Nov. / Dec., 2012

November/December 2012 • Volume 10 • Issue 6

EDITORIAL Hair Then and Now Lavery and Parish

COMMENTARY Female Pattern Hair Loss Sharma, Dabaghian, and Lambert

Striae Distensae: The Fibrillin/Transforming Growth Factor b Signaling Puzzle Lacerda

ORIGINAL CONTRIBUTIONS Hair Care Practices in Diverse Populations: What Makes the Difference?

Chappell, Armbrecht, and Jensen

Topical Acne Treatment With Acetylcysteine: Clinical and Experimental Effects Montes, Wilborn, and Montes

REVIEW Green Tea in Dermatology Pazyar, Feily, and Kazerouni

Topical Vitamin D Analogs Available to Treat Psoriasis Oquendo, Abramovits, and Morrell

CORE CURRICULUM Pathophysiology of Adverse Cutaneous Drug Reactions—Applied Perceptions: Part II Sehgal, Verma, and Bhattacharya

DEPARTMENTS PERILS OF DERMATOPATHOLOGY On Bossing: Taking Charge Without The Facts Wassef, Serna-Tamayo, McDonough, Tumer, and Lambert

HISTORY OF DERMATOLOGY SOCIETY NEWSLETTER Mosquito Wars: Malaria and Bioterrorism in Italy, 1943–1945 Snowden

CASE STUDIES Radiation Port Erythema Multiforme: Erythema Multiforme Localized to the Radiation Port in a Patient With Non–Small Cell Lung Cancer Chodkiewicz and Cohen

Cladosporium Scalp Infection Sosa, Cohen, and Tschen

Metastatic Melanoma From an Unknown Primary Site Presenting as Skin-Colored Nodules and Multiple Visceral Involvement Ghosh, Bandyopadhyay, Barma, Basu, and Roy

BOOK REVIEW ACS(I) Textbook on Cutaneous and Aesthetic Surgery Reviewed by Parish

Indicated for the topical treatment of plaque psoriasis in patients aged 18 years or older

My doctor has prescribed SORILUX Foam for my plaque psoriasis...

My Life. My Treatment.

The only vitamin D3 analog treatment in a topical foam formulation VersaFoam®-AEF: Aqueous-based Emulsion Formulation Free of ethanol, preservatives, parabens, and fragrance SORILUX Foam, with VersaFoam technology, penetrates the skin barrier to deliver the molecule into the epidermis and dermis1 The contribution to efficacy of individual components of the vehicle has not been established.

Important Safety Information for SORILUX Foam SORILUX Foam should not be used by patients with known hypercalcemia The propellant in SORILUX Foam is flammable. Instruct the patient to avoid fire, flame, and/or smoking during and immediately following application Transient, rapidly reversible elevation of serum calcium has occurred with use of calcipotriene. If elevation in serum calcium outside the normal range should occur, discontinue treatment until normal calcium levels are restored Instruct the patient to avoid excessive exposure of the treated areas to either natural or artificial sunlight, including tanning booths and sun lamps. Physicians may wish to limit or avoid use of phototherapy in patients who use SORILUX Foam SORILUX Foam has not been evaluated in patients with erythrodermic, exfoliative, or pustular psoriasis

Adverse events reported in greater than 1% of subjects and in a higher rate in subjects treated with SORILUX Foam compared with vehicle were limited to erythema SORILUX Foam should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus It is not known whether calcipotriene is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when SORILUX Foam is administered to a nursing woman Safety and effectiveness of SORILUX Foam in pediatric patients less than 18 years of age have not been established SORILUX Foam is not for oral, ophthalmic, or intravaginal use

Please see Brief Summary of Prescribing Information on the next page.

Reference: 1. Data on file, Stiefel Laboratories, Inc. SORILUX is a trademark and VersaFoam is a registered trademark of Stiefel Laboratories, Inc. ©2012 Stiefel Laboratories, Inc. All rights reserved. Printed in USA. SLX001R0 March 2012

SORILUX

™

BRIEF SUMMARY The enlarged fontanelles are most likely due to calcipotriene’s (calcipotriene) Foam, 0.005% ribs. effect upon calcium metabolism. The maternal and fetal no-effect

The following is a brief summary only; see full prescribing information for complete product information.

exposures in the rat (43.2 mcg/m2/d) and rabbit (17.6 mcg/m2/d) studies are approximately equal to the expected human systemic exposure level (18.5 mcg/m2/d) from dermal application.

INDICATIONS AND USAGE

Nursing Mothers

SORILUX Foam is indicated for the topical treatment of plaque psoriasis in patients aged 18 years and older.

It is not known whether calcipotriene is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when SORILUX Foam is administered to a nursing woman.

CONTRAINDICATIONS

Pediatric Use

SORILUX Foam should not be used by patients with known hypercalcemia.

Safety and effectiveness of SORILUX Foam in pediatric patients less than 18 years of age have not been established.

WARNINGS AND PRECAUTIONS

Geriatric Use

Flammability The propellant in SORILUX is flammable. Instruct the patient to avoid fire, flame, and/or smoking during and immediately following application.

Effects on Calcium Metabolism Transient, rapidly reversible elevation of serum calcium has occurred with use of calcipotriene. If elevation in serum calcium outside the normal range should occur, discontinue treatment until normal calcium levels are restored.

Ultraviolet Light Exposure Instruct the patient to avoid excessive exposure of the treated areas to either natural or artificial sunlight, including tanning booths and sun lamps. Physicians may wish to limit or avoid use of phototherapy in patients who use SORILUX Foam. [See Nonclinical Toxicology (13.1).]

Unevaluated Uses SORILUX Foam has not been evaluated in patients with erythrodermic, exfoliative, or pustular psoriasis.

ADVERSE REACTIONS Clinical Trials Experience Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in clinical practice.

SORILUX Foam was studied in 3-vehicle controlled trials. Seven hundred and thirty-one subjects with plaque psoriasis, including 473 exposed to SORILUX Foam were treated twice daily for 8 weeks.

Adverse events reported in greater than 1% of subjects and in a higher rate in subjects treated with SORILUX Foam compared to vehicle were limited to erythema.

DRUG INTERACTIONS

No drug interaction studies were conducted with SORILUX Foam.

USE IN SPECIFIC POPULATIONS Pregnancy Teratogenic Effects, Pregnancy Category C: There are no adequate and well-controlled studies in pregnant women.

Therefore, SORILUX Foam should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Studies of teratogenicity were done by the oral route where bioavailability is expected to be approximately 40–60% of the administered dose. Increased rabbit maternal and fetal toxicity was noted at 12 mcg/kg/d (132 mcg/m2/d). Rabbits administered 36 mcg/kg/d (396 mcg/m2/d) resulted in fetuses with a significant increase in the incidences of incomplete ossification of pubic bones and forelimb phalanges. In a rat study, doses of 54 mcg/kg/d (318 mcg/m2/d) resulted in a significantly higher incidence of skeletal abnormalities consisting primarily of enlarged fontanelles and extra

Clinical studies of SORILUX Foam did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients.

OVERDOSAGE

Topically applied calcipotriene can be absorbed in sufficient amounts to produce systemic effects. Elevated serum calcium has been observed with use of topical calcipotriene. [See Warnings and Precautions (5.2).]

NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Calcipotriene topically administered to mice for up to 24 months at dose levels of 3, 10, or 30 mcg /kg/d (corresponding to 9, 30, or 90 mcg /m2/d) showed no significant changes in tumor incidence when compared to controls. In a study in which albino hairless mice were exposed to both UVR and topically applied calcipotriene, a reduction in the time required for UVR to induce the formation of skin tumors was observed (statistically significant in males only), suggesting that calcipotriene may enhance the effect of UVR to induce skin tumors.

[See Warnings and Precautions (5.3).]

The genotoxic potential of calcipotriene was evaluated in an Ames assay, a mouse lymphoma TK locus assay, a human lymphocyte chromosome aberration assay, and a mouse micronucleus assay. All assay results were negative.

Studies in rats at doses up to 54 mcg /kg/d (318 mcg /m2/d) of calcipotriene indicated no impairment of fertility or general reproductive performance.

PATIENT COUNSELING INFORMATION

[See FDA-approved Patient Labeling in full Prescribing Information].

The patient should be instructed as follows: t %o not place SORILUX Foam in the refrigerator or freezer. t "WPJd excessive exposure of the treated areas to either natural or artificial sunlight, including tanning beds and sun lamps. t *f SORILUX Foam gets in or near their eyes, to rinse thoroughly with water. t Talk to their doctor if their skin does not improve after treatmen with SORILUX Foam for 8 weeks. t Wash their hands after applying SORILUX Foam unless their hands are the affected site t "WPJd fire, flame, or smoking during and immediately following application since SORILUX Foam is flammable.

SOR:4BRS

SORILUX is a trademark of Stiefel Laboratories, Inc. ©2011 Stiefel Laboratories, Inc. April 2011

University of Athens Medical School, Athens, Greece

WORLD CONGRESS

OF COSMETIC

DERMATOLOGY

BY THE INTERNATIONAL ACADEMY OF COSMETIC DERMATOLOGY

ATHENS, GREECE JUNE 27-30, 2013 www.wcocd2013.com info@wcocd2013.com Congress Organising Bureau ERASMUS CONFERENCES TOURS & TRAVEL S.A. E-mail: info@wcocd2013.com Website: www.erasmus.gr

TABLE OF CONTENTS /PWFNCFS %FDFNCFS t 7PMVNF t *TTVF

EDITORIAL Hair Then and Now...................................................................................................................................... 334 Michael Joseph Lavery, MB BCh BAO; Lawrence Charles Parish, MD, MD (Hon)

COMMENTARY Female Pattern Hair Loss ............................................................................................................................ 336 Amit Sharma, BA; Laurie Dabaghian, BA; W. Clark Lambert, MD, PhD

Striae Distensae: The Fibrillin/Transforming Growth Factor β Signaling Puzzle .............................................. 338 Davi de Lacerda, MD

ORIGINAL CONTRIBUTIONS Hair Care Practices in Diverse Populations: What Makes the Difference? ...................................................... 341 Jeaneen Chappell, MD; Eric Armbrecht, PhD; Sara Jensen, MD

Topical Acne Treatment With Acetylcysteine: Clinical and Experimental Effects ............................................. 348 Leopold F. Montes, MD, MS, FRCPC; Walter H. Wilborn, PhD, MS; Carolina M. Montes, MD

REVIEW Green Tea in Dermatology ........................................................................................................................... 352 Nader Pazyar, MD; Amir Feily, MD; Afshin Kazerouni, MD

Topical Vitamin D Analogs Available to Treat Psoriasis .................................................................................. 356 Marcial Oquendo, MD; William Abramovits, MD; Peter Morrell, DO

CORE CURRICULUM Virendra N. Sehgal, MD, Section Editor

Pathophysiology of Adverse Cutaneous Drug Reactions—Applied Perceptions: Part II.................................... 373 Virendra N. Sehgal, MD; Prashant Verma, MD; Sambit N. Bhattacharya, MD

DEPARTMENTS PERILS OF DERMATOPATHOLOGY W. Clark Lambert, MD, PhD, Section Editor On Bossing: Taking Charge Without The Facts .............................................................................................. 385 Cindy Wassef, BA; Cristian Serna-Tamayo, BS; Patrick McDonough, BA; Gizem Tumer, MD; W. Clark Lambert, MD, PhD

HISTORY OF DERMATOLOGY SOCIETY NEWSLETTER Eve J. Lowenstein, MD, PhD, Section Editor

Mosquito Wars: Malaria and Bioterrorism in Italy, 1943–1945 ...................................................................... 388 Frank M. Snowden, PhD

CASE STUDIES Vesna Petronic-Rosic, MD, MSc, Section Editor

Radiation Port Erythema Multiforme: Erythema Multiforme Localized to the Radiation Port in a Patient With Non–Small Cell Lung Cancer.............................................................................................. 390 Hubert M. Chodkiewicz, MD; Philip R. Cohen, MD

Cladosporium Scalp Infection ...................................................................................................................... 393 Erwin Eduardo Argueta Sosa, MD; Philip R. Cohen, MD; Jaime A. Tschen, MD

329

TABLE OF CONTENTS /PWFNCFS %FDFNCFS t 7PMVNF t *TTVF Metastatic Melanoma From an Unknown Primary Site Presenting as Skin-Colored Nodules and Multiple Visceral Involvement ...................................................................................................................... 396 Sudip Kumar Ghosh, MD, DNB; Debabrata Bandyopadhyay, MD; Kuntal Deb Barma, MBBS; Swapnendu Basu, MD; Amit Roy, MS

BOOK REVIEW Jennifer L. Parish, MD, Section Editor

ACS(I) Textbook on Cutaneous and Aesthetic Surgery................................................................................... 401

ABOUT OUR JOURNAL SKINmed: Dermatology for the Clinician® QSJOU *44/ POMJOF *44/ JT QVCMJTIFE CJNPOUIMZ CZ 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$ MPDBUFE BU 1FOJOTVMB "WFOVF 4FB #SJHIU /+

Editorial MANAGING EDITOR %IBZBOJEIJ ,BSVOBOJEIJ TLJONFE!EJBDSJUFDI DPN

1SJOUFE JO UIF 64" %JTDMBJNFS ɨF 1VCMJTIFS &EJUPST BOE &EJUPSJBM #PBSE DBOOPU CF IFME SFTQPOTJCMF GPS FSSPST PS BOZ DPOTFRVFODFT BSJTJOH GSPN UIF VTF PG JOGPSNBUJPO DPOUBJOFE JO UIJT KPVSOBM UIF WJFXT BOE PQJOJPOT FYQSFTTFE IFSFJO EP OPU OFDFTTBSJMZ SFnFDU UIPTF PG UIF 1VCMJTIFS &EJUPST BOE &EJUPSJBM #PBSE OFJUIFS EPFT UIF QVCMJDBUJPO PG BEWFSUJTFNFOUT DPOTUJUVUF BOZ FOEPSTFNFOU CZ UIF 1VCMJTIFS &EJUPST BOE &EJUPSJBM #PBSE PG UIF QSPEVDUT PS TFSWJDFT BEWFSUJTFE ɨF 1VCMJTIFS &EJUPST &EJUPSJBM #PBSE 3FWJFXFST "VUIPST BOE "ċMJBUFE "HFOUT TIBMM OPU CF IFME SFTQPOTJCMF PS JO BOZ XBZ MJBCMF GPS UIF DPOUJOVFE BDDVSBDZ PG UIF JOGPSNBUJPO PS GPS BOZ FSSPST JOBDDVSBDJFT PS PNJTTJPOT PG BOZ LJOE JO UIJT QVCMJDBUJPO XIFUIFS BSJTJOH GSPN OFHMJHFODF PS PUIFSXJTF PS GPS BOZ DPOTFRVFODFT BSJTJOH UIFSFBGUFS

COPYEDITOR &MJ[BCFUI )PMDPNC FIPMDPNC!TLJONFEKPVSOBM DPN

MEDIA WEB DIRECTOR +PBO 0THPPECZ KPBO!TLJONFEKPVSOBM DPN

Publishing PUBLISHER "SU ,BMBLB

$PQZSJHIU © 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$ "MM SJHIUT SFTFSWFE /P QBSU PG UIJT QVCMJDBUJPO NBZ CF SFQSPEVDFE TUPSFE PS USBOTNJUUFE JO BOZ GPSN PS CZ BOZ NFBOT XJUIPVU UIF QSJPS QFSNJTTJPO JO XSJUJOH GSPN UIF 1VCMJTIFS 3FRVFTUT TIPVME CF BEESFTTFE UP UIF 1FSNJTTJPOT &EJUPS BU 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$ 1FOJOTVMB "WFOVF 4FB #SJHIU /+

ASSOCIATE PUBLISHER +BNFT 3 "EBNT KBEBNT!TLJONFEKPVSOBM DPN

Corporate PRESIDENT "SUIVS ,BMBLB BLBMBLB!TLJONFEKPVSOBM DPN

CHIEF EXECUTIVE OFFICER +P "OO ,BMBLB "EBNT KBEBNT!TLJONFEKPVSOBM DPN

"CTUSBDUJOH *OEFYJOH ɨF KPVSOBM JT JOEFYFE JO *OEFY .FEJDVT .&%-*/&

GENERAL COUNSEL .BSJBOOF .DLFO[JF NNDLFO[JF!TLJONFEKPVSOBM DPN

5P TVCNJU B NBOVTDSJQU GPS QFFS SFWJFX TFOE BT BO F NBJM BUUBDINFOU UP UIF &EJUPS JO $IJFG BU MQBSJTI!TLJONFEKPVSOBM DPN 1MFBTF WJTJU XXX TLJONFEKPVSOBM DPN GPS *OGPSNBUJPO GPS "VUIPST

1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$ 1FOJOTVMB "WFOVF t 4FB #SJHIU /+ 5FM t 'BY

330

Arnika Forte

速

The New Gold Standard for treating bruising, swelling, pain 1st and only combination of Arnica Montana 30x and Bromelain

Arnika Forte速 SPEED THE HEALING

One convenient capsule twice a day All natural, safe, physician - formulated

Speed the healing time from bruising, swelling and pain after surgery or dermal filler injections

To Order Call 484-568-0306

November/December 2012

EDITORIAL BOARD

EDITOR IN CHIEF

Lawrence Charles Parish, MD, MD (Hon) Philadelphia, PA

DEPUTY EDITORS William Abramovits, MD Dallas, TX

W. Clark Lambert, MD, PhD Newark, NJ

Larry E. Millikan, MD Meridian, MS

Vesna Petronic-Rosic, MD, MSc Chicago, IL

Marcia Ramos-e-Silva, MD, PhD Rio de Janeiro, Brazil

Jennifer L. Parish, MD Philadelphia, PA

EDITORIAL BOARD Mohamed Amer, MD Cairo, Egypt

Howard A. Epstein, PhD Philadelphia, PA

Jasna Lipozencic, MD, PhD Zagreb, Croatia

Noah S. Scheinfeld, MD, JD New York, NY

Robert L. Baran, MD Cannes, France

Ibrahim Hassan Galadari, MD, PhD, FRCP Dubai, United Arab Emirates

Eve J. Lowenstein, MD, PhD New York, NY

Virendra N. Sehgal, MD Delhi, India

Anthony V. Benedetto, DO Philadelphia, PA

Anthony A. Gaspari, MD Baltimore, MD

George M. Martin, MD Kihei, HI

Riccarda Serri, MD Milan, Italy

Brian Berman, MD, PhD Miami, FL

Michael Geiges, MD Zurich, Switzerland

Marc S. Micozzi, MD, PhD Rockport, MA

Charles Steffen, MD Oceanside, CA

Jack M. Bernstein, MD Dayton, OH

Michael H. Gold, MD Nashville, TN

George F. Murphy, MD Boston, MA

Alexander J. Stratigos, MD Athens, Greece

Sarah Brenner, MD Tel Aviv, Israel

Lowell A. Goldsmith, MD, MPH Chapel Hill, NC

Oumeish Youssef Oumeish, MD, FRCP Amman, Jordan

James S. Studdiford III, MD Philadelphia, PA

Joaquin Calap Calatayud, MD Cadiz, Spain

Aditya K. Gupta, MD, PhD, FRCP(C) London, Ontario, Canada

Joseph L. Pace, MD, FRCP Naxxar, Malta

Robert J. Thomsen, MD Los Alamos, NM

Henry H.L. Chan, MB, MD, PhD, FRCP Hong Kong, China

Seung-Kyung Hann, MD, PhD Seoul, Korea

Art Papier, MD Rochester, NY

Julian Trevino, MD Dayton, OH

Noah Craft, MD, PhD, DTMH Torrance, CA

Roderick J. Hay, BCh, DM, FRCP, FRCPath London, UK

Johannes Ring, MD, DPhil Munich, Germany

Snejina Vassileva, MD, PhD Sofia, Bulgaria

Ncoza C. Dlova, MBChB, FCDerm Durban, South Africa

Tanya R. Humphreys, MD Philadelphia, PA

Roy S. Rogers III, MD Rochester, MN

Daniel Wallach, MD Paris, France

Richard L. Dobson, MD Mt Pleasant, SC

Camila K. Janniger, MD Englewood, NJ

Donald Rudikoff, MD New York, NY

Michael A. Waugh, MB, FRCP Leeds, UK

William H. Eaglstein, MD Palo Alto, CA

Abdul-Ghani Kibbi, MD Beirut, Lebanon

Robert I. Rudolph, MD Wyomissing, PA

Wm. Philip Werschler, MD Spokane, WA

Boni E. Elewski, MD Birmingham, AL

Andrew P. Lazar, MD Livermore, California

Vincenzo Ruocco, MD Naples, Italy

Joseph A. Witkowski, MD Philadelphia, PA

Charles N. Ellis, MD Ann Arbor, MI

Ronni Wolf, MD Rechovot, Israel

332

7PMVNF t *TTVF

November/December 2012

EDITORIAL

Hair Then and Now Michael Joseph Lavery, MB BCh BAO;1 Lawrence Charles Parish, MD, MD (Hon)2 You can’t part the skin of a sausage, Or a dad from his fond son and heir.

