Acad Dermatol 1999;41:414-8.)

Penile cancer among patients with genital lichen sclerosus

Abstract: Background: Genital lichen sclerosus (LS) has sporadically been reported to be associated with penile squamous cell carcinoma (SCC). Objective: The purpose of this study was to assess the risk of malignant degeneration in a series of male patients affected by genital LS. Methods: All cases of histologically proven epithelial malignancy associated with penile LS recorded in our pathology files over a 10-year period (1987-1997) were reviewed. Assessment for presence of human papillomavirus (HPV) was performed from paraffin-embedded tissues using polymerase chain reaction (PCR). Results: Five of 86 white and uncircumcised men with genital LS (mean age at diagnosis, 53 years; range, 22-83 years) showed malignant or premalignant histopathologic features: 3 had SCC, one had erythroplasia of Queyrat (unifocal SCC in situ), and one verrucous carcinoma. The average lag time from onset of LS was 17 years (range, 10-23 years). Histologically, transition from LS to frank neoplastic foci was evident in all cases of SCC. In these SCC cases, areas of epithelial dysplasia were well evident at the tumor periphery. In the remaining cases, the histologic findings were consistent with erythroplasia of Queyrat and verrucous carcinoma. PCR detected HPV 16 infection in 4 of the 5 cases; one SCC patient was negative for HPV. Conclusion: Malignant changes were associated with 5.8% of the cases of penile LS in our series. Therefore patients with genital LS are at considerable risk of the development of penile SCC, as well as other epithelial and in situ carcinomas, namely verrucous carcinoma and erythroplasia of Queyrat. HPV infection probably plays a major role because 4 of 5 patients were positive for HPV. Histologically, epithelial dysplasia may represent a precancerous stage before the development of neoplasia in atrophic nonproliferative LS lesions, as its presence at the tumor periphery in our SCC biopsy samples seemed to suggest. (J Am Acad Dermatol 1999;41:911-4.)

The effects of finasteride on scalp skin and serum androgen levels in men with androgenetic alopecia.

Abstract: Background: Data suggest that androgenetic alopecia is a process dependent on dihydrotestosterone (DHT) and type 2 5α-reductase. Finasteride is a type 2 5α-reductase inhibitor that has been shown to slow further hair loss and improve hair growth in men with androgenetic alopecia. Objective: We attempted to determine the effect of finasteride on scalp skin and serum androgens. Methods: Men with androgenetic alopecia (N=249) underwent scalp biopsies before and after receiving 0.01, 0.05, 0.2, 1, or 5 mg daily of finasteride or placebo for 42 days. Results: Scalp skin DHT levels declined significantly by 13.0% with placebo and by 14.9%, 61.6%, 56.5%, 64.1%, and 69.4% with 0.01, 0.05, 0.2, 1, and 5 mg doses of finasteride, respectively. Serum DHT levels declinied significantly ( P Conclusion: In this study, doses of finasteride as low as 0.2 mg per day maximally decreased both scalp skin and serum DHT levels. These data support the rationale used to conduct clinical trials in men with male pattern hair loss at doses of finasteride between 0.2 and 5 mg.

Evaluating the relevance of aeroallergen sensitization in atopic eczema with the atopy patch test: A randomized, double-blind multicenter study

Abstract: Background: IgE-mediated sensitization of questionable clinical relevance is routinely demonstrated in patients with atopic eczema (AE) by skin prick test or radioallergosorbent test (RAST). We report the results of a randomized, double-blind multicenter study in patients with AE on the relevance and technical aspects of aeroallergen patch testing (atopy patch test, APT). Methods: Two hundred fifty-three adult patients with AE in remission were tested in 7 study centers on clinically uninvolved, unabraded back skin with 3000 to 10,000 PNU/g of Dermatophagoides pteronyssinus, cat dander, grass, birch, and mugwort pollen allergen extracts in petrolatum. After skin prick and RAST and a detailed history on aeroallergen-induced eczema flares was obtained, reading was done at 48 to 72 hours. Results: Previous eczema flares after contact with specific allergens were reported by 10% (mugwort pollen) to 52% (D pteronyssinus) of patients. The percentage of clear-cut positive APT reactions ranged from 44% with D pteronyssinus to 5% with mugwort. Positive skin prick (36% to 65%) and RAST (49% to 75%) results were more frequent. APT results showed significant concordances with history, skin prick, and RAST for D pteronyssinus, cat dander, and grass pollen ( P D pteronyssinus , cat dander). The APT had a higher specificity (69% to 92% depending on allergen) with regard to clinical relevance of an allergen compared with skin prick test (44% to 53%) and RAST (42% to 64%). Conclusion: Aeroallergens are able to elicit eczematous skin reactions after epidermal application. The relevance of aeroallergens for AE flares may be evaluated by APT. (J Am Acad Dermatol 1999;40:187-93.)