And you can’t part the hair on a bald-headed man, For there’ll be no parting there1

T

IF SFNJU PG UIJT FEJUPSJBM JT OPU UIF NBOZ DBVTFT PG IBJS MPTT PS FYDFTTJWF IBJS CVU SBUIFS UIF DVMUVSBM BOE BOUISPQPMPHJDBM JNQPSUBODF PG IBJS UP Homo sapiens PWFS UIF ZFBST VQ VOUJM OPX &MTFXIFSF JO UIJT JTTVF UIFSF BSF TFWFSBM QSFTFOUBUJPOT PO WBSJPVT BTQFDUT PG UIF QSFTFODF PS BCTFODF PG IBJS

P DDVQBUJPO GPS UIF UPOTPS UIF 3PNBO NBO T CBSCFS &RVBMMZ B 3PNBO XPNBO PG UIF VQQFS DMBTTFT XPVME IBWF IFS IBJS ESFTTFE CZ NBOZ TFSWBOUT JO UIF EJTUJODUJWF TUZMF PG UIF VQQFS DMBTTFT 4 4FSWBOUT BOE TMBWFT VTVBMMZ IBE TIPSUFS IBJS 8JHT XFSF BT JO &HZQUJBO UJNFT BMTP QPQVMBS XJUI UIF (SFFLT BOE 3PNBOT BT JU NFBOU UIBU DIBOHJOH IBJSTUZMFT DPVME CF SBQJEMZ GBDJMJUBUFE 5

8IFO UIF 3PNBOT JOWBEFE #SJUBJO UIF #SJUJTI XPNFO IBE UIFJS IBJS MPOH FJUIFS JO QMBJUT PS IFME VQ JO QJOT XIJMF UIF NFO XPVME ɨSPVHIPVU UIF BHFT IBJSTUZMF IBT CFFO BOE SFNBJOT B EJTUJODUJWF IBWF IBE CFBSET BOE NPVTUBDIFT ɨJT DPOUSBTUFE XJUI UIF DMFBO QBSU PG DVMUVSF GPS DFSUBJO TFDUJPOT PG FBDI DPNNVOJUZ "ODJFOU TIBWFO DMPTF DSPQQFE IBJS PG UIF JOWBEJOH 3PNBO TPMEJFST *SPO&HZQUJBOT XIP PGUFO IBE UIFJS IFBET TIBWFE XPVME DPOTF- JDBMMZ UIF &NQFSPS )BESJBO NBEF CFBSET GBTIJPOBCMF BNPOH UIF RVFOUMZ XFBS XJHT UP QSPUFDU UIFJS TDBMQ GSPN UIF TVO "U mSTU 3PNBOT BHBJO TP UIBU IF NJHIU SFTFNCMF B (SFFL QIJMPTPQIFS UIFTF XJHT XFSF NBEF GSPN BOJNBM IBJS CVU MBUFS IVNBO IBJS XBT VTFE CFJOH XPSO CZ NFO XPNBO BOE DIJMESFO 2 -BUFS BT THROUGH THE YEARS EFQJDUFE JO UIF mMN UIF Ten Commandments CPZT GSPN VQQFS 0WFS UIF DFOUVSJFT JO #SJUBJO BOE FMTFXIFSF JO &VSPQF IBJSTUZMFT DMBTTFT IBE TIBWFO IFBET FYDFQU GPS POF TNBMM QJFDF PG IBJS nVDUVBUFE 'PS FYBNQMF UIFZ DPOUSBTUFE NBSLFEMZ EVSJOH UIF XIJDI GFMM PWFS UIF SJHIU QBSU PG UIF GBDF 4ZNCPMJDBMMZ 4BNTPO T &OHMJTI $JWJM 8BS CFUXFFO UIPTF mHIUJOH GPS ,JOH $IBSMFT * CJCMJDBM TUSFOHUI MBZ JO UIF MFOHUI PG IJT IBJS "GUFS CFUSBZJOH (PE UIF $BWBMJFST XIP DIBSBDUFSJTUJDBMMZ IBE MPOH DVSMZ IBJS BOE BOE SFWFBMJOH UIJT TFDSFU UP %FMJMBI IJT IFBE XBT TIPSO MFBWJOH UIF 3PVOEIFBET XIP XFSF UIF PQQPTJUJPO BOE XIP BEPQUFE IJN JO B XFBLFOFE TUBUF TIPSU DMPTFMZ DSPQQFE IBJS 6 -PVJT 9*** PG 'SBODF JO UIF FBSMZ UI DFOUVSZ NBEF XJHT GBTIJPOBCMF XIFO IF CFHBO UP XFBS ɨF JNQPSUBODF PG IBJS BT B GFBUVSF PG DVMUVSBM MJGF DPOUJOVFE UIFN UP DPNQFOTBUF GPS IJT QSFNBUVSF CBMEJOH 7 ɨF VTF PG XJHT JO "ODJFOU (SFFDF BOE 3PNF XIFSF IFBE TUZMF BHBJO UZQJmFE CFDBNF WFSZ QPQVMBS UISPVHIPVU EJĊFSFOU QBSUT PG UIF XPSME TPDJFUZ T QSFGFSFODF GPS B QBSUJDVMBS IBJSTUZMF GPS UIPTF PG B DFS"MM XBT OPU SPTFZ IPXFWFS BT UIF EJBSJTU 4BNVFM 1FQZT XSPUF JO UBJO TUBUVT *O BODJFOU (SFFDF HPMEFO SFE IBJS XBT UIF QSFGFSBCMF UIBU IJT XJH XBT GVMM PG OJUT TP IF IBE UP IBWF JU DMFBOFE DPMPS BOE ZPVOH CPZT XPVME CF BMMPXFE UP HSPX UIFJS IBJS VOUJM QSPQFSMZ *OEFFE JO IF XBT DPODFSOFE BCPVU XFBSJOH B QVCFSUZ XIFO JU XBT UIFO TIPSO BOE BMMPXFE UP SFHSPX BHBJO BT XJH CFDBVTF BU UIF UJNF UIFSF XBT B WJSVMFOU QMBHVF 8 UIFZ CFDBNF B NBO %VSJOH UIF UI DFOUVSZ NFO T XJHT XFSF QPXEFSFE CVU UIJT When red-haired people are above a certain social JDPO PG TPDJBM TUBUVT XBT TZNCPMJDBMMZ EJTDBSEFE JO UIF 6OJUFE grade their hair is auburn.3 4UBUFT BOE 'SBODF CZ UIF CFHJOOJOH PG UIF UI DFOUVSZ *O UIF 'PS UIF (SFFLT BOE 3PNBOT UIF IBJSTUZMF WBSJFE GSPN B 6OJUFE 4UBUFT POMZ UIF mSTU QSFTJEFOUT BSF LOPXO UP IBWF XPSO DMPTF DSPQQFE IBJSTUZMF UP B XBWZ QSFTFOUBUJPO ɨJT FOTVSFE QPXEFSFE XJHT ANCIENT TIMES

From the Department of Medicine, Mater Infirmorum Hospital, Belfast, Northern Ireland;1 and Department of Dermatology and Cutaneous Biology and the Jefferson Center for International Dermatology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA2 Address for Correspondence: Lawrence Charles Parish, MD, MD (Hon), 1760 Market Street, Suite 301, Philadelphia, PA 19103 t E-mail: larryderm@yahoo.com

SKINmed. 2012;10:334–335

334

ª 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$

&%*503*"-

November/December 2012

FEJUPSJBM MFU VT SFDBMM UIBU :VM #SZOOFS BOE 5FMMZ 4BWBMBT BT XFMM 1FPQMF IBWF VTFE IBJS DVUT PS MBDL PG BT B TUBUFNFOU PG JEFOUJUZ BT TPNF )PMZXPPE TUBSMFUT CBSF UIFJS QFSTPOB PO UIFJS NBOF 8JUOFTT UIF DSFX DVU GPS UIF NJMJUBSZ BOE QSJTPOFST PS UIF XIJÄŒF From the Egyptians, Greeks, and Romans to now, PG TPNF ZFBST BHP .PSF SFDFOUMZ MPOH IBJS IBT CFDPNF GBTIHair has played an important role, showing how JPOBCMF GPS ZPVOH QFPQMF XIP XJTI UP SFCFM BHBJOTU UIFJS NPSF Culture has evolved throughout the years, DPOTFSWBUJWF FMEFST With hair loss frequently causing many tears MODERN TIMES

*OEFFE UIF 8FTU &OE BOE #SPBEXBZ IBWF TFFO NBOZ QSPEVDREFERENCES UJPOT SFWPMWJOH BSPVOE IBJS 3PEHFS BOE )BNNFSTUFJO T South 1 McDonald P. Oxford dictionary of medical quotations. Oxford, England; PaciďŹ c JODMVEFT B TPOH BCPVU B HJSM XBOUJOH UP iXBTI UIBU NBO Oxford University Press. 2004:10.

SJHIU PVUUB NZ IBJS w .PSF DPOUSPWFSTJBMMZ UIF NVTJDBM Hair 2 Cox JS. The construction of an Ancient Egyptian wig (c. 1400 B.C.) in the DPNFT UP NJOE BT B QSPUFTU BHBJOTU BVUIPSJUZ *O NPSF SFDFOU British Museum. J Egyptian Archaeol. 1977;63:67–70.

3 Twain M. A Connecticut Yankee in King Arthur’s Court. 1889.

UJNFT UIF BEWFOU PG IBJS USBOTQMBOUT BOE UIF VTF PG UPQJDBM NJONew York, NY. http://www.twainquotes.com/Redheads.html Accessed PYJEBM BOE PSBM mOBTUFSJEF IBWF BEESFTTFE UIF DPODFSOT PG SFDFESeptember 23, 2012.

JOH IBJSMJOFT 4 Olson K. Dress and the Roman Women: Self-Presentation and Society.

London, England: Routledge; 2008:71.

I’m not really bald, I’m a hair donor.9 I bought a book on hair loss and the pages kept falling out.10 8IJMF UIF "NFSJDBO XSJUFS 4BN &XJOH DPNNFOUFE Ination is when you pay ďŹ fteen dollars for the ten-dollar haircut you used to get for ďŹ ve dollars when you had hair.11 CONCLUSIONS 4FBO $POOFSZ BQQBSFOUMZ CFHBO MPTJOH IJT IBJS XIFO BHFE BOE XPSF XJHT GPS FBDI PG UIF +BNFT #POE NPWJFT IPXFWFS IF XBT DPOUFOU XJUI IJT JNBHF )F XBT FWFO TFFO QSJWBUFMZ BOE JO NPTU PUIFS mMNT HPJOH CBME "T XF DPNF UP UIF FOE PG UIJT

5

Olson K. Dress and the Roman Women: Self-Presentation and Society.

London, England: Routledge; 2008:74.

6

Sherrow V. Encyclopedia of Hair: A Cultural History. Greenwood Press: Westport, CT; 2006:320.

7

Corson R. Fashions in Hair: The First Five Thousand Years. 8th ed.

London, England: Peter Owen Limited; 2001:21.

8

Latham R, Matthews WG. The Diary of Samuel Pepys: Volume X - Companion. London, England: Harper Collins; 2010:10–100.

9

Byrne R. The 2,548 Wittiest Things Anybody Ever Said. New York, NY: Simon & Schuster; 2012: Quote 978.

10 Byrne R. The 2,548 Wittiest Things Anybody Ever Said. New York, NY: Simon & Schuster; 2012: Quote 984.

11 Twibell D. Protecting your portfolio against rising inflation. Denver Business Journal. 2012. Accessed 09/23/2012. http://www.bizjournals. com/denver/print-edition/2012/08/03/protecting-your-portfolioagainst.html.

VINTAGE LABEL

Courtesy of BuyEnlarge, Philadelphia, PA SKINmed. 2012;10:334–335

335

)BJS ɨFO BOE /PX

November/December 2012

Volume 10 • Issue 6

COMMENTARY

Female Pattern Hair Loss Amit Sharma, BA; Laurie Dabaghian, BA; W. Clark Lambert, MD, PhD

T

he accompanying article1 comprehensively reviews the important topic of androgenic alopecia in the female population. Female pattern hair loss affects millions of individuals worldwide and has significant psychosocial consequences. Although there has been considerable investigation into the development of male pattern hair loss, it is only recently that there has been a growing interest in understanding female pattern hair loss and its similarities and differences to its male counterpart.

The authors accurately describe the normal physiology of hair growth and cycle and relate how disruption leads to androgenetic alopecia. The authors mention a possible genetic involvement in pattern hair loss. It is noteworthy that in addition to the cited studies concerning the mutations in the metabolism gene CYP 17 and 17-alpha-hydroxylase, there has been ongoing investigation into the polymorphism of the androgen receptor (AR), especially in regards to the trinucleotide repeat found in the gene. The AR gene is on the X chromosome and has an amino terminus with CAG repeats. The number of CAG repeats differs from individual to individual. It is thought that the more CAG repeats in the AR gene, the less the gene is expressed. Moreover, the expansion of this trinucleotide repeat has been found to be present in patients with polycystic ovarian syndrome, hirsuitism, and acne.2,3 An initial study concluded that there is an inverse relationship between the number of repeats and androgen levels.

Moreover, a reduced triplet length was found to be prevalent among balding men.4 The authors thoroughly discuss the diagnostic methods for pattern hair loss. Although diagnosis of androgenic alopecia is mostly clinical, there has been a surge in newer technologies, such as dermoscopy, that aid in characterizing the condition.

With the recent findings concerning the CAG triplet repeats in the androgen receptor gene, tests are becoming available that assess the risk of developing pattern hair loss based on triplet length. It is reported that 97.3% of women with a CAG length of ≤15 develop either Ludwig II or III grade hair loss.5 A current Hair Genetic Test examines 8 variants of the AR gene. One important variant is known as rs6152.

The positive and negative predictive values for the test detecting this variant are both 70%.5 The changes associated with the development and progression of androgenetic alopecia are complex. Histological examination provides apparent changes associated with the development of pattern hair loss but is limited by the small sample size examined on a punch biopsy. This may prove amenable to special types of histological investigation, such as creation of histological images using ultrasound, perhaps incorporating new developments such as recently developed high frequency sonography,6 which could potentially provide diagnostic images of large areas without removal of tissue. An additional exciting prospect would be to investigate the chemical changes that occur with hair growth, aging, and disease. Raman spectroscopy is an innovative optical technology that provides a rapid chemical analysis of tissue in vivo. By measuring the inelastic interactions of light with matter, Raman spectroscopy can accurately determine the chemical composition of a sample. Polarized Raman microspectroscopy has been applied to study the composition of human hair shafts, characterizing the structural variations of keratin.7 Raman spectra of bleached hair, when compared with normal hair, confirm changes in keratotic disulfide bonds.8,9 Moreover, the technology has been applied to study diagnostic changes in trichothiodystrophy. Using biochemical and electron microscopy techniques, it has been demonstrated that trichothiodystrophic hair has reduced cysteine content compared with normal hair.10 Raman spectra of trichothiodystrophic hair evidences alteration of molecular structure of the sulfur-rich proteins, leading to fragility and brittleness.11 It would be of value to investigate biochemical changes that occur with androgenic alopecia. Such chemical characterization of disease may help in screening, diagnosing, and selecting therapy.

CONCLUSIONS Pattern hair loss is a stressful condition that the physician must recognize and treat appropriately. The authors of this paper systematically discuss the intricacies of normal and abnormal hair development. In recent years, much has been revealed regarding

From the Department of Dermatology, New Jersey Medical School, Newark, NJ Address for Correspondence: W. Clark Lambert, MD, PhD, Room H576 Medical Science Building, UMDNJ-New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07103 • E-mail: lamberwc@umdnj.edu

SKINmed. 2012;10:336–337

336

© 2012 Pulse Marketing & Communications, LLC

November/December 2012

COMMENTARY

the pathogenesis of androgenetic alopecia at the molecular level; yet, the disruption of the hair cycle and aberrations in signaling events that lead to the development and progression of pattern hair loss are not fully understood. With future investigations into the development and diagnosis of androgenic alopecia, it should be possible to design more specific therapies and drug regimens.

5

Schweiger E, Boychenko O, Bernstein R. Update on the pathogenesis, genetics and medical treatment of patterned hair loss. J Drugs Dermatol.

2010;9:1412.

6

Hayashi K, Koga H, Uhara H, Saida T. High-frequency 30-MHz sonography in preoperative assessment of tumor thickness of primary melanoma: usefulness in determination of surgical margin and indication for sentinel lymph node biopsy. Int J Clin Oncol. 2009;14: 426–430.

7

Ackermann K, Koster J, Schlücker S. Polarized Raman microspectroscopy on intact human hair. J Biophotonics. 2008;1:419–424.

REFERENCES

8

Gniadecka M, Nielsen O, Christensen D, Wulf H. Structure of water, proteins, and lipids in intact human skin, hair, and nail. J Invest Dermatol.

1998;110:393–398.

9

Akhtar W, Edwards H, Farwell D, Nutbrown M. Fourier-transform Raman spectroscopic study of human hair. Spectrochim Acta A Mol Biomol Spectrosc. 1997;53:1021–1031.

1

Sehgal VN, Srivastava G, Aggarwal AK, Midha R. Hair biology and its comprehensive sequence in female pattern baldness: diagnosis and treatment modalities—part I. SKINmed. 2012.

2

Pugeat M, Nicolas MH, Craves JC, et al. Androgens in polycystic ovarian syndrome. Ann NY Acad Sci. 1993;687:124–135.

3

Futterweit W. Polycystic ovary syndrome: clinical perspectives and management. Obstet Gynecol. 1999;54:403.

10 Itin P, Sarasin A, Pittelkow M. Trichothiodystrophy: update on the sulfur-deficient brittle hair syndromes. J Am Acad Dermatol. 2001; 44:891–920.

4

Ellis JA, Stebbing M, Harrap SB. Polymorphism of the androgen receptor gene is associated with male pattern baldness. J Invest Dermatol.

2001;116:452–455.

11 Liang C, Morris A, Schlücker S, et al. Structural and molecular hair abnormalities in trichothiodystrophy. J Invest Dermatol. 2006;126: 2210–2216.

VINTAGE LABEL

Courtesy of BuyEnlarge, Philadelphia, PA SKINmed. 2012;10:336–337

337

Female Pattern Hair Loss

7PMVNF t *TTVF

November/December 2012

COMMENTARY

Striae Distensae: The Fibrillin/Transforming Growth Factor β Signaling Puzzle Davi de Lacerda, MD

S

USJBF EJTUFOTBF 4% BMTP LOPXO BT TUSFUDI NBSLT BSF MJOFBS MFTJPOT DPOTJEFSFE UP CF BTTPDJBUFE XJUI FYDFTTJWF EJTUFOUJPO PG UIF TLJO "MNPTU BMM JOEJWJEVBMT EFWFMPQ 4% BU TPNF QPJOU EVSJOH UIFJS MJGFUJNF ɨF JODJEFODF PG 4% JT JODSFBTFE EVSJOH BEPMFTDFOU HSPXUI TQVSUT QSFHOBODZ NVTDVMBS BOE TVCDVUBOFPVT IZQFSUSPQIZ PS QSPTUIFUJD JOEVDFE UJTTVF FYQBOTJPO -FTJPOT VTVBMMZ IBWF B CJNPEBM QSFTFOUBUJPO ɨFZ JOJUJBMMZ QSFTFOU BT FSZUIFNBUPVT TPNFUJNFT QSVSJUJD JOnBNNBUPSZ QMBRVFT 'JHVSF "GUFS TFWFSBM NPOUIT UIFZ FWPMWF UP TUBCMF BUSPQIJD IZQPQJHNFOUFE TUSFBLT UIBU DBO CF DPOTJEFSFE mOBM TDBS UJTTVF TFDPOEBSZ UP UIF QSFDFEJOH JOnBNNBUPSZ DIBOHFT "DDPSEJOHMZ SFQPSUT IBWF TIPXO UIBU NZPmCSPCMBTUT DFMMT UZQJDBMMZ TFFO JO UIF FBSMZ QIBTFT PG UIF TDBSJOH QSPDFTT BSF JODSFBTFE JO SFE 4% CVU OPU JO MBUF MFTJPOT 1 ɨF FUJPMPHZ PG 4% SFNBJOT FMVTJWF BOE QBUJFOUT BSF VTVBMMZ SFMVDUBOU UP FOSPMM JO TUVEJFT SFRVJSJOH UJTTVF CJPQTJFT &WBMVBUJPO PG TUSFUDI NBSLT XJUI PQUJDBM DPIFSFODF UPNPHSBQIZ TIPXT EJTUJODU SFnFDUJWF QSPQFSUJFT JO UIF BĊFDUFE BSFBT XIFO DPNQBSFE XJUI OPSNBM TLJO 'JHVSF

)JTUPMPHJDBM BOBMZTFT PG 4% EFNPOTUSBUF EFSNBM FYUSBDFMMVMBS NBUSJY BCOPSNBMJUJFT XJUI GSBHNFOUFE DPMMBHFO mCFST 'JHVSF

BMUIPVHI TJNJMBS mOEJOHT DPVME SFQSFTFOU BO BSUJGBDU GSPN UIF JOmMUSBUJPO PG BOFTUIFUJD TPMVUJPO /PUXJUITUBOEJOH TFWFSBM DMVFT JO UIF MJUFSBUVSF QPJOU UP mCSJMMJO EBNBHF B NPMFDVMF QSFTFOU JO FMBTUJD mCFST BOE JUT QPTTJCMF SPMF JO BMUFSJOH UIF USBOTGPSNJOH HSPXUI GBDUPS β 5(' β TJHOBMJOH QBUIXBZ BT B DFOUSBM QIFOPNFOPO JO 4% GPSNBUJPO ɨJT DPOUSJCVUJPO XJMM TIPSUMZ DPNNFOU PO FWJEFODF TVQQPSUJOH UIBU DMBJN SD AND FIBRILLIN/TGFβ ɨF EFSNBM FMBTUJD TZTUFN IBT TQSJOH MJLF QSPQFSUJFT BMMPXJOH UIF TLJO UP SFUVSO UP JUT SFTUJOH DPOGPSNBUJPO BGUFS CFJOH NFDIBOJDBMMZ EJTUFOEFE *U JT GPSNFE CZ B OFUXPSL PG EJTUFOTJCMF TUSVDUVSFT DMBTTJDBMMZ EFTDSJCFE BT BO FMBVOJO DPNQPOFOU JO UIF VQQFS SFUJDVMBS EFSNJT NBEF PG UIJDL mCFST DPOUBJOJOH FMBTUJO BMJHOFE PO B TDBĊPME PG mCSJMMJO NJDSPmCSJMT BOE B NPSF

TVQFSmDJBM PYZUBMBO DPNQPOFOU XJUI UIJOOFS mCFST MBDLJOH FMBTUJO .BOZ BVUIPST QPJOU PVU UIBU NFDIBOJDBM TUSFTT DBO CSFBL UIF FMBTUJD OFUXPSL TZTUFN MFBEJOH UP UIF GPSNBUJPO PG TUSFUDI NBSLT 2 ɨJT JT DPSSPCPSBUFE CZ UIF DMJOJDBM GFBUVSFT EFTDSJCFE BCPWF BOE CZ NPSQIPMPHJDBM BOBMZTJT PG 4% MFTJPOT &MBVOJO BOE PYZUBMBO FMBTUJD mCFST BSF TJHOJmDBOUMZ SFEVDFE BOE EJTPSHBOJ[FE JO 4% 3FTFBSDIFST IBWF EFNPOTUSBUFE UIBU CPUI FMBTUJO BOE mCSJMMJO BSF EFDSFBTFE JO UIF BĊFDUFE BSFBT 3 0UIFS DPNQPOFOUT PG UIF FYUSBDFMMVMBS NBUSJY EP OPU TFFN UP CF BT VMUSBTUSVDUVSBMMZ BĊFDUFE BT UIF FMBTUJD OFUXPSL 8IFSFBT NVUBUJPOT JO UIF FMBTUJO HFOF BSF MJOLFE UP DVUJT MBYB TVQSBWBMWBS BPSUJD TUFOPTJT BOE 8JMMJBNT #FVSFO TZOESPNF QSFEJTQPTJUJPO UP 4% JT OPU EFTDSJCFE BT B NBSLFS GPS UIPTF TZOESPNFT 4 0O UIF PUIFS IBOE mCSJMMJO BCOPSNBMJUZ BT TFFO JO .BSGBO TZOESPNF JT MJOLFE UP TJHOJmDBOUMZ IJHIFS JODJEFODF PG 4% 5 #FTJEFT UIFJS TUSVDUVSBM QSPQFSUJFT mCSJMMJOT TIBSF B TJHOBUVSF FJHIU DZTUFJOF 5# EPNBJO XJUI MBUFOU 5(' βoCJOEJOH QSPUFJOT BOE DPOUBJOT "SH (MZ "TQ 3(% EPNBJOT UIBU GBWPS CJOEJOH UP JOUFHSJOT 'JCSJMMJOT BMTP CJOE UP B MBSHF OVNCFS PG FYUSBDFMMVMBS NBUSJY QSPUFJOT BOE HMZDPTBNJOPHMZDBOT %JTUPSUJPOT JO mCSJMMJO NJDSPmCSJMT BSF USBOTNJUUFE UP UIF JOUSBDFMMVMBS DZUPTLFMFUPO SFTVMUJOH JO BEBQUJWF SFTQPOTFT BTTPDJBUFE XJUI SFMFBTF BOE BDUJWBUJPO PG 5(' β 0G OPUF 5(' β TJHOBMJOH IBT CFFO JNQMJDBUFE BT B QJWPUBM NPMFDVMF JO UIF IPNFPTUBTJT PG UIF FYUSB DFMMVMBS NBUSJY BOE mCSJMMJO GPSNBUJPO 7 8IFSFBT mCSJMMJO NVUBUJPOT DBVTJOH .BSGBO T JOUFSGFSF XJUI NJDSPmCSJM GPSNBUJPO SFTVMUJOH JO JNQSPQFS 5(' β BDUJWBUJPO TUJĊ TLJO TZOESPNF QIFOPUZQFT BSF MJOLFE UP BCOPSNBMJUJFT JO UIF JOUFHSJO CJOEJOH TJUFT 8 *OUFSFTUJOHMZ NVUBUJPOT JO UIF 5(' β SFDFQUPS HFOF DBVTF -PFZT %JFU[ TZOESPNF GPSNFSMZ DBMMFE .BSGBO UZQF ** TZOESPNF XJUI TLJO mOEJOHT TJNJMBS UP .BSGBO 5 "MM UIPTF EBUB TVHHFTU UIF SPMF PG mCSJMMJO BOE 5(' β EJTSVQUJPO JO UIF HFOFTJT PG 4% 4% BSF GSFRVFOUMZ TFFO JO $VTIJOH TZOESPNF 5PQJDBM BOE TZTUFNJD HMVDPDPSUJDPJET BSF LOPXO UP QSPEVDF 4% JO OPSNBM TLJO (MVDPDPSUJDPJET NPEJGZ 5(' β TJHOBMJOH JO EFSNBM mCSPCMBTUT CVU UIFJS FĊFDUT PO mCSJMMJO IBWF OPU CFFO FYUFOTJWFMZ TUVEJFE

From Clin. Med. Dr. Davi de Lacerda, Av. Angélica, 2530 Cj 46, São Paulo, Brazil Address for Correspondence: Davi de Lacerda, MD, Clin. Med. Dr. Davi de Lacerda, Av. Angélica, 2530 Cj 46, São Paulo – SP 01228-200 #SB[JM t & NBJM EMBDFSEB!VTQ CS

SKINmed. 2012;10:338–340

338

ª 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$

$0..&/5"3:

November/December 2012

XIFUIFS UIF NJDSPFOWJSPONFOUBM DIBOHFT JO SFE DPNQBSFE XJUI XIJUF 4% JOUFSGFSF XJUI UIF BDUJWBUJPO PG 5(' β TJHOBMJOH BMUFSJOH mCSJMMJO NJDSPmCSJMBS TUBCJMJUZ ɨF BTTFNCMZ PG FMBTUJD mCFST JT B DPNQMFY QSPDFTT OPU ZFU DPNQMFUFMZ FMVDJEBUFE .VUBUJPO JO POMZ POF UZQF PG mCSJMMJO EPFT OPU QSFWFOU FMBTUPHFOFTJT IPXFWFS NJDF XJUI DPODPNJUBOU NVUBUJPOT JO CPUI mCSJMMJO BOE HFOFT IBWF JNQBJSFE FMBTUPHFOFTJT ɨF FYQSFTTJPO PG mCSJMMJO BOE JT EJĊFSFOUJBMMZ DPOUSPMMFE CVU PWFSMBQT EVSJOH UIF FNCSZPMPHJDBM EFWFMPQNFOU PG FMBTUJD mCFST ɨF FNCSZPOJD mCSJMMJO OFUXPSL TFSWFT BT B TDBĊPME GPS TVCTFRVFOU EFQPTJUJPO PG QSPFMBTUJO NPMFDVMFT 13 *OWFTUJHBUPST QSPEVDFE LOPDLPVU NJDF PG BOPUIFS FNCSZPOJDBMMZ FYQSFTTFE NPMFDVMF mCVMJO 14 15 .JDF EFmDJFOU JO mCVMJO QSFTFOU WBTDVMBS EFGFDUT FNQIZTFNBUPVT MVOH BOE TFWFSF MPPTF TLJO MBDLJOH FMBTUJD mCFST ɨFJS XPSL EFNPOTUSBUFT UIBU mCVMJO JT SFRVJSFE GPS FMBTUPHFOFTJT

Figure 1. Typical red striae distensae that appeared during pregnancy.

5(' β TJHOBMJOH EJTSVQUJPO NBZ CF SFMFWBOU JO HMVDPDPSUJDPJE JOEVDFE 4% 9 1BSBEPYJDBMMZ SFTFBSDIFST SFDFOUMZ SFQPSUFE UIBU EFYBNFUIBTPOF OPSNBMJ[FT BCFSSBOU FMBTUJD mCFS QSPEVDUJPO BOE DPMMBHFO TFDSFUJPO CZ -PFZT %JFU[ TZOESPNF mCSPCMBTUT QSFTFOUJOH 5(' β SFDFQUPS NVUBUJPOT 10 *U JT VODMFBS IPX UIFTF mOEJOHT mU XJUI UIF JOEVDUJPO PG 4% BGUFS QSPMPOHFE UPQJDBM HMVDPDPSUJDPJE BQQMJDBUJPO PO OPSNBM TLJO PG TUSFUDI NBSLoQSPOF MPDBUJPOT 5SFUJOPJO IBT CFFO VTFE BT BO FNQJSJDBM USFBUNFOU GPS SFE 4% CVU JU EPFT OPU JNQSPWF XIJUF 4% 3FUJOPJD BDJE JODSFBTFT mCSJMMJO EFQPTJUJPO JO UIF FYUSBDFMMVMBS NBUSJY PG QIPUPEBNBHFE TLJO QPTTJCMZ UISPVHI 5(' β BDUJWBUJPO 11 5(' β JT LOPXO UP JOEVDF NZPmCSPCMBTU GPSNBUJPO "T NFOUJPOFE BCPWF SFE 4% CVU OPU XIJUF 4% BSF SJDI JO DFMMT QSFTFOUJOH B NZPmCSPCMBTU QIFOPUZQF 12 8F DBO TQFDVMBUF UIBU USFUJOPJO NJHIU FOIBODF mCSJMMJO QSPEVDUJPO CZ SFE 4% NZPmCSPCMBTUT JO B 5(' β– EFQFOEFOU GBTIJPO BWPJEJOH DPNQMFUF CSFBLBHF PG UIF QSF FTUBCMJTIFE NJDSPmCSJMBS TDBĊPME UIFSFGPSF BMMPXJOH QBSUJBM SFWFSTBM PG UIF FMBTUJD OFUXPSL *U XPVME CF JOUFSFTUJOH UP FWBMVBUF

5BLJOH JOUP BDDPVOU UIF UFNQPSBM BOE TQBUJBM DPNQMFYJUZ PG NPMFDVMBS JOUFSBDUJPOT SFRVJSFE GPS FMBTUPHFOFTJT JU JT OP TVSQSJTF UIBU 4% BSF EJċDVMU UP SFWFSTF BTTVNJOH B USFBUNFOU PG 4% XPVME SFRVJSF UIF DSFBUJPO PG B GVODUJPOBM FMBTUJD OFUXPSL MPOH BGUFS JUT OBUVSBM FNCSZPMPHJDBM EFWFMPQNFOU GPS XIJDI XF DPVME VTF UIF UFSN OFPFMBTUPHFOFTJT CONCLUSIONS 4% BSF EJċDVMU UP USFBU DPTNFUJD OVJTBODFT #FUUFS LOPXMFEHF PG JUT QBUIPQIZTJPMPHZ XJMM QSPWJEF NPSF PCKFDUJWF QBSBNFUFST UP UFTU UIF JODSFBTJOH OVNCFS PG USFBUNFOUT DMBJNFE UP JNQSPWF TUSFUDI NBSLT *O BEEJUJPO VMUSBTUSVDUVSBM VOEFSTUBOEJOH PG 4% GPSNBUJPO BOE FWPMVUJPO XJMM TIFE MJHIU POUP UIF JOUSJHVJOH JOUFSBDUJPOT PG UIF FYUSBDFMMVMBS FMBTUJD OFUXPSL TZTUFN BOE DMBSJGZ JUT SPMF JO DFMMVMBS IPNFPTUBTJT #FTJEFT IFMQJOH UP JNQSPWF DPTNFTJT UIFSBQJFT DBQBCMF PG JOEVDJOH OFPFMBTUPHFOFTJT JO 4% XJMM BMTP QSPWJEF NBKPS BEWBODFT JO UJTTVF FOHJOFFSJOH BOE NBZ MFBE UP FĊFDUJWF UIFSBQJFT GPS .BSGBO TZOESPNF 4PMWJOH UIF TUSFUDI NBSL NPMFDVMBS QV[[MF JT OPU B TVQFSnVPVT HBNF

Figure 2. 0QUJDBM DPIFSFODF UPNPHSBQIZ 0$5 PG OPSNBM TLJO MFGU TJEF PG UIF XIJUF CBS BOE PG TUSJBF distensae (right side). The epidermal/dermal junction (arrow) is sharper and the dermis (*) appears denser in UIF OPSNBM TLJO XIFO DPNQBSFE XJUI UIF BGGFDUFE BSFBT 0$5 JNBHF PCUBJOFE JO DPMMBCPSBUJPO XJUI "OEFSTPO 'SFJUBT *OTUJUVUP EF 1FTRVJTBT &OFSHÏUJDBT F /VDMFBSFT 4ÍP 1BVMP #SB[JM SKINmed. 2012;10:338–340

339

4USJBF %JTUFOTBF ɨF 'JCSJMMJO 5SBOTGPSNJOH (SPXUI 'BDUPS

$0..&/5"3:

November/December 2012

diagnostic value of striae. J Am Acad Dermatol. 201;64: 290–295.

Figure 3. )JTUPMPHZ IFNBUPYZMJO BOE FPTJO PSJHJOBM NBHOJĂĽDBUJPO x20) of striae distensae demonstrating fragmented collagen from the same patient as that shown in Figure 2.

REFERENCES 1

7JFOOFU $ #SJEF + "SNCSVTUFS 7 FU BM $POUSBDUJMF GPSDFT HFOFSBUFE CZ TUSJBF EJTUFOTBF üCSPCMBTUT FNCFEEFE JO DPMMBHFO MBUtices. Arch Dermatol Res. 2005;297:10–17.

2

Agache P. Mechanical factors in striae distensae. In: Morettig ( 3FCPSB " FET Stria Distensae. Milan, Italy: Brocades; 1976: 87–96.

3

8BUTPO 3& 1BSSZ &+ )VNQISJFT +% FU BM 'JCSJMMJO NJDSPüCSJMT BSF SFEVDFE JO TLJO FYIJCJUJOH TUSJBF EJTUFOTBF Bri Dermatol J. 1998;138:931–937.

4

.JMFXJD[ %. 6SCĂˆO ; #PZE $ (FOFUJD EJTPSEFST PG UIF FMBTUJD ĂĽCFS TZTUFN Matrix Biol. 2000;19:471–480.

5

Ledoux M, Beauchet A, Fermanian C, et al. A case-control study of cutaneous signs in adult patients with Marfan disease:

6

3PCFSUTPO * +FOTFO 4 )BOEGPSE 1 5# EPNBJO QSPUFJOT FWPMVUJPOBSZ JOTJHIUT JOUP UIF NVMUJGBDFUFE SPMFT PG üCSJMMJOT BOE -5#1T Biochem J. 2010;433:263–276.

7

3BHIVOBUI . 6OTÚME $ ,VCJUTDIFDL 6 5IF DVUBOFPVT NJDSPüCSJMMBS BQQBSBUVT DPOUBJOT MBUFOU USBOTGPSNJOH HSPXUI GBDUPS CFUB CJOEJOH QSPUFJO -5#1 BOE JT B SFQPTJUPSZ GPS MBUFOU 5(' CFUB J Invest Dermatol. 1998;111:559–564.

8

0MJWJFSJ + 4NBMEPOF 4 3BNJSF[ ' 'JCSJMMJO BTTFNCMJFT FYUSBDFMMVMBS EFUFSNJOBOUT PG UJTTVF GPSNBUJPO BOE üCSPTJT Fibrogenesis Tissue Repair. 2010;3:24–31.

9

Leivo T, Arjomaa P, Oivula J, et al. Differential modulation of transGPSNJOH HSPXUI GBDUPS CFUB CZ CFUBNFUIBTPOF WBMFSBUF BOE isotretinoin: corticosteroid decreases and isotretinoin increases UIF MFWFM PG USBOTGPSNJOH HSPXUI GBDUPS CFUB JO TVDUJPO CMJTUFS fluid. Skin Pharmacol Appl Skin Physiol. 2000;13:150–156.

10 #BSOFUU $1 $IJUBZBU % #SBEMFZ 5+ 8BOH : )JOFL " %FYBNFUIBTPOF OPSNBMJ[FT BCFSSBOU FMBTUJD üCFS QSPEVDUJPO BOE DPMMBHFO TFDSFUJPO CZ -PFZT %JFU[ TZOESPNF üCSPCMBTUT B QPTTJCMF treatment? Eur J Hum Genet. 2011;19:624–633.

11 8BUTPO 3& $SBWFO /. ,BOH 4 FU BM " TIPSU UFSN TDSFFOJOH QSPUPDPM VTJOH üCSJMMJO BT B SFQPSUFS NPMFDVMF GPS QIPUPBHJOH repair agents. J Invest Dermatol. 2001;116:672–678.

12 ,JTTJO &: -FNBJSF 3 ,PSO +) -BGZBUJT 3 5SBOTGPSNJOH HSPXUI factor β JOEVDFT üCSPCMBTU üCSJMJO NBUSJY GPSNBUJPO Arthritis Rheum. 2002;46:3000-3009.