Microfine zinc oxide (Z-Cote) as a photostable UVA/UVB sunblock agent

Abstract: Background: Microfine zinc oxide (Z-Cote) is used as a transparent broad-spectrum sunblock to attenuate UV radiation (UVR), including UVA I (340-400 nm). Objective: Our purpose was to assess the suitability of microfine zinc oxide as a broad-spectrum photoprotective agent by examining those properties generally considered important in sunscreens: attenuation spectrum, sun protection factor (SPF) contribution, photostability, and photoreactivity. Methods: Attenuation spectrum was assessed by means of standard spectrophotometric methods. SPF contribution was evaluated according to Food and Drug Administration standards. Photostability was measured in vitro by assessing SPF before and after various doses of UVR. Photoreactivity was evaluated by subjecting a microfine zinc oxide/organic sunscreen formulation to escalating doses of UVR and determining the percentage of organic sunscreen remaining. Results: Microfine zinc oxide attenuates throughout the UVR spectrum, including UVA I. It is photostable and does not react with organic sunscreens under irradiation. Conclusion: Microfine zinc oxide is an effective and safe sunblock that provides broad-spectrum UV protection, including protection from long-wavelength UVA. (J Am Acad Dermatol 1999;40:85-90.)

Suberythemogenic narrow-band UVB is markedly more effective than conventional UVB in treatment of psoriasis vulgaris

Abstract: Background: Narrow-band UVB (NB-UVB) is a new phototherapy option for psoriasis. Action spectrum studies previously done with different UVB wavelengths suggest that suberythemogenic doses of NB-UVB could be highly effective in treating psoriasis vulgaris. Even so, no comparative studies with suberythemogenic doses of NB versus conventional UVB have been performed previously. Objective: Our purpose was to compare conventional broad-band UVB (BB-UVB) with NB-UVB at suberythemogenic doses for the treatment of psoriasis vulgaris. Methods: Eleven patients were treated using a split-body approach for 6 weeks on a three-times-a-week basis. Outcomes were evaluated by means of Psoriasis Severity Index scores and quantitative histologic measures. Results: We were able to induce clinical clearing in 81.8% of patients after NB-UVB, but in only 9.1% of patients after BB-UVB ( P Conclusion: NB-UVB is superior to UVB-BB in reversing psoriasis at suberythemogenic doses when given three times per week. This schedule was well tolerated by all patients.(J Am Acad Dermatol 1999;40:893-900.)

Microcystic adnexal carcinoma: Collaborative series review and update

Abstract: Background: Microcystic adnexal carcinoma (MAC) is a malignant appendageal tumor first described in 1982. It can be clinically and histologically confused with other malignant and benign cutaneous neoplasms, leading to inadequate initial treatment. This neoplasm is locally aggressive and deeply infiltrating, characterized by high morbidity and frequent recurrence. Mohs micrographic surgery has been used to conserve tissue and improve the likelihood for cure. Objective: We report our experience using Mohs micrographic surgery for the treatment of MAC and compare with earlier reports in the literature. In addition, we review the epidemiology, clinical and histologic characteristics, and optimal treatment of this rare neoplasm. We also describe a 15-year-old white male patient with MAC on the scalp occurring only 7 years after radiation exposure. Methods: The medical records of 11 patients with MAC who were treated by Mohs micrographic surgery were reviewed at both departments, and follow-up data were obtained. Results: In all patients treated with Mohs micrographic surgery, there were no recurrences after a mean follow-up of 5 years. Conclusion: Mohs technique enables the detection of clinically unrecognizable tumor spread and perineural invasion often encountered with MAC. Aggressive initial treatment by microscopically controlled excision appears to offer the greatest likelihood of cure for this neoplasm, while providing conservation of normal tissue. In addition, we describe the second youngest patient with MAC and readdress the issue of previous radiotherapy as an important predisposing factor. (J Am Acad Dermatol 1999;41:225-31.)