13 )JSBJ . )PSJHVDIJ . 0ICBZBTIJ 5 FU BM -BUFOU 5(' β CJEJOH QSPUFJO CJOET UP %"/$& üCVMJO BOE SFHVMBUFT FMBTUJD üCFS BTTFNCMZ EMBO J. 2007;26:3283–3295.

14 /BLBNVSB 5 -P[BOP 13 *LFEB : FU BM 'JCVMJO %"/$& JT essential for elastogenesis in vivo. Nature. 2002;417:171–175.

15 :BOBHJTBXB ) %BWJT &$ 4UBSDIFS #$ FU BM 'JCVMJO JT BO FMBTUJO CJEJOH QSPUFJO FTTFOUJBM GPS FMBTUJD üCSF EFWFMPQNFOU JO WJWP Nature. 2002;415:168–171.

VINTAGE LABEL

$PVSUFTZ PG #VZ&OMBSHF 1IJMBEFMQIJB 1" SKINmed. 2012;10:338–340

340

4USJBF %JTUFOTBF ɨF 'JCSJMMJO 5SBOTGPSNJOH (SPXUI 'BDUPS

7PMVNF t *TTVF

November/December 2012

ORIGINAL CONTRIBUTION

Hair Care Practices in Diverse Populations: What Makes the Difference?

Jeaneen Chappell, MD; Eric Armbrecht, PhD; Sara Jensen, MD ABSTRACT ɨJT TUVEZ FYBNJOFT XIFUIFS TPDJPEFNPHSBQIJD GBDUPST BOE PS IBJS BUUSJCVUFT BSF CFUUFS QSFEJDUPST PG IBJS XBTI GSFRVFODZ " UPUBM PG QBUJFOUT XFSF SFDSVJUFE GSPN UIF HFOFSBM EFSNBUPMPHZ PVUQBUJFOU DMJOJD UP DPNQMFUF BO JUFN RVFTUJPOOBJSF CZ TFMG SFQPSU ɨSFF MJOFBS SFHSFTTJPO NPEFMT XFSF DPOTUSVDUFE BOE DPNQBSFE UP EFUFSNJOF XIFUIFS TPDJPEFNPHSBQIJD GBDUPST IBJS XBTI GSFRVFODZ PS B DPNCJOBUJPO PG UIF UXP XPVME CFTU QSFEJDU XBTI GSFRVFODZ 3FTVMUT TIPXFE UIBU TPDJPEFNPHSBQIJD GBDUPST TQFDJmDBMMZ SBDF TFY BOE BHF HSPVQ BSF BMM CFUUFS QSFEJDUPST PG IBJS XBTI GSFRVFODZ UIBO IBJS BUUSJCVUFT TVDI BT IBJS UZQF UFYUVSF MFOHUI BOE TDBMQ UZQF BEKVTUFE R 2 WT SFTQFDUJWFMZ SKINmed. o

W

IFO NBOBHJOH IBJS BOE TDBMQ EJTPSEFST POF NVTU VOEFSTUBOE GBDUPST UIBU JOnVFODF IBJS XBTI GSFRVFODZ UP FOTVSF QSPQFS USFBUNFOU WFIJDMF TFMFDUJPO 0VS SFWJFX PG UIF MJUFSBUVSF TVHHFTUT UIBU OP TUVEJFT IBWF BUUFNQUFE UP BTTFTT XIJDI EJĊFSFODFT TPDJPEFNPHSBQIJD BOE PS IBJS BUUSJCVUFT CFTU DPSSFMBUF UP XBTI GSFRVFODZ *O UIFPSZ JEFOUJGZJOH XIJDI GBDUPST BSF UIF CFTU QSFEJDUPST PG IBJS XBTI GSFRVFODZ 8' XPVME IFMQ DMJOJDJBOT RVJDLMZ BOE BDDVSBUFMZ DIPPTF UIF NPTU BQQSPQSJBUF USFBUNFOU WFIJDMF 'PS FYBNQMF B GPBN QSFQBSBUJPO XPVME CF B CFUUFS WFIJDMF UIBO TIBNQPP GPS QBUJFOUT XIP QSBDUJDF MFTT UIBO PODF XFFLMZ IBJS XBTIJOH ɨJT TUVEZ XJMM EFUFSNJOF XIJDI GBDUPST FJUIFS TPDJPEFNPHSBQIJD PS IBJS BUUSJCVUFT BSF UIF CFTU QSFEJDUPST PG IBJS XBTI GSFRVFODZ

QSBDUJDFT TQFDJmDBMMZ XBTIJOH GSFRVFODZ ɨF GSFRVFODZ EJTUSJCVUJPO PG UIF QSJNBSZ PVUDPNF WBSJBCMF 8' XBT BTTFTTFE CZ B IJTUPHSBN BOE NFBTVSFT PG EJTQFSTJPO UP DPOmSN JUT TVJUBCJMJUZ GPS B MJOFBS SFHSFTTJPO NPEFM ɨSFF MJOFBS SFHSFTTJPO NPEFMT XFSF DPOTUSVDUFE UP EFUFSNJOF UIF BTTPDJBUJPO CFUXFFO IBJS 8' BOE 4%' )" PS B DPNCJOBUJPO PG CPUI 4%' )" ɨF 4%' POMZ NPEFM DPOTJEFSFE UISFF QSFEJDUPS WBSJBCMFT SBDF "GSJDBO "NFSJDBO $BVDBTJBO

TFY NBMF GFNBMF BOE BHF HSPVQ o o o ǚ ZFBST ɨF )" POMZ NPEFM DPOTJEFSFE GPVS QSFEJDUPS WBSJBCMFT JODMVEJOH IBJS UZQF DVSMZ TUSBJHIU XBWZ UFYUVSF mOF DPBSTF

MFOHUI TIPSU NFEJVN MPOH BOE TDBMQ UZQF ESZ PJMZ

3BDF UIF QSJNBSZ QSFEJDUJWF WBSJBCMF JO UIF NPEFMT XBT DPEFE BT CMBDL BOE XIJUF ɨF DBUFHPSJDBM WBSJBCMFT XJUI UXP MFWFMT 0O BQQSPWBM GSPN UIF 4BJOU -PVJT 6OJWFSTJUZ 4DIPPM PG .FEJ- JF TFY IBJS UFYUVSF BOE TDBMQ UZQF XFSF BMTP DPEFE JO B TJNJMBS DJOF T JOTUJUVUJPOBM SFWJFX CPBSE QBUJFOUT XFSF SFDSVJUFE NBOOFS JO XIJDI UIF WBMVF PG XBT BTTJHOFE UP UIF MFWFM NPTU GSPN UIF HFOFSBM EFSNBUPMPHZ PVUQBUJFOU DMJOJD UP DPNQMFUF BO BTTPDJBUFE XJUI NPSF GSFRVFOU IBJS XBTIJOH .PTU WBSJBCMFT XJUI JUFN RVFTUJPOOBJSF CZ TFMG SFQPSU 'JHVSF ɨF RVFTUJPO- ǚ MFWFMT FH BHF HSPVQ IBJS MFOHUI XFSF USFBUFE BT PSEJOBM WBSJOBJSF NFBTVSFE TPDJPEFNPHSBQIJD GBDUPST 4%'T IBJS BUUSJCVUFT BCMFT XJUI BO FRVBM EJTUBODF CFUXFFO FBDI MFWFM )BJS UZQF XBT )" BOE IBJS DBSF QSBDUJDFT JODMVEJOH CVU OPU MJNJUFE UP OVN- DPEFE BT B EVNNZ WBSJBCMF GPS FBDI MFWFM JF DVSMZ TUSBJHIU XBWZ

CFS PG XBTIFT QFS XFFL "MM UISFF SFHSFTTJPO NPEFMT XFSF DSFBUFE VTJOH 4144 WFSTJPO %FTDSJQUJWF TUBUJTUJDT XFSF DBMDVMBUFE GPS SBDF BHF BOE TFY PG UIF $IJDBHP *- ɨF TJHOJmDBODF MFWFM BOE b DPFċDJFOU PG FBDI QBUJFOUT BOE EJĊFSFODFT JO BHF BOE TFY XFSF BTTFTTFE CZ SBDF QSFEJDUPS WBSJBCMF JO UIF SFTQFDUJWF NPEFMT XBT EFUFSNJOFE BOE HSPVQ "GSJDBO "NFSJDBO WT $BVDBTJBO " t UFTU GPS JOEFQFOEFOU SFDPSEFE "O BMQIB MFWFM PG XBT TFMFDUFE GPS TUBUJTUJDBM TJHTBNQMFT XBT FNQMPZFE GPS UIF DPOUJOVPVT WBSJBCMF BHF XIJMF B OJmDBODF ɨF BEKVTUFE R2 GPS FBDI NPEFM XBT SFDPSEFE BOE VTFE DIJ TRVBSF UFTU XBT QFSGPSNFE GPS UIF EJDIPUPNPVT WBSJBCMF TFY UP DPNQBSF UIF EFHSFF UP XIJDI FBDI NPEFM FYQMBJOFE UIF WBSJ%JĊFSFODFT CFUXFFO SBDF HSPVQT XFSF BMTP BTTFTTFE GPS IBJS DBSF BODF JO UIF PVUDPNF WBSJBCMF 8' METHODS

From the Department of Dermatology, Saint Louis University School of Medicine, Saint Louis, MO Address for Correspoindence: Jeaneen Chappell, MD, Saint Louis University School of Medicine, Department of Dermatology, 1402 South (SBOE #PVMFWBSE 4U -PVJT .0 t & NBJM KDIBQQF !TMV FEV

SKINmed. o

341

ª 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$

03*(*/"- $0/53*#65*0/

November/December 2012

Department of Dermatology

Hair Care Survey 1. What is your age?

__________

2. What is your gender?

Male________

Female________

3. What is your ethnicity?

Non-Hispanic________

Hispanic________

4. What is your race?

Black________

White________

Hispanic_________

Native American________

Asian________

Other (please explain) _____________________________

5. What is your natural hair color?

Brown________

Black________

Blonde________

Red________

Gray________

6. What is your hair texture?

Fine________

Coarse________

7. Is your hair either? (check all that apply) Straight________

Curly________

Wavy________

Oily________

Neither________

Thin________

Normal________

8. Is your hair usually?

Dry________

Combination________

9. Is your hair?

Thick________

10. What is your hair length?

Short________

Medium________

Long________

11. What is your average styling time after washing your hair? £5 min_______ 6–10 min________ 11–20 min________ 21–30 min________ >30 min________ 12. Do you oil your scalp? (If yes include what product you are currently using) Yes_________________________________

No________

13. How often do you wash your hair? (please enter a number in appropriate spot) _______ times/week

_______ times/month

Other________________________________________ 14. Who washes your hair?

Yourself________

Hairdresser________

SKINmed. o

342

)BJS $BSF 1SBDUJDFT JO %JWFSTF 1PQVMBUJPOT

03*(*/"- $0/53*#65*0/

November/December 2012 15. Do you currently color your hair?

Yes________

No________

16. Do you currently have any of the following?

Perm________

Relaxer________

Braids________ None________

Texturizer________

Jheri curl________

S curl________

Other_____________________________

17. Do you have dandruff/ямВaky scalp? (If yes, continue to questions below) Yes________

No________

18. Are you currently being treated for seborrheic dermatitis (i.e. dandruff) by a doctor? (If yes include the most recent treatment) Yes________

No________

Medication: ________________________________

Strength___________

Medication: ________________________________

Strength___________

Frequency of use______________________________ 19. If you are currently being treated for seborrheic dermatitis, how satisямБed are you with your current treatment?

Very much________

Very________

Somewhat________

A little________

Not at all_________ 20. If you are currently being treated for seborrheic dermatitis, were you ever asked about your hair care practices by your physician?

Yes________

No________

Figure 1. 4BNQMF PG UIF JUFN IBJS DBSF TVSWFZ

WBSJBCMFT SBDF P TFY P BOE BHF HSPVQ P

SFTVMUFE JO TUBUJTUJDBM TJHOJmDBODF ╔иF TUBOEBSEJ[FE b DPF─ЛDJFOU XFSF o BOE GPS SBDF BHF BOE TFY SFTQFDUJWFMZ "T PCTFSWFE JO UIF 4%' POMZ NPEFM SBDF DPOUSJCVUFE BMNPTU UJNFT UIF BNPVOU PG BOZ PUIFS WBSJBCMF JO UIF )" 4%' NPEFM /POF PG UIF )"T XFSF TUBUJTUJDBMMZ TJHOJmDBOU QSFEJDUPST PG XBTI GSFRVFODZ JO UIF )" 4%' NPEFM

RESULTS

&JHIUZ POF XPNFO BOE NFO CFUXFFO UIF BHFT PG BOE ZFBST DPNQMFUFE UIF TVSWFZ ╔иJSUZ TFWFO XFSF "GSJDBO "NFSJDBO BOE XFSF $BVDBTJBO 5BCMF ╔иF BWFSBHF BHF XBT ZFBST ╔иFSF XFSF OP TUBUJTUJDBMMZ TJHOJmDBOU EJ─КFSFODFT JO BHF HSPVQ PS TFY EJTUSJCVUJPOT CZ SBDF 0WFSBMM PG "GSJDBO "NFSJDBO SFTQPOEFST SFQPSUFE XBTIJOH UIFJS IBJS PS GFXFS UJNFT QFS XFFL $POWFSTFMZ PG $BVDBTJBO SFTQPOEFST SFQPSUFE XBTIJOH ╔иF )" POMZ NPEFM 'JHVSF ZJFMEFE BO BEKVTUFE R2 PG UIFJS IBJS ╟Ъ UJNFT QFS XFFL XJUI UIF POMZ TJHOJmDBOU WBSJBCMFT CFJOH DVSMZ IBJS UZQF P

╔иF NPEFM DPOUBJOJOH POMZ 4%' 'JHVSF ZJFMEFE BO BEKVTUFE BOE TDBMQ UZQF P ╔иF TUBOEBSEJ[FE b DPF─ЛDJFOUT XFSF R2 PG XJUI BMM GBDUPST XJUIJO UIF 4%' HSPVQ CFJOH TUBUJTUJ- o BOE GPS DVSMZ IBJS UZQF BOE TDBMQ UZQF SFTQFDUJWFMZ DBMMZ TJHOJmDBOU QSFEJDUPST PG XBTI GSFRVFODZ SBDF P $VSMZ IBJS IBE B MPXFS XBTI GSFRVFODZ UIBO PUIFS IBJS UZQFT BOE TFY P BOE BHF HSPVQ P ╔иF TUBOEBSEJ[FE b ESZ TDBMQ UZQFT IBE MPXFS XBTI GSFRVFODZ UIBO PJMZ UZQFT $VSMZ DPF─ЛDJFOUT XFSF o BOE GPS SBDF BHF BOE TFY IBJS UZQF IBE UIF HSFBUFTU SFMBUJWF DPOUSJCVUJPO UP UIJT NPEFM SFTQFDUJWFMZ 3BDF IBE UIF HSFBUFTU SFMBUJWF DPOUSJCVUJPO UP UIJT DPOUSJCVUJOH BMNPTU UJNFT BT NVDI BT BOZ PUIFS WBSJBCMF NPEFM DPOUSJCVUJOH NPSF UIBO UJNFT BT NVDI BT BOZ PUIFS DISCUSSION WBSJBCMF BT NFBTVSFE CZ UIF SFMBUJWF TJ[F PG JUT b DPF─ЛDJFOU " XJEF WBSJFUZ PG UPQJDBM WFIJDMFT BSF BWBJMBCMF GPS NFEJDBUJPOT ╔иF NPEFM UIBU DPNCJOFE UIF )" BOE 4%' 'JHVSF HSPVQT UIBU USFBU TDBMQ EJTPSEFST 1SPQFS WFIJDMF TFMFDUJPO JT JNQPSUBOU BMTP ZJFMEFE BO BEKVTUFE R2 PG IPXFWFS POMZ UIF 4%' XIFO NBOBHJOH TDBMQ DPOEJUJPOT TVDI BT QTPSJBTJT PS TFCPSSIFJD SKINmed. o

343

)BJS $BSF 1SBDUJDFT JO %JWFSTF 1PQVMBUJPOT

03*(*/"- $0/53*#65*0/

November/December 2012

Table. Demographic Characteristics and Hair Attributes of Study Participants (N=96)

7

AFRICAN CAUCASIAN AMERICAN

Actual Wash Hair Times Per Week

6

n=59

P VALUE

.FBO BHF Z

'FNBMF

#MPOE PS 3FE

(SBZ

'JOF

$PBSTF

4IPSU

.FEJVN

-POH

ɨJO

/PSNBM

ɨJDL

%SZ

0JMZ

/PSNBM PS $PNCP

:FT

No

DEMOGRAPHIC CHARACTERISTICS 4

3

HAIR ATTRIBUTES

2

/BUVSBM $PMPS 1

#SPXO PS #MBDL

0 0.0

1.0

2.0

3.0 4.0 Predicted Value

5.0

6.0

7.0

5FYUVSF

Figure 2. Sociodemographic factor linear regression model (95% confidence interval, lines; R2=0.59)

-FOHUI

7

6 Actual Wash Hair Times Per Week

n=37

5

5

ɨJDLOFTT

4

3

4DBMQ 5ZQF

2

1

0 0.0

1.0

2.0

3.0 4.0 Predicted Value

5.0

6.0

%BOESVÄŠ

7.0

Figure 3. Hair attributes plus sociodemographic factors linear regression model (95% confidence interval, lines; R2=0.59)

$IFNJDBM 1SPDFTT 3FMBYFS

EFSNBUJUJT CFDBVTF UIF FÄ‹DBDZ PG UIFTF USFBUNFOUT EFQFOET :FT

MBSHFMZ PO DPNQMJBODF BOE UIF BNPVOU PG BDUJWF JOHSFEJFOU EFMJW1 No

FSFE UP UIF TDBMQ *U JT UIFSFGPSF JNQPSUBOU UP QSFTDSJCF WFIJDMFT UIBU BSF FBTZ UP BQQMZ BOE DBVTF UIF MFBTU BNPVOU PG EJTSVQUJPO UP UIF QBUJFOU T QSF FYJTUJOH IBJS DBSF QSBDUJDFT 2–3 *EFBMMZ SFBMJTUJDBMMZ UJNF JT PGUFO UPP MJNJUFE JO UIF DMJOJDBM TFUUJOH UP WFIJDMF TFMFDUJPO XPVME CF JOEJWJEVBMJ[FE UP FBDI QBUJFOU CVU GVMMZ FWBMVBUF FBDI QBUJFOUT IBJS BUUSJCVUFT BOE IBJS DBSF QSBDUJDFT SKINmed. o

344

)BJS $BSF 1SBDUJDFT JO %JWFSTF 1PQVMBUJPOT

03*(*/"- $0/53*#65*0/

November/December 2012

$IFNJDBM SFMBYFST B TUSBJHIUFOJOH UFDIOJRVF DPNNPO BNPOH "GSJDBO "NFSJDBOT BT ZPVOH BT UP ZFBST VTF TPEJVN QPUBTTJVN MJUIJVN PS HVBOJEJOF IZESPYJEFT UP DMFBWF DZTUFJOF EJTVMmEF CPOET JO UIF IBJST XIJDI SFTVMUT JO B TPGUFS DVSM QBUUFSO "MUIPVHI UIFJS VTF XBT SFQPSUFE CZ PG "GSJDBO "NFSJDBO SFTQPOEFOUT JU XBT OPU BTTPDJBUFE XJUI BO FĊFDU PO 8' *OUFSFTUJOHMZ BMUIPVHI DVSMZ IBJS UZQF XBT UIF CFTU QSFEJDUPS PG 8' BNPOH UIF )"T UFTUFE UIFTF BUUSJCVUFT JO HFOFSBM XFSF UIF QPPSFTU QSFEJDUPST PG 8' BOE ZJFMEFE UIF MPXFTU BEKVTUFE R2 PG BMM UIF NPEFMT UFTUFE WT )" BMTP EJE OPU DPOUSJCVUF BOZ TUBUJTUJDBMMZ TJHOJmDBOU WBSJBCMFT UP UIF )" 4%' NPEFM ɨJT TVHHFTUT UIBU 8' BOE QPTTJCMZ PUIFS IBJS DBSF QSBDUJDFT XFSF NPSF EFQFOEFOU PO FUIOJDJUZ TFY BOE TPDJBM PS DVMUVSBM OPSNT SBUIFS UIBO UIF BUUSJCVUFT PG UIF IBJS JUTFMG

7

Actual Wash Hair Times Per Week

6

5

4

3

2

1

0

"T QBUJFOU QPQVMBUJPOT CFDPNF JODSFBTJOHMZ NVMUJDVMUVSBM BOE QIFOPUZQFT CFDPNF MFTT TUFSFPUZQJDBM JU XJMM CF JNQPSUBOU GPS QIZTJDJBOT UP CF FUIOJDBMMZ DPOTDJPVT TJODF IBJS DBSF QSBDUJDFT Figure 4. Hair attributes linear regression model (95% NBZ CF EJDUBUFE NPSF CZ B QBUJFOU T DVMUVSBM CBDLHSPVOE PS confidence interval, lines; R2=0.27) EFNPHSBQIJD BUUSJCVUFT UIBO UIF QIFOPUZQJD BUUSJCVUFT PG UIF IBJS JUTFMG 8IFO FWBMVBUJOH QBUJFOUT JO UPUP TJNVMBUFE CZ UIF ɨJT MFBET UP QIZTJDJBOT BQQMZJOH CSPBE HFOFSBMJ[BUJPOT SFHBSEJOH )" 4%' NPEFM POMZ 4%' SBDF TFY BOE BHF BSF SFMJBCMF QSFIBJS DBSF QSBDUJDFT BDSPTT IFUFSPHFOFPVT FUIOJD HSPVQT UIBU NBZ EJDUPST PG 8' 4%' BSF UIFSFGPSF UIF NPTU IFMQGVM GBDUPST UP UBLF OPU OFDFTTBSJMZ BQQMZ UP JUT NFNCFST 0OF PG UIF NPTU DPNNPO JOUP DPOTJEFSBUJPO XIFO TFMFDUJOH B NFEJDBUJPO XIPTF FċDBDZ SBUF MJNJUJOH IBJS DBSF QSBDUJDFT BNPOH EJĊFSFOU DVMUVSFT JT 8' 4– SFMJFT PO 8' #BTFE PO BOUISPQPMPHJD TUVEJFT JU JT XFMM LOPXO UIBU WBSJBCJMJUZ FYJTUT CFUXFFO IBJS TIBQFT BNPOH FUIOJD HSPVQT 4PNF BVUIPST LIMITATIONS CSPBEMZ EJWJEF UIFTF HSPVQT CBTFE PO FUIOJD PSJHJO SFTVMUJOH JO 3FTVMUT XFSF MJNJUFE CZ QBUJFOU SFDBMM PG 8' GBJMVSF UP NFBTVSF PUIFS UISFF NBJO DMBTTJmDBUJPOT "GSJDBO "TJBO BOE $BVDBTJBO 0UIFS GBDUPST UIBU NBZ JOnVFODF 8' BOE GBJMVSF UP JODMVEF SBDF PUIFS UIBO BVUIPST SFMZ PO TIBQF QBUUFSO EFTDSJQUPST TVDI BT XBWZ DVSMZ BOE $BVDBTJBO BOE "GSJDBO "NFSJDBO ɨJT QBUJFOU TBNQMF ESBXO GSPN TUSBJHIU XIJMF PUIFST VTF B NPSF TDJFOUJmD NFUIPE PG DMBTTJGZJOH B VOJWFSTJUZ CBTFE DMJOJD NBZ OPU CF SFQSFTFOUBUJWF PG UIF HFOFSBM IBJS UZQFT CBTFE PO GBDUPST TVDI BT UIF DVSWF EJBNFUFS DVSM JOEFY QPQVMBUJPO BOE SFTVMUT TIPVME CF HFOFSBMJ[FE XJUI DBVUJPO &WFO BOE OVNCFS PG XBWFT BOE UXJTUT –8 "MUIPVHI JU JT JNQPSUBOU UP XJUI JUT MJNJUBUJPOT UIJT TUVEZ ESBXT BUUFOUJPO UP B DMJOJDBM OFFE HFOFSBUF B SFQSPEVDJCMF NFUIPE PG EJTUJOHVJTIJOH EJĊFSFOU IBJS BNPOH EFSNBUPMPHJTUT UP BTTFTT EFNPHSBQIJD GBDUPST JO B DVMUVSBMMZ UZQFT GFX TUVEJFT TDJFOUJmDBMMZ BEESFTT XIFUIFS UIFTF EJĊFSFODFT TFOTJUJWF BOE SFTQFDUGVM NBOOFS JNQBDU 8' 0.0

1.0

2.0

3.0 4.0 Predicted value

5.0

6.0

7.0

*O UIJT TUVEZ "GSJDBO "NFSJDBO XPNFO PMEFS UIBO XFSF GPVOE UP XBTI UIFJS IBJS UIF MFBTU XIJMF $BVDBTJBO NFO CFUXFFO UIF BHFT PG BOE ZFBST XBTIFE NPTU PGUFO 6TJOH UIF 4%' POMZ NPEFM UP DPNQBSF UIF TBNF TFY BOE BHF HSPVQ BMTP TIPXT B RVBOUJUBUJWF EJĊFSFODF JO 8' "GSJDBO "NFSJDBO XPNFO PMEFS UIBO BSF QSFEJDUFE UP XBTI UIFJS IBJS MFTT UIBO PODF B XFFL Z XBTIFT QFS XFFL XIJMF $BVDBTJBO XPNFO PMEFS UIBO ZFBST BSF QSFEJDUFE UP XBTI UIFJS IBJS BMNPTU UJNFT QFS XFFL Z XBTIFT QFS XFFL %FDSFBTFE 8' JT OPU FYDMVTJWF UP UIF BEVMU "GSJDBO "NFSJDBO QPQVMBUJPO *U JT BMTP QSBDUJDFE CZ "GSJDBO "NFSJDBO HJSMT XJUI PG SFTQPOEFOUT JO POF TUVEZ SFQPSUJOH B 8' PG PODF FWFSZ UP XFFLT SKINmed. o

CONCLUSIONS )BJS RVBMJUJFT TVDI BT UFYUVSF BOE DVSMJOFTT XFSF PCUBJOFE CZ TFMG SFQPSU WJB TVSWFZ *U JT QPTTJCMF UIBU UIFSF JT B DVMUVSBM CJBT JO SFTQPOTFT CFUXFFO $BVDBTJBOT BOE "GSJDBO "NFSJDBOT CVU UIFSF JT OP FWJEFODF JO UIF SFWJFXFE MJUFSBUVSF PS UIF DMJOJDBM BOE SFTFBSDI FYQFSJFODF PG UIF BVUIPST UIBU B SFTQPOEFOU T DVMUVSF XPVME BĊFDU SFTQPOTFT SFHBSEJOH IBJS RVBMJUJFT 8F CFMJFWF UIF SJTL PG QPTTJCMF DPOGPVOEJOH BUUSJCVUBCMF UP DVMUVSBM CJBT JT TNBMM 0VS TUVEZ EJE OPU JODPSQPSBUF BOZ TQFDJBM NFDIBOJTN UP DPOUSPM PS BTTFTT UIJT CJBT JG QSFTFOU 'VUVSF SFTFBSDI JT OFFEFE UP BTTFTT DVMUVSBM CJBT CFUXFFO $BVDBTJBOT BOE "GSJDBO "NFSJDBOT JO TFMG BTTFTTNFOU PG QIZTJDBM BUUSJCVUFT PG IBJS

)BJS $BSF 1SBDUJDFT JO %JWFSTF 1PQVMBUJPOT

03*(*/"- $0/53*#65*0/

November/December 2012 5

REFERENCES 1

#BJMFZ 1 "SSPXTNJUI $ %BSMJOH , FU BM " EPVCMF CMJOE SBOEPNJ[FE WFIJDMF DPOUSPMMFE DMJOJDBM USJBM JOWFTUJHBUJOH UIF FGGFDU PG ;O150 EPTF PO the scalp vs. antidandruff efficacy and antimycotic activity. Int J Cosmet Sci. 2003;25:183–188.

2

)PVTNBO 54 .FMMFO #( 3BQQ 43 'MFJTDIFS "# +S 'FMENBO 43 1BUJFOUT with psoriasis prefer solution and foam vehicles: a quantitative assess ment of vehicle preference. Cutis. 2002;70:327–332.

3

(SJNBMU 3 " QSBDUJDBM HVJEF UP TDBMQ EJTPSEFST J Investig Dermatol Symp Proc. 2007;12:10–14.

4

McMichael AJ. Hair and scalp disorders in ethnic populations. Dermatol Clin. 2003;2:629–644.

6

7 8

9

2VJOO $3 2VJOO 5. ,FMMZ "1 )BJS DBSF QSBDUJDFT JO "GSJDBO "NFSJDBO women. Cutis. 2003;72:280–282, 285–289. %F MB .FUUSJF 3 4BJOU -�HFS % -PVTTPVBSO ( FU BM 4IBQF WBSJBCJMJUZ BOE classification of human hair: a worldwide approach. Hum Biol.

2007;79:265–281.

-PVTTPVBSO ( (BSDFM "- -P[BOP * FU BM 8PSMEXJEF EJWFSTJUZ PG IBJS DVSMJ ness: a new method of assessment. Int J Dermatol. 2007;46 suppl 1:2–6. ,BKJVSB : 8BUBOBCF 4 *UPV 5 FU BM 4USVDUVSBM BOBMZTJT PG IVNBO hair single fibres by scanning microbeam SAXS. J Struct Biol. 2006; 155:438–444.

3VDLFS 8SJHIU % (BUIFST 3 ,BQLF " +PIOTPO % +PTFQI $- )BJS DBSF practices and their association with scalp and hair disorders in African American girls. J Am Acad Dermatol. 2011;64:253–262.

VINTAGE LABEL

Courtesy of BuyEnlarge, Philadelphia, PA SKINmed. o

)BJS $BSF 1SBDUJDFT JO %JWFSTF 1PQVMBUJPOT

SMCOMP_v10_i6_ADS.indd 347

14/12/12 6:00 PM

7PMVNF t *TTVF

November/December 2012

ORIGINAL CONTRIBUTION

Topical Acne Treatment With Acetylcysteine: Clinical and Experimental Effects Leopold F. Montes, MD, MS, FRCPC;1,2 Walter H. Wilborn, PhD, MS;2 Carolina M. Montes, MD3 ABSTRACT "NPOH UIF MBSHF WBSJFUZ PG FĊFDUT PG BDFUZMDZTUFJOF TFWFSBM PG UIFN SFMBUF UP DVUBOFPVT GVODUJPO JO HFOFSBM BOE UP TFCBDFPVT BDUJWJUZ JO QBSUJDVMBS %VF UP UIF MBUUFS B TUVEZ XBT VOEFSUBLFO UP JOWFTUJHBUF B QPTTJCMF FĊFDU PG UIJT TVCTUBODF JO HSBEF * BDOF "O BOBMZTJT PG UIF EBUB GSPN QBUJFOUT JO B EPVCMF CMJOE TUVEZ EFNPOTUSBUFE UIBU BDFUZMDZTUFJOF UPQJDBM HFM JT TJHOJmDBOUMZ TVQFSJPS UP QMBDFCP P JO SFEVDJOH DPNFEP DPVOUT $PNQBSBCMF SFTVMUT XFSF PCUBJOFE JO CPUI TFYFT ɨJT TUVEZ JOEJDBUFT UIBU BDFUZMDZTUFJOF JT BO FĊFDUJWF UIFSBQFVUJD PQUJPO GPS UIF USFBUNFOU PG NJME UP NPEFSBUF BDOF SKINmed. o

A

DFUZMDZTUFJOF PS $5H9NO34 JT UIF N BDF UZMDZTUFJOF EFSJWBUJWF PG - DZTUFJOF BO BNJOP BDJE UIBU PDDVST JO NBOZ QSPUFJOT BOE GSPN XIJDI NBZ CF PCUBJOFE CZ IZESPMZTJT "DFUZMBUJPO PG DZTUFJOF QSPEVDFT BDFUZM DZTUFJOF 1 B TVCTUBODF XJUI B WBSJFUZ PG FĊFDUT2–23 5BCMF * 4PNF PG UIFTF BDUJPOT BSF FJUIFS DVUBOFPVT SFMBUFE12 14–20 PS MJOLFE UP TFCVN GVODUJPO 7 8 21

1SFWFOUJPO PG DPOUSBTU NFEJVNoJOEVDFE OFQISPQBUIZ11

ɨVT JU PDDVSSFE UP VT UIBU B TUVEZ EJSFDUFE BU FYQMPSJOH B QPT TJCMF FĊFDU PG UPQJDBM BDFUZMDZTUFJOF JO QBUJFOUT XJUI BDOF XPVME CF XPSUIXIJMF ɨJT SFQPSU TVNNBSJ[FT UIF SFTVMUT PG TVDI B USJBM QFSGPSNFE PO B EPVCMF CMJOE CBTJT

.FMBOPDZUF TIJFME GSPN PYJEBUJWF EBNBHF BOE EFMBZ PG POTFU PG NFMBOPNB17

1SFWFOUJPO PG DZDMPQIPTQIBNJEF DZUBSBCJOF JOEVDFE BMPQFDJB12 5SFBUNFOU PG BVUJTUJD TQFDUSVN EJTPSEFST13 1SFWFOUJPO PG 67 MJHIUoJOEVDFE QIPUPBHJOH PG IVNBO TLJO JO WJWP14 1SPUFDUJPO GSPN 67 #oQSPEVDFE TZTUFNJD JNNVOPTVQQSFTTJPO15 1SPUFDUJPO JO IBQUFO JOEVDFE JSSJUBOU BOE DPOUBDU IZQFSTFOTJUJWJUZ SFBDUJPOT

.PEVMBUJPO PG QSP PODPHFOJD PYJEBUJWF TUSFTT JO OFWJ18 *NQSPWFNFOU PG OFPOBUBM JDIUIZPTJT19 5SFBUNFOU PG USJDIPUJMMPNBOJB20

Table I. Clinical and Experimental Effects of Acetylcysteine

ɨFSBQFVUJD FĊFDU PO UIF TLJO PG TFCPSSIFJD SBUT21 *OIJCJUJPO PG GVOHBM HSPXUI22

.VDPMZTJT UISPVHI CSFBLJOH EJTVMmEF CPOET JO NVDVT1

&OIBODFNFOU PG XPVOE IFBMJOH UISPVHI QSPNPUJPO PG BOHJPHFOFTJT23

5SFBUNFOU PG QBSBDFUBNPM PWFSEPTF CZ JODSFBTJOH HMVUBUIJPOF SFTFSWFT2 5SFBUNFOU PG DISPOJD PCTUSVDUJWF QVMNPOBSZ EJTFBTF3

MATERIAL AND METHODS

1SFWFOUJPO PG TDMFSPTJT JO NZSJOHPUPNJ[FE UZNQBOJD NFNCSBOF4 3FMJFG JO DISPOJD TVQQVSBUJWF PUJUJT NFEJB5

$IFNPQSPUFDUJPO JO MVOH DBODFS BOE PUIFS GPSNT PG DBODFS *NQSPWFNFOU PG .FJCPNJBN HMBOE GVODUJPO7 5SFBUNFOU PG DISPOJD CMFQIBSJUJT8 5SFBUNFOU PG ESZ FZF JO 4KPHSFO TZOESPNF9 .PEVMBUJPO PG JOnBNNBUJPO JO DZTUJD mCSPTJT10

ACETYLCYSTEINE ɨF UPQJDBM QSFQBSBUJPO TUVEJFE XBT B BDFUZMDZTUFJOF HFM &BDI HSBN PG UIJT DMFBS IZESPQIJMJD HFM DPOUBJOFE BDFUZMDZTUF JOF NH BOE UIF QSFTFSWBUJWFT NFUIZMQBSBCFO NH QSPQZM QBSBCFO NH BOE EJTPEJVN FEFUBUF NH JO B DMFBS BRVFPVT HFM PG DBSCPYZWJOZM QPMZNFS HMZDFSJOF BOE XBUFS ɨF HFM XBT BEKVTUFE UP B Q) PG XJUI TPEJVN IZESPYJEF

From the Vitiligo Unit, Buenos Aires, Argentina;1 the Department of Dermatology Research, Structural Research Center, Mobile, AL;2 and Trumbull Laboratories, Germantown, TN3 Address for Correspondence: Leopold F. Montes, MD, MS, FRCPC, Paraguay 2302 (9-A), C1121ABL Buenos Aires, Argentina t & NBJM MFPQPMEP NPOUFT!IPUNBJM DPN

SKINmed. 2012;10:348–351

348

ª 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$

03*(*/"- $0/53*#65*0/

November/December 2012

Table II. General Population Characterization

ACETYLCYSTEINE

PLACEBO

PATIENTS, NO.

PERCENTAGES

PATIENTS, NO.

PERCENTAGES

<13–18

31

19–21

3

3

"HF Z

.FBO

4FY .FO

37

18

8PNFO

28

8IJUF

37

24

#MBDL

27

10

0UIFS

1

0

3BDF

%VSBUJPO PG BDOF Z /PU TUBUFE

3

2

39

>2

23

.FBO

<2

17

15

PATIENTS

STATISTICAL METHOD

" UPUBM PG QBUJFOUT TFFLJOH USFBUNFOU GPS HSBEF * BDOF FOUFSFE UIF TUVEZ 4JYUZ mWF QBUJFOUT XFSF USFBUFE XJUI BDFUZMDZTUFJOF HFM XIJMF QBUJFOUT XFSF USFBUFE XJUI QMBDFCP UIF WFIJDMF BMPOF XJUIPVU BDFUZMDZTUFJOF ɨSFF QBUJFOUT JO UIF BDFUZMDZTUFJOF USFBUFE HSPVQ WPMVOUBSJMZ ESPQQFE PVU PG UIF TUVEZ CFGPSF DPNQMFUJPO ɨF QBUJFOUT EFSNBUPMPHJD BOE HFOFSBM IFBMUI IJTUPSZ XBT SFDPSEFE PO BENJTTJPO UP UIF TUVEZ ɨF DIBSBDUFSJTUJDT PG UIF HFOFSBM QPQVMBUJPO BSF TVNNBSJ[FE JO 5BCMF **

ɨF MFTJPO EBUB XFSF USBOTGPSNFE UP MPHBSJUIN CBTF PG UIF DPNFEP DPVOUT BOE FBDI QBUJFOU T SFTQPOTF UP USFBUNFOU XBT EFUFSNJOFE BT UIF SBUF PG DIBOHF JO UIF MPHBSJUIN PG UIF DPNFEP DPVOU PWFS UIF UJNF DPVSTF PG USFBUNFOU ɨF DBMDVMBUFE DPFċ DJFOUT XFSF CBTFE PO UIF BDUVBM OVNCFS PG EBZT FMBQTFE CFUXFFO UIF TUBSU PG USFBUNFOU BOE BOZ HJWFO PCTFSWBUJPO ɨF EBUB XFSF FWBMVBUFE CZ BO BOBMZTJT PG B ¨ UBCMF XJUI VOFRVBM BOE EJT QSPQPSUJPOBUF TVCDMBTT OVNCFST 5SFBUNFOU BOE TFY FĊFDUT XFSF DBMDVMBUFE BOE UIFJS TJHOJmDBODF EFUFSNJOFE CZ VTJOH UIF 4UV EFOU t TUBUJTUJD

'BDJBM DPNFEP DPVOUT XFSF NBEF QSJPS UP FOUFSJOH UIF TUVEZ BOE FWFSZ XFFLT GPS XFFLT 'PMMPXJOH B QSFUSFBUNFOU EFSNBUP MPHJD FYBNJOBUJPO QBUJFOUT XFSF BTTJHOFE UP B DPEFE QSPEVDU ɨF BTTJHONFOUT UP USFBUNFOU XFSF SBOEPNJ[FE CVU TP PSEFSFE UIBU BQQSPYJNBUFMZ UXP UIJSET PG UIF QBUJFOUT SFDFJWFE BDFU ZMDZTUFJOF HFM BOE UIF SFNBJOJOH QBUJFOUT UIF WFIJDMF BMPOF ɨF EPVCMF CMJOE TUVEZ XBT DPOEVDUFE XJUI UIF QSPEVDU DPEF CFJOH VOLOPXO UP CPUI UIF QBUJFOU BOE UIF JOWFTUJHBUPS