Specific cutaneous infiltrates in patients with myelogenous leukemia: a clinicopathologic study of 26 patients with assessment of diagnostic criteria.

Abstract: Background: Few recent studies have analyzed the clinicopathologic features of specific cutaneous manifestations of myelogenous leukemia in a large number of patients Objective: We characterize the clinical and histopathologic spectrum of specific cutaneous manifestations in acute (AML) and chronic (CML) myelogenous leukemia, ascertain further diagnostic criteria, and examine current prognosis Methods: Thirty-six lesions of specific cutaneous infiltrates from 26 patients with my-elogenous leukemia (AML: 17 patients; M:F = 1:24; mean age: 526 years; AML-French-American-British [FAB] classification subtypes:M1 =1, M2=3, M4=8, M5=5 CML=9 patients; M:F = 45:1; mean age: 606 years) were retrospectively collected for the study Results: Cutaneous manifestations presented as solitary or multiple reddish to violaceous papules, plaques, and nodules (17 lesions), or as a generalized erythematous maculopapular eruption (9 lesions) Concurrent extramedullary involvement in other peripheral sites (eg, gums, pharynx, orbits) was observed in 10 patients Histopathologically, lesions revealed nodular/diffuse infiltrates, often with perivascular and periadnexal accentuation, sparing of the upper papillary dermis, and prominent single arraying of neoplastic cells between collagen bundles Extension to the subcutis was noted in all deep biopsy specimens (26 lesions) Cytomorphologically, medium to large-sized mononuclear cells (myeloblasts and atypical myelocytes) predominated in AML-M1 and M2, whereas M4 and M5 mainly showed small, medium-sized, or large mononuclear cells with slightly eosinophilic cytoplasm and indented, bi-lobular, or kidney-shaped nuclei (atypical monocytoid cells) In CML, either a variable mixture of mature and immature cells of the granulocytic series (myelocytes, metamyelocytes, eosinophilic metamyelocytes, and neutrophils) or a rather monomorphous infiltrate of mononuclear cells were found Staining for naphthol AS-D chloroacetate-esterase (NASD) was positive in 24 of 36 lesions (666%; AML: 16; CML: 8) Immunohistochemical analysis on paraffin sections using a large panel of antibodies (16 lesions: AML: 13; CML: 3) showed strong reactivity for LCA (CD45), lysozyme, myeloperoxidase (MPD), LN2 (CD74), HLA-DR, and MT1 (CD43) in the majority of cases, and variable staining for monocyte/macrophage markers (KP1/CD68, PGM1/CD68, Mac387, Ki-M1p) The neuronal cell adhesion molecule (N-CAM) marker CD56 was reactive in 2 cases of CML, but negative in all cases of AML MIB1(Ki67) stained 20% to 80% of neoplastic cells CD34, CD15, CD20, and CD3 were negative in all cases No correlation between histochemical/immunohistochemical features with type of leukemia or FAB-subtype of AML was observed All patients with CML and AML with adequate follow-up died within 24 months after onset of skin lesions (mean survival, AML: 76 months; CML: 94 months) Conclusion: Specific cutaneous lesions in AML and CML show distinctive clinicopathologic features that allow diagnosis in most cases Immunohistochemistry on routinely fixed, paraffin-embedded tissue sections provides useful adjunctive information Simultaneous expression of lysozyme, MPD, CD45, CD43, and CD74 militates in favor of a diagnosis of specific cutaneous infiltrate of myelogenous leukemia Pitfalls in immunohistologic diagnosis mainly include lack of expression of some myeloid markers (lysozyme, MPD), and aberrant expression of T-cell markers (eg, CD45RO) Regardless of type of myelogenous leukemia, onset of specific skin manifestations correlates with an aggressive course and short survival (J Am Acad Dermatol 1999;40:966-78)

Monoclonal gammopathies and associated skin disorders

Abstract: The monoclonal gammopathies are characterized by clonal proliferation of plasma cells and other clonally related cells in the B-cell lineage. These disorders include monoclonal gammopathy of undetermined significance, multiple myeloma, Waldenstrom macroglobulinemia, heavy chain diseases, plasmacytoma, and primary amyloidosis. Many skin disorders have been described in association with monoclonal gammopathies. This article provides an introduction to the definition, detection, natural course, and spectrum of monoclonal gammopathies and a brief discussion of pathogenesis. The article also reviews the skin disorders associated with monoclonal gammopathies, categorizes the association, and evaluates the strength of the association.