RESULTS

ɨF SBUF PG SFEVDUJPO JO DPNFEP DPVOUT XBT TJHOJmDBOUMZ P

HSFBUFS GPS QBUJFOUT USFBUFE XJUI BDFUZMDZTUFJOF HFM XIFO DPN QBSFE XJUI UIPTF USFBUFE XJUI QMBDFCP "O FTUJNBUF PG UIF QFS DFOU SFEVDUJPO PG DPNFEP DPVOUT BGUFS XFFLT PG USFBUNFOU XBT DBMDVMBUFE UP CF GPS NFO UBLJOH BDFUZMDZTUFJOF UIFSBQZ BOE GPS NFO UBLJOH QMBDFCP ɨF QFSDFOU SFEVDUJPO TREATMENT XBT GPS XPNFO UBLJOH BDFUZMDZTUFJOF BOE GPS &BDI QBUJFOU XBT JOTUSVDUFE UP BQQMZ UIF QSFQBSBUJPO CZ SVCCJOH XPNFO UBLJOH QMBDFCP 5BCMF ***

JU UIPSPVHIMZ PO UIF FOUJSF GBDF UXJDF EBJMZ VOUJM DPNQMFUF QFO FUSBUJPO XBT BDIJFWFE $PODPNJUBOU MPDBM PS TZTUFNJD UIFSBQZ /JOF QFSDFOU PG UIF BDFUZMDZTUFJOF USFBUFE QBUJFOUT BOE PG UIF QMBDFCP USFBUFE QBUJFOUT SFQPSUFE NJME JSSJUBUJPO QFFMJOH XBT FYDMVEFE " OPONFEJDBUFE TPBQ XBT VTFE FYDMVTJWFMZ

SKINmed. 2012;10:348–351

349

5PQJDBM "DOF 5SFBUNFOU 8JUI "DFUZMDZTUFJOF

03*(*/"- $0/53*#65*0/

November/December 2012

Table III. Comparison of 5% Acetylcysteine Gel vs Placebo for the Treatment of Acnea

MEN

WOMEN

37

28

o

o

5% ACETYLCYSTEINE GEL 1BUJFOUT /P .FBO SBUF PG DIBOHF 3FEVDUJPO BU XFFLT

PLACEBO 1BUJFOUT /P .FBO SBUF PG DIBOHF 3FEVDUJPO BU XFFLT

18

o

o

B

ɨF NFBO EBJMZ SBUF PG DIBOHF JO DPNFEP DPVOUT MPH DPVOUT BOE BO FTUJNBUF PG UIF QFSDFOU SFEVDUJPO JO DPNFEP DPVOUT BU UIF UI XFFL PG USFBUNFOU BSF DMBTTJmFE BT UP USFBUNFOU BOE TFY PG QBUJFOU 8FJHIUFE TFY EJÄ&#x160;FSFODF NBMFoGFNBMF o P 8FJHIUFE USFBUNFOU EJÄ&#x160;FSFODF ESVHoQMBDFCP o P

ɨF QSFDJTF NFDIBOJTN PG BDUJPO PG UPQJDBM BDFUZMDZTUFJOF JO BDOF SFNBJOT UP CF JOWFTUJHBUFE ɨF QPTTJCJMJUZ PG BO FÄ&#x160;FDU PO T FCBDFPVT HMBOE TFDSFUJPO XPVME OPU TFFN VOMJLFMZ CFDBVTF BNPOH UIF WBSJPVT FÄ&#x160;FDUT PG BDFUZMDZTUFJOF 5BCMF * BO PVU TUBOEJOH PVUDPNF JT UIF JNQSPWFNFOU PG EZTGVODUJPO PG UIF .FJCPNJBN HMBOE 7 UIF TFCBDFPVT HMBOE PG UIF FZFMJE 3FMBUFE UP UIJT FÄ&#x160;FDU JT UIF FÄ&#x160;FDUJWFOFTT PG BDFUZMDZTUFJOF JO DISPOJD CMFQIBSJUJT 8 ɨF TUVEZ PG B QPTTJCMF FÄ&#x160;FDU PG BDFUZMDZTUFJOF PO UIF TFCBDFPVT HMBOET XPVME UIFSFGPSF CF UIF OFYU MPHJDBM TUFQ *O BEEJUJPO CFDBVTF PG UIF QSFTFODF XJUIJO DPNFEPOFT PG DFMMT PG Pityrosporum ovale 24 33 B QPUFOUJBMMZ DPNFEPHFOJD PSHBO JTN 33 UIF BOUJGVOHBM BDUJPO PG BDFUZMDZTUFJOF22 NBZ MJLFXJTF CF QMBZJOH B SPMF CONCLUSIONS

"T UIF TQFDUSVN PG FÄ&#x160;FDUT BOE VTBHF PG BDFUZMDZTUFJOF DPOUJOVF UP FYQBOE BOPUIFS PVUDPNF JT JUT BCJMJUZ UP SFEVDF UIF OVNCFS PG DPNFEPOFT JO NJME UP NPEFSBUF BDOF XJUIPVU UIF JSSJUBUJPO PS TMJHIU FYBDFSCBUJPO PG BDOF IPXFWFS OPOF PG UIF QBUJFOUT QSPEVDFE CZ PUIFS BDOF USFBUNFOUT ɨJT FYDFMMFOU UPMFSBODF TVH EJTDPOUJOVFE USFBUNFOU CFDBVTF PG UIFTF SFBDUJPOT HFTUT UIBU BDFUZMDZTUFJOF EFTFSWFT UP BMTP CF UFTUFE JO UIF NPSF TFWFSF GPSNT PG BDOF DISCUSSION $PNFEPOFT BSF UIF FBSMJFTU OPOJOGMBNNBUPSZ MFTJPOT PG BDOF Acknowledgment: Harold W. Hermann, MD, contributed to the 5XP GPSNT PG DPNFEPOFT24 25 BSF SFDPHOJ[FE UIF DMPTFE DPN preparation of this presentation.

FEP BOE UIF PQFO DPNFEP ɨF DMPTFE DPNFEP JT FOUJSFMZ DPW FSFE CZ BO BMNPTU JOUBDU FQJUIFMJBM MBZFS BOE IBT B NJDSPTDPQJD REFERENCES QPSF ɨF PQFO DPNFEP EJTQMBZT B EJTDPOUJOVPVT FQJUIFMJBM MBZFS 1 Acetylcysteine. In: Osol A, Pratt R, eds. The United States Dis JOUFSSVQUFE CZ B EJMBUFE PQFOJOH ɨF TUVEZ PG NBOZ DPNFEPOFT pensatory. Philadelphia: JB Lippincott Company; 1973:10.

CZ USBOTNJTTJPO BOE TDBOOJOH FMFDUSPO NJDSPTDPQZ SFWFBMFE UIBU 2 Kanter MZ. Comparison of oral and IV acetylcysteine in the treatUIF DPOUFOU PG DPNFEPOFT JT NBEF VQ PG TFCVN LFSBUJOJ[FE DFMMT ment of acetaminophen poisoning. Am J Health System Pharm.

IBJST DFMMT PG Propionibacterium acnes BOE ZFBTUT 24â&#x20AC;&#x201C;29 8IJMF CBD 2006;6:1821.

UFSJB QSPMJGFSBUF NPTUMZ JO UIF EFFQFS MBZFST PG DPNFEPOFT ZFBTUT 3 (SBOEKFBO & #FSUIFU 1 3VGGNBO 3 FU BM &GĂĽDBDZ PG MPOH UFSN acetylcysteine in chronic bronchopulmonary disease: a metaJOIBCJU NBJOMZ UIF TVQFSmDJBM MBZFST 30 $MPTFE DPNFEPOFT NBZ analysis of published double-blind, placebo-controlled clinical FJUIFS SFTPMWF PS USBOTGPSN UIFNTFMWFT JOUP PQFO DPNFEPOFT trials. Clin Therapeut. 2000;22:209â&#x20AC;&#x201C;221.

QVTUVMFT PS QBQVMFT ɨFTF FWFOUT NBZ UBLF QMBDF TQPOUBOFPVTMZ 4 Ozcan C, Gorur K, Cinel L, et al. The inhibitory effect of topical 31 32 PS BT B SFTVMU PG USFBUNFOUT TVDI BT UPQJDBM USFUJOPJO $PN N-acetylcysteine application on myringosclerosis in perforated rat FEPOFT IBWF BMTP CFFO FNQMPZFE GPS JO WJUSP BTTBZ PG UPQJDBM BDOF tympanic membrane. Int J Ped Otorhinoar. 2002;63:179â&#x20AC;&#x201C;184.

USFBUNFOUT 27 28 5 0WFTFO 5 'FMEJOH +6 5PNNFSVQ # FU BM &GGFDU PG N-acetyl*O UIJT TUVEZ PG NJME HSBEF * BDOF POMZ DPNFEPOFT XFSF VTFE GPS MFTJPO DPVOUT 0UIFS MFTJPOT TVDI BT QBQVMFT PS QVTUVMFT JG QSFTFOU XFSF UPP GFX UP KVTUJGZ DPVOUJOH 8IJMF PVS QBUJFOUT TIPXFE SFTPMVUJPO PS PQFOJOH PG DMPTFE DPNFEPOFT B OPUFXPS UIZ USBOTGPSNBUJPO PG DPNFEPOFT JOUP QVTUVMFT PS QBQVMFT XBT OPU PCTFSWFE ɨJT EPVCMF CMJOE DPNQBSJTPO PG B UPQJDBM BDFUZMDZTUFJOF HFM WT UIF WFIJDMF BMPOF SFWFBMFE B TUBUJTUJDBMMZ TJHOJmDBOU TVQFSJPSJUZ PG UIF BDUJWF QSFQBSBUJPO PWFS UIF WFIJDMF JO SFEVDJOH UIF OVNCFS PG DPNFEPOFT JO QBUJFOUT XJUI HSBEF * BDOF SKINmed. 2012;10:348â&#x20AC;&#x201C;351

350

cysteine on the incidence and recurrence of otitis media with effusion and re-insertion of ventilation tubes. Acta Otolaryngol Suppl. 2000;543:79â&#x20AC;&#x201C;81.

6

van Zandwijk N. N-acetylcysteine for lung cancer prevention.

Chest. 1995;107:1437â&#x20AC;&#x201C;1441.

7

"LZZPM 4BMNBO * "[J[J 4 .VNDV 6 FU BM &GĂĽDBDZ PG UPQJDBM N-acetylcysteine in the treatment of Meibomiam gland dysfunction. J Ocul Pharm Therapeut. 2010;26:329â&#x20AC;&#x201C;333.

8

:BMDJO & "MUJO ' $JOIVTFZJOPHMVF ' FU BM N-acetylcysteine in chronic blepharitis. Cornea. 2002;21:164â&#x20AC;&#x201C;168.

9

Williamson J, Doig WM, Forrester JV, et al. Management of the dry eye in Sjogrenâ&#x20AC;&#x2122;s syndrome. Brit J Ophthal. 1974;58:798.

5PQJDBM "DOF 5SFBUNFOU 8JUI "DFUZMDZTUFJOF

03*(*/"- $0/53*#65*0/

November/December 2012 10 Tirouvanziam R, Conrad CK, Bottiglieri T, et al. High-dose oral N-acetylcysteine, a glutathione prodrug, modulates inflammation JO DZTUJD ĂĽCSPTJT Proc Nat Acad Sc. 2006;103:4628â&#x20AC;&#x201C;4633.

11 .BSFO[J ( "TTBOFMMJ & .BSBOB * FU BM N-acetylcysteine and contrast-induced nephropathy in primary angioplasty. N Engl J Med. 2006;354:2773â&#x20AC;&#x201C;2782.

12 Jimenez JJ, Huang HS, Yunis AA. Treatment with ImuVert/N-acetylcysteine protects rats from cyclophosphamide/cytarabineinduced alopecia. Cancer Invest. 1992;10:271â&#x20AC;&#x201C;276.

13 Bradstreet J, Geier DA, Kartzinel JJ. A case-control study of mercury burden in children with autistic spectrum disorders. J Am Phys Surg. 2003;8:76â&#x20AC;&#x201C;79.

14 Kang S, Chung JH, Fisher GT, et al. Topical N-acetylcysteine and genistein prevent ultraviolet light-induced signaling that leads to photoaging in human skin in vitro. J Invest Dermat.

2003;120:835â&#x20AC;&#x201C;841.

15 den Broeke, Gerard MJ. Topically applied N-acetylcysteine as a protector against UVB-induced immunosuppression. J Photochem Photobiol. 1995;27:61â&#x20AC;&#x201C;66.

16 Senaldi G, Pointaire P, Piguet PF, et al. Protective effect of N-acetylcysteine in hapten-induced irritant and contact hypersensitive reactions. J Invest Dermat. 1994;102:934â&#x20AC;&#x201C;937.

17 Cotter MA, Thomas J, Cassidy P. et al. N-acetylcysteine protects melanocytes against oxidative/stress damage and delays onset in ultraviolet-induced melanoma in mice. Clin Cancer Res. 2007;13:5952â&#x20AC;&#x201C;5958.

18 Goodson AG, Cotter MA, Cassidy P, et al. Use of oral acetylcysteine for protection of melanocytic nevi against UV-induced oxidative stress: towards a paradigma for melanoma prevention.

Clin Cancer Res. 2009;15:7434â&#x20AC;&#x201C;7440.

19 Sarici SĂ&#x153;, Sahin M, YurdakĂśk M. Topical N-acetylcysteine treatment of neonatal ichthyosis. Turk J Pediatr. 2003;45:245â&#x20AC;&#x201C;247.

20 (SBOU +& 0EMBVH #- ,JN 48 N-acetylcysteine, a glutamate modulator in the treatment of trichotillomania: a double-blind, placebo controlled study. Arch Gen Psychiatr. 2009;66:756â&#x20AC;&#x201C;763.

21 Laporte G. New anti-seborrheic substances. Am Perfum Cosmetic. 1970;85:47â&#x20AC;&#x201C;51.

22 De Lucca AJ, Walsh TJ, Daigle DJ. N-acetylcysteine inhibits germination of conidia and growth of Aspergillus spp. and Fusarium spp. Antimicrob Agents Chemother. 1996;40: 1274â&#x20AC;&#x201C;1276.

23 "LUVOD & 0[BDNBL 7) 0[BDNBD )4 FU BM N-acetylcysteine promotes angiogenesis and clearance of free oxygen radicals, thus improving wound healing in an alloxan-induced diabetic mouse model of incisional wound. Clin Exp Dermatol. 2010; 35:902â&#x20AC;&#x201C;909.

24 Plewig G, Kligman AM. Acneâ&#x20AC;&#x201C;Morphogenesis and Treatment.

Berlin-Heidelberg: Springer Verlag; 1975.

25 Wilborn WH, Hyde BM, Montes LF. Scanning Electron Microscopy of Normal and Abnormal Skin %FFSĂĽFME #FBDI '- 7$) Publishers; 1985:127â&#x20AC;&#x201C;135.

26 Wilborn WH, Montes LF. Scanning electron microscopy of comedones. Scan Electron Microsc. 1978;2:253â&#x20AC;&#x201C;258.

27 .POUFT -' 8JMCPSO 8) 'MBOBHBO "% &MFDUSPO NJDSPTDPQJD BTsay of a topical acne treatment. Benzoyl peroxide acetone gel.

Scan Electron Microsc. 1979;3:185â&#x20AC;&#x201C;188.

28 8JMCPSO 8) .POUFT -' -ZPOT 3& FU BM 6MUSBTUSVDUVSBM CBTJT GPS the assay of topical acne treatments. Transmission and scanning electron microscopy of untreated comedones. J Cutan Pathol. 1978;5:165â&#x20AC;&#x201C;183.

29 Montes LF, Wilborn WH. Fine structure of Corynebacterium acnes. J Invest Dermat. 1970;54:338â&#x20AC;&#x201C;345.

30 Montes LF. Acne J C Pathol. 1974;1:230.

31 ,MJHNBO ". 'VMUPO +& 1MFXJH ( 5PQJDBM WJUBNJO " BDJE JO BDOF vulgaris. Arch Dermat. 1969;99:469â&#x20AC;&#x201C;476.

32 Bradford LG, Montes LF. Topical application of vitamin A acid in acne vulgaris. South Med J. 1974;67:683â&#x20AC;&#x201C;687.

33 Weary P. Comedogenic potential of the lipid extract of Pityrosporum ovale. Arch Dermat. 1970;102:84â&#x20AC;&#x201C;91.

VINTAGE LABEL

$PVSUFTZ PG #VZ&OMBSHF 1IJMBEFMQIJB 1" SKINmed. 2012;10:348â&#x20AC;&#x201C;351

351

5PQJDBM "DOF 5SFBUNFOU 8JUI "DFUZMDZTUFJOF

7PMVNF t *TTVF

November/December 2012

REVIEW

Green Tea in Dermatology Nader Pazyar, MD; Amir Feily, MD; Afshin Kazerouni, MD

ɨF QVSQPTF PG UIJT CSJFG SFWJFX JT UP TVNNBSJ[F BMM JO WJUSP JO WJWP BOE DPOUSPMMFE DMJOJDBM USJBMT PO HSFFO UFB QSFQBSBUJPOT BOE UIFJS VTFT JO EFSNBUPMPHZ "O FYUFOTJWF MJUFSBUVSF TFBSDI XBT DBSSJFE PVU UP JEFOUJGZ JO WJWP BOE JO WJUSP TUVEJFT BT XFMM BT DMJOJDBM USJBMT 5XFOUZ TUVEJFT XFSF BTTFTTFE BOE UIF SFTVMUT TVHHFTU UIBU PSBM BENJOJTUSBUJPO PG HSFFO UFB DBO CF FĊFDUJWF JO UIF TDBWFOHJOH PG GSFF SBEJDBMT DBODFS QSFWFOUJPO IBJS MPTT BOE TLJO BHJOH QMVT QSPUFDUJPO BHBJOTU UIF BEWFSTF FĊFDUT BTTPDJBUFE XJUI QTPSBMFOo67 " UIFSBQZ 5PQJDBM BQQMJDBUJPO PG HSFFO UFB FYUSBDU TIPVME CF QPUFOUJBMMZ FĊFDUJWF GPS BUPQJD EFSNBUJUJT BDOF WVMHBSJT SPTBDFB BOESPHFOFUJD BMPQFDJB IJSTVUJTN LFMPJET HFOJUBM XBSUT DVUBOFPVT MFJTINBOJBTJT BOE DBOEJEJPTJT ɨFSF BSF QSPNJTJOH SFTVMUT XJUI UIF VTF PG HSFFO UFB GPS TFWFSBM EFSNBUPMPHJD DPOEJ UJPOT IPXFWFS UIF FċDBDZ PG PSBM BOE UPQJDBM HSFFO UFB IBT OPU BMXBZT CFFO DPOmSNFE SKINmed. o

T

FB JT POF PG UIF NPTU QPQVMBS CFWFSBHFT BSPVOE UIF XPSME ɨF BWFSBHF DVQT PG UFB DPOTVNFE QFS QFSTPO BOOVBMMZ TIPXT UIBU UFB JT B SBQJEMZ HSPXJOH EJFUBSZ TVQQMFNFOU JO UIF 6OJUFE 4UBUFT 5FB DPNFT GSPN UIF QMBOU camellia sinensis XIPTF DPNQPVOET BSF QPMZQIFOPMT QPMZTBDDIBSJEFT BNJOPBDJET BOE WJUBNJOT XIJDI NBZ QSFWFOU NBOZ EJTFBTFT *U JT BWBJMBCMF JO UISFF GPSNT HSFFO CMBDL BOE PPMPOH USBEJUJPOBM $IJOFTF UFB 1 2 (SFFO UFB 'JHVSF

IBT CFFO TIPXO UP IBWF BOUJPYJEBOU BOUJ JOnBNNBUPSZ BOE BOUJ DBSDJOPHFOJD BDUJWJUZ BOE QPTTFTTFT DBSEJPOFVSPQSPUFDUJWF BDUJWJUZ BOE XFJHIU MPTT FĊFDU 3

UIJPMT BU IJHI DPODFOUSBUJPOT 20 ɨF NBKPS HSFFO UFB DBUFDIJOT JODMVEF o oFQJDBUFDIJO &$ o oFQJDBUFDIJO HBMMBUF &$H

o oFQJHBMMPDBUFDIJO &($ BOE o oFQJHBMMPDBUFDIJO HBMMBUF &($H 21 &QJDBUFDIJO HBMMBUF &$( BOE FQJHBMMPDBUFDIJO HBM MBUF &($( BSF UIF NPTU BCVOEBOU DPOTUJVFOUT JO HSFFO UFB 22 /PUBCMZ &($( JT UIF NBJO QPMZQIFOPM QSFTFOU JO HSFFO UFB BOE UIF CFTU TUVEJFE DBUFDIJO 23 ɨF DIFNJDBM GPSNVMBF PG HSFFO UFB DPNQPVOET BSF MJTUFE JO UIF 5BCMF 24 6OGPSUVOBUFMZ UIF DMJOJDBM VTF PG HSFFO UFB JT TVQQPSUFE NPTUMZ CZ BOFDEPUBM EBUB "MUIPVHI UIFTF SFQPSUT BSF JOUFSFTUJOH DPOUSPMMFE USJBMT BSF OFFEFE GPS DPOmSNJOH JUT WBSJPVT DMBJNT

(SFFO UFB FYUSBDU JT NBEF CZ MJHIUMZ TUFBNJOH BOE ESZJOH MFBWFT PG camellia sinensis 4 0G OPUF JO B IJHI UFNQFSBUVSF FOWJSPO NFOU HSFFO UFB JT OPU TUBCMF BOE UIF DIBOHJOH PG JUT JOHSFEJFOUT JT MJLFMZ UP PDDVS 5 GENERAL USAGE

Table. Chemical Formulae of Green Tea Compounds

COMPOUND

CHEMICAL FORMULA

&$ FQJDBUFDIJO

$ ) 0

&($ FQJHBMMPDBUFDIJO

$ ) 0

&$( FQJDBUFDIJO HBMMBUF

$ ) 0M

(SFFO UFB JT VTFE JO DPTNFUJDT BOE JT TVHHFTUFE GPS TMPXJOH PG &($( FQJHBMMPDBUFDIJO HBMMBUF $ ) 0M

UIF BHJOH QSPDFTTFT 7 QSFWFOUJPO PG B WBSJFUZ PG NBMJHOBODJFT 8–14 IZQFSUFOTJPO 15 PCFTJUZ QVMNPOBSZ EJTFBTFT 17–19 BOE NBOZ PUIFS EJTFBTFT 4DJFOUJmD TUVEJFT JOWFTUJHBUJOH UIFTF DMBJNT BSF DERMATOLOGIC APPLICATIONS OF ORAL GREEN TEA GFX BOE UIF NBKPSJUZ IBWF OPU CFFO BQQSPWFE ɨFSF IBWF CFFO TPNF BOFDEPUBM SFQPSUT PO UIF VTF PG PSBM HSFFO INGREDIENTS AND MOLECULAR UFB JO UIF USFBUNFOU PG TZTUFNJD EJTFBTF TVDI BT FTPQIBHFBM TRVB PHARMACOLOGY NPVT DFMM DBSDJOPNB DPMPSFDUBM DBODFS 9 11 DFSWJDBM DBSDJOPNB 13 $BUFDIJOT QPMZQIFOPMT EFSJWBUJWF GSPN HSFFO UFB MFBWFT IBWF B QVMNPOBSZ mCSPTJT 17 QVMNPOBSZ UVCFSDVMPTJT 18 DBSEJPWBTDV XJEF SBOHF PG CJPMPHJDBM BDUJWJUJFT BMUIPVHI UIF TQFDJmD NPMFDV MBS EBNBHF 15 BOE PUIFS EJTFBTFT CVU XF XFSF POMZ BCMF UP mOE MBS NFDIBOJTNT SFTQPOTJCMF BSF OPU LOPXO 1PMZQIFOPMT CJOE UP UIF GPMMPXJOH JO WJWP TUVEJFT GPS UIF TZTUFNJD BQQMJDBUJPO PG NFNCSBOF QIPTQIPMJQJE BOE BSF FBTJMZ BVUP PYJEJ[FE UP HFOFSBUF HSFFO UFB JO EFSNBUPMPHJD EJTFBTFT /P LOPXO DMJOJDBM USJBM PG UIF TVQFSPYJEF BOJPO BOE TFNJRVJOPOFT ɨFZ DBO BEEVDU UP QSPUFJO TZTUFNJD BQQMJDBUJPO PG HSFFO UFB XBT GPVOE From the Department of Dermatology, Jahrom University of Medical Sciences, Jahrom, Iran Address for Correspondence: Amir Feily, MD, Motahari Street, Honari Clinic, Department of Dermatology, Jahrom, Iran t & NBJM ES GFJMZ!ZBIPP DPN

SKINmed. 2012;10:352–355

352

ª 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$

3&7*&8

November/December 2012

EFUFDUFE JO TLJO TFCVN QSPEVDUJPO BGUFS MPOH UFSN BQQMJDBUJPO PG B GPSNVMBUJPO PG HSFFO UFB FYUSBDU PO BDOF WVMHBSJT 29 " QSPTQFDUJWF OPOSBOEPNJ[FE DMJOJDBM USJBM PG QBUJFOUT SFWFBMFE UIBU B MPUJPO PG HSFFO UFB FYUSBDU JT FċDJFOU JO UIF USFBUNFOU PG BDOF WVMHBSJT 30 ROSACEA 0OF QMBDFCP DPOUSPMMFE EPVCMF CMJOE TUVEZ SFWFBMFE UIBU PG &($( JO B IZESPQIJMJD DSFBN JT TBGF UPMFSBCMF BOE TJHOJmDBOUMZ NPSF CFOFmDJBM JO DPOUSJCVUJOH TVQFSJPS DMJOJDBM FċDBDZ UIBO QMBDFCP UP USFBU QBQVMPQVTUVMBS SPTBDFB 31 PSORIASIFORM LESIONS "DDPSEJOH UP B TUVEZ PO NJDF B UPQJDBM QSFQBSBUJPO PG HSFFO UFB QPMZQIFOPM TJHOJmDBOUMZ EFDSFBTFE nBLJOH BTTPDJBUFE Figure. (SFFO UFB QMBOU XJUI FċDJFOU DBTQBTF QSPDFTTJOH BOE SFEVDUJPO JO QSPMJGFSBU JOH DFMM OVDMFBS BOUJHFO MFWFMT (51 BDUJWBUFE QBUIXBZT NBZ CF "O FYQFSJNFOUBM TUVEZ PO GFNBMF NJDF XIJDI IBE EFWFMPQFE QPUFOUJBM UBSHFUT GPS OPWFM UIFSBQFVUJD BQQSPBDIFT UP UIF USFBU TQPOUBOFPVT IBJS MPTT SFWFBMFE UIBU DPOTVNJOH GSBDUJPO PG NFOU PG TPNF QTPSJBTJGPSN TLJO EJTPSEFST 32 QPMZQIFOPM FYUSBDU QSPEVDFE TJHOJmDBOU IBJS SFHSPXUI EVSJOH NPOUIT 25 "DDPSEJOH UP POF TUVEZ PO NJDF HSFFO UFB UFOET GENITAL WARTS UP EFDSFBTF TLJO QFOUPTJEJOF MFWFMT BOE EFMBZ DPMMBHFO BHJOH CZ *O B SBOEPNJ[FE EPVCMF CMJOE QMBDFCP DPOUSPMMFE USJBM BO BOUJPYJEBOU NFDIBOJTN XJUI EPVCMJOH PG JUT FĊFDU XIFO PVUQBUJFOUT SFDFJWFE UPQJDBM BQQMJDBUJPO PG QPMZQIFOPO & DPNCJOFE XJUI WJUBNJO $ BOE WJUBNJO & PJOUNFOU UP BMM FYUFSOBM HFOJUBM XBSUT ɨJT TUVEZ SFWFBMFE UIBU 3FTFBSDI CBTFE PO NVSJOF TLJO TIPXT UIBU UIF QSF BOE QPTU QPMZQIFOPO & PJOUNFOU DPNQPTFE PG B EFmOFE HSFFO UFB USFBUNFOU XJUI TUBOEBSEJ[FE HSFFO UFB FYUSBDU JO QTPSBMFOo67 " FYUSBDU JT FĊFDUJWF BOE TBGF JO UIF USFBUNFOU PG FYUFSOBM HFOJ 167" USFBUNFOU QPQVMBUJPOT BCSPHBUFT UIF 167" JOEVDFE UBM XBSUT 33 "OPUIFS SBOEPNJ[FE QMBDFCP DPOUSPMMFE USJBM QIPUPDIFNJDBM EBNBHF UP TLJO "ENJOJTUSBUJPO PG HSFFO UFB QBUJFOUT XJUI FYUFSOBM HFOJUBM BOE QFSJBOBM XBSUT XFSF USFBUFE FYUSBDU QSJPS UP BOE EVSJOH NVMUJQMF 167" USFBUNFOUT EFDSFBTFT XJUI B DSFBN DPOUBJOJOH PS QPMZQIFOPO & $POTF IZQFSQMBTJB BOE IZQFSLFSBUPTJT ɨF VTF PG HSFFO UFB FYUSBDU EBZ RVFOUMZ B IJHIFS SFNJTTJPO SBUF XBT TFFO GPS CPUI DPODFOUSBUJPOT BGUFS 167" USFBUNFOU JT FĊFDUJWF JO EFDSFBTJOH 167" JOEVDFE JO DPNQBSJTPO UP WFIJDMF ɨFTF SFTVMUT XFSF DPOmSNFE JO JOnBNNBUPSZ SFTQPOTFT JODMVEJOH FSZUIFNB BOE FEFNB 27 QBUJFOUT JO BOPUIFS NVMUJDFOUFS TUVEZ 29 ATOPIC DERMATITIS

ANDROGENETIC ALOPECIA

4UBQIZMPDPDDBM TVQFSBOUJHFOT 4T"HT IBWF HBJOFE BUUFOUJPO BT POF PG UIF FYBDFSCBUJOH GBDUPST PG BUPQJD EFSNBUJUJT "% " TUVEZ PO NJDF EFNPOTUSBUFE UIF JOIJCJUPSZ FĊFDU PG UIF HSFFO UFB DBUFDIJO FYUSBDU QPMZQIFOPO BOE &($( PO TUBQIZMPDPDDBM FOUFSPUPYJO # 4&# &($( JOIJCJUT 4&# JOEVDFE JOnBNNB UPSZ DZUPLJOFT *OIJCJUJPO PG 4T"H JOEVDFE 5 DFMM BDUJWBUJPO CZ DBUFDIJO JT PCTFSWFE JO CPUI JO WJWP BOE JO WJUSP TUVEJFT TVHHFTU JOH UIBU DBUFDIJO NBZ CF VTFGVM JO UIF USFBUNFOU PG "% 28

&($( NBZ CF VTFGVM JO UIF QSFWFOUJPO PS USFBUNFOU PG BOESP HFOFUJD BMPQFDJB CZ TFMFDUJWFMZ JOIJCJUJOH α SFEVDUBTF BDUJWJ UJFT &($( QSPNPUFT IBJS HSPXUI JO TDBMQ IBJS GPMMJDMFT FY WJWP BOE BDDFMFSBUFT UIF QSPMJGFSBUJPO PG UIF DVMUVSFE IVNBO EFSNBM QBQJMMB DFMMT JO WJWP BOE JO WJUSP 34

DERMATOLOGIC APPLICATIONS OF TOPICAL GREEN TEA EXTRACT

HIRSUTISM 8F GPVOE POMZ POF IZQPUIFTJT UIBU EFTDSJCFT UIBU HSFFO UFB FYUSBDU DBO CF B OPWFM BEEJUJPO UP UIF IJSTVUJTN USFBUNFOU BSNB NFOUBSJB CFDBVTF PG JUT QPUFOU JOIJCJUPSZ FĊFDUT PO PSOJUIJOF EFDBSCPYZMBTF BOE α SFEVDUBTF FO[ZNFT 34

ACNE VULGARIS

&($( IBT NVMUJGBDUPSJBM CFOFmUT BHBJOTU TFCVN QSPEVDUJPO *U PROTECTION AGAINST PUVA JT B TFMFDUJWF JOJCJUPS PG α SFEVDUBTF UZQF * BOE JU SFEVDFT NJDSP " TUVEZ SFWFBMFE UIBU QSFUSFBUNFOU PG IVNBO TLJO XJUI UPQJ DPNFEPOF TJ[F JO NJDSPDPNFEPOBM BDOF 4JHOJmDBOU SFTVMUT XFSF DBM BQQMJDBUJPO PG NH TUBOEBSEJ[FE HSFFO UFB FYUSBDU QFS DN2 SKINmed. 2012;10:352–355

353

(SFFO 5FB JO %FSNBUPMPHZ

3&7*&8

November/December 2012

NJOVUFT QSJPS UP 167" USFBUNFOU SFTVMUT JO BO BMNPTU DPN REFERENCES QMFUF BCSPHBUJPO PG 167" JOEVDFE FSZUIFNB 4UBOEBSEJ[FE 1 .POPCF . &NB , 5PLVEB : .BFEB :BNBNPUP . *ODSFBTFE QMBTNB concentration of epigallocatechin in mice after orally administering a HSFFO UFB FYUSBDU QSPUFDUT BHBJOTU 167" JOEVDFE QIPUPUPYJDJUZ HSFFO UFB $BNFMMJB TJOFOTJT - FYUSBDU TVQQMFNFOUFE CZ TUFBNFE SJDF CZ JOIJCJUJOH %/" EBNBHF BOE EJNJOJTIJOH UIF JOnBNNBUPSZ Biosci Biotechnol Biochem o 35 FĊFDUT PG UIJT NPEBMJUZ 2 1BTUPSF 3- 'SBUFMMPOF 1 1PUFOUJBM IFBMUI CFOFåUT PG HSFFO UFB Camellia sinensis B OBSSBUJWF SFWJFX Explore (NY) o

KELOIDS " TUVEZ JO QBUJFOUT XJUI LFMPJET EFNPOTUSBUFE UIBU &($( ESBNBUJDBMMZ JOIJCJUT UZQF * DPMMBHFO TZOUIFTJT UIFSFGPSF JU NBZ CF QPUFOUJBMMZ VTFE BT B UIFSBQFVUJD BEEJUJPO GPS UIF JOUFSWFOUJPO BOE QSFWFOUJPO PG LFMPJET BOE PUIFS mCSPUJD EJTFBTFT

3

,JEE 1. #JPBWBJMBCJMJUZ BOE BDUJWJUZ PG QIZUPTPNF DPNQMFYFT GSPN botanical polyphenols: the silymarin, curcumin, green tea, and grape TFFE FYUSBDUT Altern Med Rev o

4

1BUFM 4) Camellia sinensis IJTUPSJDBM QFSTQFDUJWFT BOE GVUVSF QSPTQFDUT J Agromedicine o

5

*LFEB * ,PCBZBTIJ . )BNBEB 5 FU BM )FBU FQJNFSJ[FE UFB DBUFDIJOT rich in gallocatechin gallate and catechin gallate are more effective to inhibit cholesterol absorption than tea catechins rich in epigallocat FDIJO HBMMBUF BOE FQJDBUFDIJO HBMMBUF J Agric Food Chem o

6

#BVNBOO -4 -FTT LOPXO CPUBOJDBM DPTNFDFVUJDBMT Dermatol Ther o

7

(SBN[B .JDIBMPXTLB " 3FHVMB + 6TF PG UFB FYUSBDUT $BNFMJB TJOFOTJT

JO KFMMZ DBOEJFT BT QPMZQIFOPMT TPVSDFT JO IVNBO EJFU Asia Pac J Clin Nutr TVQQM o

8

4IJO %. 0SBM DBODFS QSFWFOUJPO BEWBODFT XJUI B USBOTMBUJPOBM USJBM PG HSFFO UFB Cancer Prev Res (Phila) o

9

4[VNJ P + $IFNPQSFWFOUJPO PG FTPQIBHFBM TRVBNPVT DFMM DBSDJOPNB DMJOJDBM USJBMT Pol Merkur Lekarski o

CUTANEOUS LEISHMANIASIS "DDPSEJOH UP TFWFSBM TUVEJFT BMM PG UIF HSFFO UFB FYUSBDUT BOE JOEJWJEVBM DBUFDIJOT DBO JOIJCJU UIF JOEVDUJPO PG PSOJUIJOF EFDBSCPYZMBTF 0%$ UIF LFZ FO[ZNF JO UIF CJPTZOUIFTJT PG QPMZBNJOFT (SFFO UFB BOE JUT BDUJWF DPNQPOFOUT BĊFDU TJHOBM USBOTEVDUJPO QBUIXBZT (JWFO UIF JNQPSUBOU SPMFT PG 0%$ QSP UFJO LJOBTFT BOE TRVBMFOF JO UIF CJPMPHZ PG MFJTINBOJB BOE UIF BCJMJUZ PG HSFFO UFB UP QPUFOUMZ JOIJCJU 0%$ QSPUFJO LJOBTFT BOE TRVBMFOF TZOUIFTJT HSFFO UFB FYUSBDU DBO CF BO FĊFDUJWF BHFOU BHBJOTU MFJTINBOJBTJT 37 CANDIDIOSIS "DDPSEJOH UP POF JOWFTUJHBUJPO B SFEVDUJPO PG WJBCMF DFMMT XBT TFFO EVSJOH CJPmMN GPSNBUJPO DVMUVSFT USFBUFE XJUI &($( *NQBJSNFOU PG QSPUFBTPNBM BDUJWJUZ CZ QPMZQIFOPMT DPOUSJCVUFT UP DFMM NFUBCPMJTN BOE TUSVDUVSBM EJTSVQUJPOT UIBU FYQFEJUF UIF JOIJCJUJPO PG CJPmMN GPSNBUJPO BOE NBJOUFOBODF CZ Candida albicans 38 CONCLUSIONS #FDBVTF HSFFO UFB FYUSBDU DBO JOIJCJU QIPUPDBSDJOPHFOFTJT HSFFO UFB FYUSBDUoDPOUBJOJOH TVOTDSFFOT NBZ CF WBMVBCMF JO "VTUSBM BTJBO DPVOUSJFT BOE JO DBODFS QSPWPLJOH DPOEJUJPOT TVDI BT JO (PSMJO T TZOESPNF BOE YFSPEFSNB QJHNFOUPTVN #FDBVTF HSFFO UFB FYUSBDU DBO EFDSFBTF TLJO QFOUPTJEJOF MFWFMT BOE EFMBZ DPM MBHFO BHJOH HSFFO UFB FYUSBDUoDPOUBJOJOH DSFBNT NBZ CF PG QBS UJDVMBS WBMVF JO QSFWFOUJOH TLJO BHJOH BOE BT B OPWFM BEEJUJPO UP SFKVWFOBUJPO *O BEEJUJPO CFDBVTF HSFFO UFB FYUSBDU JT BCMF UP TFMFDUJWFMZ JOIJCJU α SFEVDUBTF BDUJWJUJFT JUT DPNCJOBUJPO XJUI NJOPYJEJM TPMVUJPO DPVME QSPWJEF B TZOFSHJTUJD FĊFDU XJUI UIF BEEJUJPOBM CFOFmU BHBJOTU BOESPHFOFUJD BMPQFDJB *O BEEJUJPO HSFFO UFB FYUSBDU FYIJCJUT QPUFOU JOIJCJUPSZ FĊFDUT PO PSOJUIJOF EFDBSCPYZMBTF BOE α SFEVDUBTF *UT DPNCJOBUJPO XJUI FnPSOJ UIJOF NBZ QSPWJEF B TZOFSHJTUJD FĊFDU XJUI UIF BEEJUJPOBM CFOFmU BHBJOTU IJSTVUJTN