A randomized comparison of narrow-band TL-01 phototherapy and PUVA photochemotherapy for psoriasis

Abstract: Background: Although PUVA treatment of psoriasis is more effective than conventional or broad-band UVB phototherapy, two small studies have suggested that narrow-band or TL-01 phototherapy may have a therapeutic effect equal to PUVA. If confirmed, this would be of considerable importance as TL-01 therapy is likely to be considerably safer in the long term than PUVA. Objective: The purpose of this study was to compare PUVA with narrow-band (TL-01) phototherapy in psoriasis. Methods: We studied 100 patients with plaque-type psoriasis who were randomly allocated to twice-weekly treatment with PUVA or narrow-band UVB. Results: Clearance of psoriasis was achieved in a significantly greater proportion of patients treated with PUVA (84%) than with TL-01 (63%) ( P = .018), and with significantly fewer treatments (median number of treatments for clearance with PUVA, 16.7; with TL-01, 25.3; P = .001). Only 12% of those treated with TL-01 were clear of psoriasis 6 months after finishing treatment compared with 35% for PUVA ( P = .002). Conclusion: When given twice weekly, PUVA is more effective for psoriasis than narrow-band UVB phototherapy. (J Am Acad Dermatol 1999;41:728-32.)

Screening for malignant melanoma: A cost-effectiveness analysis.

Abstract: Background: Skin cancer is the most common cancer in the United States. Increasing evidence suggests that screening for malignant melanoma is effective, but its cost-effectiveness has not been determined. Objective: We attempted to determine the effectiveness and costs of a visual screen to diagnose malignant melanoma in high-risk persons. Methods: We developed a decision analysis comparing no skin cancer screen with a single screen by a dermatologist. Clinical outcomes included malignant melanoma, nonmelanoma skin cancer, or no skin cancer. Life expectancy and costs of care were projected on the basis of clinical findings. Results: Skin cancer screening increased average discounted life expectancy from 15.0963 years to 15.0975 years. Based on the prevalence of malignant melanoma, however, this translates into an increased discounted life expectancy of 0.9231 years for each person with diagnosed melanoma. Using a cost of $30 per screen, total skin cancer–related costs for a cohort of 1 million people increased from $826 million with no screen to $861 million with screening, with an increase of 1200 years of life. This results in an incremental cost-effectiveness ratio of $29,170 per year of life saved (YLS) with screening. Sensitivity analysis showed that the cost-effectiveness ratio for screening remained below $50,000/YLS if the prevalence of melanoma in the screened population was at least 0.0009, the probability that a melanoma detected in screening was localized was at least 94.8%, or the cost of each screen was below $57. Conclusion: Skin cancer screening in high-risk patients is likely to be associated with a small increase in discounted life expectancy and is reasonably cost-effective compared with other cancer screening strategies. (J Am Acad Dermatol 1999;41:738-45.)

Increased risk of bullous pemphigoid in male and very old patients: A population-based study on incidence.

Abstract: No data are available on gender- and age-specific incidences for bullous pemphigoid (BP). The aim of this study was to calculate incidences for different gender- and age-strata and to assess risk differences between these strata in BP. A retrospective population-based cohort was recruited from all patients diagnosed with BP in 2 well-defined regions of Germany. The average population number was 1.7 million, and the observation period was 9 years (1989-1997). Incidences were calculated as newly diagnosed cases for a population of 1 million per year. Confidence intervals (CI) were estimated based on a Poisson distribution. For evaluation of risk between different age and gender strata a Poisson regression analysis was used. The highest incidence was calculated for individuals older than 90 years, with 398 (CI: 360, 439) new cases of BP per 1 million residents for men, and 87 (CI: 70, 108) new cases per 1 million residents for women. Risk (95% CI) was 1.9 (1.3, 2.9) fold higher in men than in women. In addition, the risk for BP was increased for patients above the age of 60 years. The highest risk was found for patients older than 90 years. For this age group, the risk was 297 (CI: 107, 826) fold higher than in patients 60 years of age and younger. Men are affected by BP almost twice as often as women. The risk for BP increases rapidly beyond the age of 60 years. Because the structure of the European population is shifting towards the aged, more people are expected to suffer from BP in the coming decades. (J Am Acad Dermatol 1999;41:266-8.)