SKINmed. 2012;10:352–355

354

10 (VUJFSSF[ 0SP[DP ' 4UFQIFOT #3 /FJMTPO "1 FU BM (SFFO BOE CMBDL UFB JOIJCJUT DZUPLJOF JOEVDFE *- QSPEVDUJPO BOE TFDSFUJPO JO "(4 HBT USJD DBODFS DFMMT WJB JOIJCJUJPO PG /' κ# BDUJWJUZ Planta Med o 11 4IJNJ[V . 'VLVUPNJ : /JOPNJZB . FU BM (SFFO UFB FYUSBDUT GPS UIF QSFWFOUJPO PG NFUBDISPOPVT DPMPSFDUBM BEFOPNBT B QJMPU TUVEZ Cancer Epidemiol Biomarkers Prev o 12 $IPBO & 4FHBM 3 +POLFS % FU BM " QSPTQFDUJWF DMJOJDBM USJBM PG HSFFO UFB for hormone refractory prostate cancer: an evaluation of the comple NFOUBSZ BMUFSOBUJWF UIFSBQZ BQQSPBDI Urol Oncol o 13 ;IBOH 2 5BOH 9 -V 2 FU BM (SFFO UFB FYUSBDU o o&QJHBMMPDBUFDIJO HBMMBUF JOIJCJU IZQPYJB BOE TFSVN JOEVDFE )*' α protein accumulation BOE 7&(' FYQSFTTJPO JO IVNBO DFSWJDBM DBSDJOPNB BOE IFQBUPNB DFMMT Mol Cancer Ther o 14 ;IBOH % "M )FOEZ . 3JDIBSE %BWJT ( FU BM "OUJQSPMJGFSBUJWF BOE QSP BQPQUPUJD FGGFDUT PG FQJHBMMPDBUFDIJO HBMMBUF PO IVNBO MFJPNZPNB DFMMT Fertil Steril o 15 "OUPOFMMP . .POUFNVSSP % #PMPHOFTJ . FU BM 1SFWFOUJPO PG IZQFSUFO TJPO DBSEJPWBTDVMBS EBNBHF BOE FOEPUIFMJBM EZTGVODUJPO XJUI HSFFO UFB FYUSBDUT Am J Hypertens o 16 1BL %FL .4 "CEVM )BNJE " 0TNBO " 4PI $4 *OIJCJUPSZ FGGFDU PG NPSJOEB DJUSJGPMJB - 0O MJQPQSPUFJO MJQBTF BDUJWJUZ J Food Sci o 17 %POË . %FMM "JDB * $BMBCSFTF ' FU BM /FVUSPQIJM SFTUSBJOU CZ HSFFO UFB JOIJCJUJPO PG JOýBNNBUJPO BTTPDJBUFE BOHJPHFOFTJT BOE QVMNPOBSZ åCSP TJT J Immunol o 18 "HBSXBM " 1SBTBE 3 +BJO " &GGFDU PG HSFFO UFB FYUSBDU DBUFDIJOT JO SFEVDJOH PYJEBUJWF TUSFTT TFFO JO QBUJFOUT PG QVMNPOBSZ UVCFSDVMPTJT PO %054 $BU * SFHJNFO 1IZUPNFEJDJOF o 19 )FP +$ 3IP +3 ,JN 5) ,JN 4: -FF 4) "O BRVFPVT FYUSBDU PG HSFFO UFB $BNFMMJB TJOFOTJT JODSFBTFT FYQSFTTJPO PG 5I DFMM TQFDJåD BOUJ BTUI NBUJD NBSLFST Int J Mol Med o 20 'FOH 8 $IFSFEOJDIFOLP ( 8BSE $8 FU BM (SFFO UFB DBUFDIJOT BSF QPUFOU TFOTJUJ[FST PG SZBOPEJOF SFDFQUPS UZQF 3Z3 Biochem Pharmacol o

(SFFO 5FB JO %FSNBUPMPHZ

3&7*&8

November/December 2012 21 /BSVLBXB . /PHB $ 6FOP : FU BM &WBMVBUJPO PG UIF CJUUFSOFTT PG HSFFOùUFB DBUFDIJOT CZ B DFMM CBTFE BTTBZ XJUI UIF IVNBO CJUUFS UBTUF SFDFQUPS I5"4 3 Biochem Biophys Res Commun o 22 -JBOH ( 5BOH " -JO 9 FU BM (SFFO UFB DBUFDIJOT BVHNFOU UIF BOUJUVNPS BDUJWJUZ PG EPYPSVCJDJO JO BO JO WJWP NPVTF NPEFM GPS DIFNPSFTJTUBOU MJWFS DBODFS Int J Oncol o 23 ,àSCJU[ $ )FJTF % 3FENFS 5 FU BM &QJDBUFDIJO HBMMBUF BOE DBUFDIJO HBMMBUF BSF TVQFSJPS UP FQJHBMMPDBUFDIJO HBMMBUF JO HSPXUI TVQQSFTTJPO BOE BOUJ JOýBNNBUPSZ BDUJWJUJFT JO QBODSFBUJD UVNPS DFMMT Cancer Sci o 24 .FEJO 4 *OWFTUJHBUJOH UIF EFHSBEBUJPO SBUF PG FQJDBUFDIJO DPNQPVOET JO HSFFO UFB EVSJOH MPOH UFSN TUPSBHF IUUQ XXX VXTUPVU FEV DPOUFOU MJC UIFTJT NFEJOT QEG "DDFTTFE +VOF 25 &TGBOEJBSJ " ,FMMZ "1 5IF FGGFDUT PG UFB QPMZQIFOPMJD DPNQPVOET PO IBJS MPTT BNPOH SPEFOUT J Natl Med Assoc o 26 3VUUFS , 4FMM %3 'SBTFS / FU BM (SFFO UFB FYUSBDU TVQQSFTTFT UIF BHF SFMBUFE JODSFBTF JO DPMMBHFO DSPTTMJOLJOH BOE ýVPSFTDFOU QSPEVDUT JO $ #- NJDF Int J Vitam Nutr Res o 27 $PPQFS 3 .PSSÏ %+ .PSSÏ %. .FEJDJOBM CFOFåUT PG HSFFO UFB QBSU ** 3FWJFX PG BOUJDBODFS QSPQFSUJFT J Altern Complement Med o 28 )JTBOP . :BNBHVDIJ , *OPVF : FU BM *OIJCJUPSZ FGGFDU PG DBUFDIJO BHBJOTU UIF TVQFSBOUJHFO TUBQIZMPDPDDBM FOUFSPUPYJO # 4&# Arch Dermatol Res o 29 .BINPPE 5 "LIUBS / ,IBO #" ,IBO ). 4BFFE 5 0VUDPNFT PG HSFFO UFB FNVMTJPO PO TLJO TFCVN QSPEVDUJPO JO NBMF WPMVOUFFST Bosn J Basic Med Sci o

30 3FVUFS + 8ÚMýF 6 8FDLFTTFS 4 4DIFNQQ $ 8IJDI QMBOU GPS XIJDI TLJO EJTFBTF 1BSU "UPQJD EFSNBUJUJT QTPSJBTJT BDOF DPOEZMPNB BOE IFSQFT TJNQMFY J Dtsch Dermatol Ges o 31 5BOXFFS 4 3B[B " "MJ "INBE 4 8POH 8 .BOBHFNFOU PG QBQVMPQVT UVMBS SPTBDFB XJUI QPMZQIFOPOF HSFFO UFB FYUSBDU JO B IZESPQIJMJD DSFBN B QMBDFCP DPOUSPMMFE EPVCMF CMJOE TUVEZ J Am Acad Dermatol

32 )TV 4 %JDLJOTPO % #PSLF + FU BM (SFFO UFB QPMZQIFOPM JOEVDFT DBT QBTF JO FQJEFSNBM LFSBUJOPDZUFT WJB ."1, QBUIXBZT BOE SFEVDFT QTPSJBTJGPSN MFTJPOT JO UIF ýBLZ TLJO NPVTF NPEFM Exp Dermatol o 33 4UPDLýFUI & #FUJ ) 0SBTBO 3 FU BM 5PQJDBM 1PMZQIFOPO & JO UIF USFBU NFOU PG FYUFSOBM HFOJUBM BOE QFSJBOBM XBSUT B SBOEPNJ[FE DPOUSPMMFE USJBM Br J Dermatol o 34 /BNB[J .3 'FJMZ " (SFFO UFB FYUSBDU B OPWFM BEEJUJPO UP UIF BOUJIJSTVUJTN BSNBNFOUBSJVN J Altern Complement Med o 35 ;IBP +' ;IBOH :+ +JO 9) FU BM (SFFO UFB QSPUFDUT BHBJOTU QTPSBMFO QMVT VMUSBWJPMFU " JOEVDFE QIPUPDIFNJDBM EBNBHF UP TLJO J Invest Dermatol o 36 ;IBOH 2 ,FMMZ "1 8BOH - FU BM (SFFO UFB FYUSBDU BOE o oFQJHBMMPDBU FDIJO HBMMBUF JOIJCJU NBTU DFMM TUJNVMBUFE UZQF * DPMMBHFO FYQSFTTJPO JO LFMPJE åCSPCMBTUT WJB CMPDLJOH 1* , "L5 TJHOBMJOH QBUIXBZT J Invest Dermatol o 37 'FJMZ " :BHIPPCJ 3 /BNB[J .3 5IF QPUFOUJBM VUJMJUZ PG HSFFO UFB FYUSBDU BT B OPWFM USFBUNFOU GPS DVUBOFPVT MFJTINBOJBTJT J Altern Complement Med o 38 &WFOTFO /" #SBVO 1$ 5IF FGGFDUT PG UFB QPMZQIFOPMT PO $BOEJEB BMCJDBOT JOIJCJUJPO PG CJPåMN GPSNBUJPO BOE QSPUFBTPNF JOBDUJWBUJPO Can J Microbiol o

VINTAGE LABEL

$PVSUFTZ PG #VZ&OMBSHF 1IJMBEFMQIJB 1" SKINmed. 2012;10:352–355

355

(SFFO 5FB JO %FSNBUPMPHZ

7PMVNF t *TTVF

November/December 2012

REVIEW

Topical Vitamin D Analogs Available to Treat Psoriasis Marcial Oquendo, MD;1 William Abramovits, MD;1,2,3 Peter Morrell, DO4 ABSTRACT 1TPSJBTJT JT B DISPOJD BOE DVSSFOUMZ JODVSBCMF JOnBNNBUPSZ TLJO EJTFBTF BĊFDUJOH UP PG UIF 64 QPQVMBUJPO ɨF DPTU PG DBSF JO UIF 6OJUFE 4UBUFT GPS IPTQJUBMJ[BUJPOT PVUQBUJFOU QIZTJDJBO WJTJUT QIPUPUIFSBQZ QSFTDSJQUJPO UIFSBQJFT BOE PWFS UIF DPVOUFS NFEJDBUJPOT JT FTUJNBUFE UP CF NPSF UIBO NJMMJPO QFS ZFBS (VJEFMJOFT EFWFMPQFE CZ UIF "NFSJDBO "DBEFNZ PG %FSNBUPMPHZ JO TUBUF UIBU BQQSPYJNBUFMZ PG UIFTF QBUJFOUT XJUI QTPSJBTJT IBWF NJME UP NPEFSBUF EJTFBTF UIBU DBO CF NBOBHFE XJUI UPQJDBM BHFOUT JODMVEJOH DPSUJDPTUFSPJET BOE WJUBNJO % BOBMPHT 5PQJDBM WJUBNJO % BOBMPHT QSPWJEF iTUFSPJE TQBSJOHw FĊFDUT BOE B GBWPSBCMF TBGFUZ QSPmMF .BOZ FYQFSUT JODMVEJOH B SFDFOU DPOTFOTVT DPOGFSFODF DMBTTJGZ UPQJDBM WJUBNJO % BHFOUT BT mSTU MJOF UIFSBQZ GPS QTPSJBTJT FJUIFS BT NPOPUIFSBQZ PS JO DPNCJOBUJPO XJUI UPQJDBM TUFSPJET EVF UP B TZOFSHJTUJD DPNQMFNFOUBSZ FĊFDUJWFOFTT 7JUBNJO % BOBMPHT BSF BO JOEJTQFOTBCMF DPNQPOFOU PG UIF DVSSFOU QIZTJDJBO T BSNBNFOUBSJVN GPS QTPSJBTJT USFBUNFOU ɨJT SFWJFX UIFSFGPSF JT PSJFOUFE UP HJWF B DPNQSFIFOTJWF VOEFSTUBOEJOH PG UIJT HSPVQ PG ESVHT BOE EJTQMBZ UIF BWBJMBCMF DMJOJDBM EBUB GPS FBDI GPSNVMBUJPO SKINmed o

P

TPSJBTJT JT B DISPOJD BOE DVSSFOUMZ JODVSBCMF JOnBNNBUPSZ TLJO EJTFBTF BĊFDUJOH UP PG UIF 64 QPQVMBUJPO *U NBZ WBSZ JO TFWFSJUZ GSPN NJME UP WFSZ TFWFSF BOE GSPN MPDBMJ[FE UP XJEFTQSFBE ɨF NPTU DPNNPOMZ FODPVOUFSFE DMJOJDBM UZQF JT DISPOJD QMBRVF BMTP SFGFSSFE UP BT QTPSJBTJT WVMHBSJT 1 1TPSJBTJT DBO IBWF B TJHOJmDBOU JNQBDU PO RVBMJUZ PG MJGF 20- DPNQBSBCMF UP UIBU PG PUIFS NBKPS NFEJDBM DPOEJUJPOT 1TPSJBTJT T DPTU PG DBSF JO UIF 6OJUFE 4UBUFT GPS IPTQJUBMJ[BUJPOT PVUQBUJFOU QIZTJDJBO WJTJUT QIPUPUIFSBQZ QSFTDSJQUJPO UIFSBQJFT BOE PWFS UIF DPVOUFS NFEJDBUJPOT JT FTUJNBUFE UP CF NPSF UIBO NJMMJPO QFS ZFBS ɨF IJHIMZ WBSJBCMF OBUVSF PG QTPSJBTJT BOE JUT JOEJWJEVBM QSFTFOUBUJPO NBLF JU EJċDVMU UP DIPPTF UIF NPTU BQQSPQSJBUF USFBUNFOU BNPOH NBOZ PQUJPOT GSPN UPQJDBMT GPS NJME EJTFBTF UP QIPUPUIFSBQZ UP TZTUFNJDT XIJDI JODMVEF GVNBSJD BDJE FTUFST JO &VSPQF NFUIPUSFYBUF DZDMPTQPSJOF IZESPYZVSFB NZDPQIFOPMBUFNPGFUJM BDJUSFUJO BOE CJPMPHJDT GPS TFWFSF EJTFBTF 2

UXP UPQJDBM WJUBNJO % NPMFDVMFT GPS QTPSJBTJT DBMDJQPUSJFOF BOE DBMDJUSPM XJUI UBDBMDJUPM BWBJMBCMF JO &VSPQF CVU OPU JO UIF 6OJUFE 4UBUFT 5PQJDBM WJUBNJO % BOBMPHT QSPWJEF iTUFSPJE TQBSJOHw FĊFDUT BOE B GBWPSBCMF TBGFUZ QSPmMF ɨJT JT SFnFDUFE CZ B TUVEZ XIFSF DPNQMJBODF XBT TMJHIUMZ IJHIFS XJUI B UPQJDBM WJUBNJO % BOBMPH DPNQBSFE XJUI BO UPQJDBM DPSUJDPTUFSPJE

XJUI UIF QBUJFOUT CFJOH MFTT DPODFSOFE XJUI NPSF QSPMPOHFE VTF XJUI UIF WJUBNJO % BOBMPH 1

"MUIPVHI UIF FYBDU NFDIBOJTN PG BDUJPO PG WJUBNJO % BOBMPHT JT OPU XFMM VOEFSTUPPE TUVEJFT EFNPOTUSBUF UIBU UIFJS UPQJDBM BQQMJDBUJPO QSPEVDFT TUBCJMJ[BUJPO PG FQJEFSNBM LFSBUJOPDZUFT CZ CJOEJOH UIF MJHBOE BDUJWBUFE USBOTDSJQUJPO GBDUPS GPS WJUBNJO % BDUJWBUJOH UIF USBOTDSJQUJPO PG HFOFT UIBU JOIJCJU JOUFSMFVLJO *-

*- BOE JOUFSGFSPO HBNNB QSPEVDUJPO *'/ γ CZ 5 DFMMT BOE SFHVMBUF UIFJS QSPMJGFSBUJPO BOE EJĊFSFOUJBUJPO 5PQJDBM WJUBNJO % XBT TIPXO UP EFDSFBTF UIF OVNCFS PG FQJEFSNBM 5 DFMMT OFVUSPQIJMT BOE EFOESJUJD -BOHFSIBOT DFMMT JO QTPSJBUJD (VJEFMJOFT EFWFMPQFE CZ UIF "NFSJDBO "DBEFNZ PG %FSNBUPMPHZ QMBRVFT ""% JO TUBUF UIBU BQQSPYJNBUFMZ PG QBUJFOUT XJUI QTPSJBTJT IBWF NJME UP NPEFSBUF EJTFBTF UIBU DBO CF NBOBHFE XJUI CLASS GENERALITIES UPQJDBM BHFOUT 3 "NPOH UIPTF WJUBNJO % BOBMPHT BOE DPSUJDPTUFPHARMACOLOGY SPJET IBWF UIF NPTU SBOEPNJ[FE DMJOJDBM USJBMT UP QSPWF FċDBDZ 4 7JUBNJO % JT NBEF JO UIF TLJO XIFO EFIZESPDIPMFTUFSPM 7JUBNJO % XBT mSTU VTFE GPS QTPSJBTJT JO PSBM GPSN EVSJOH UIF SFBDUT XJUI 67 # JO UIF CBTBM DFMM MBZFS BOE TUSBUVN TQJOPTVN T 5 ɨF 64 'PPE BOE %SVH "ENJOJTUSBUJPO IBT BQQSPWFE QIPUPDIFNJDBMMZ QSPEVDJOH DIPMFDBMDJGFSPM 8IFUIFS NBEF JO From the Dermatology Treatment & Research Center, Dallas, TX1; Department of Medicine, Baylor University Medical Center, Dallas, TX2; the Departments of Dermatology & Family Practice, University of Texas Southwestern Medical School, Dallas, TX3; and the Dermatology Institute, Duncanville, TX4 Address for Correspondence: Marcial Oquendo, MD, Dermatology Treatment and Research Center. 5310 Harvest Hill Road, Suite 160, %BMMBT 59 t & NBJM ES PRVFOEP!HNBJM DPN

SKINmed. o

ª 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$

3&7*&8

November/December 2012 UIF TLJO PS JOHFTUFE DIPMFDBMDJGFSPM JT IZESPYZMBUFE JO UIF MJWFS UP IZESPYZDIPMFDBMDJGFSPM DBMDJEJPM PS 0) %

$BMDJEJPM JT USBOTQPSUFE UP UIF QSPYJNBM UVCVMFT PG UIF LJEOFZT XIFSF JU JT α IZESPYZMBUFE UP DBMDJUSJPM EJIZESPYZDIPMFDBMDJGFSPM PS 0) % B QPUFOU MJHBOE PG UIF WJUBNJO % SFDFQUPS 7%3 XIJDI NFEJBUFT NPTU PG UIF QIZTJPMPHJD BDUJPOT PG UIF WJUBNJO

SOLUTIONS 4PMVUJPOT BSF XBUFS PS BMDPIPM CBTFE BOE DBO IBWF B ESZJOH FĊFDU ɨFZ BSF FBTJFS UP BQQMZ UP IBJS CFBSJOH BSFBT TVDI BT UIF TDBMQ $BMDJQPUSJFOF JT BWBJMBCMF JO UIJT QSFTFOUBUJPO

SUSPENSIONS 4VTQFOTJPOT BSF IFUFSPHFOFPVT NJYUVSFT XJUI VOEJTTPMWFE QBSUJDMFT *O HFOFSBM UIFZ TFQBSBUF PO TUBOEJOH " DPNCJOBUJPO PG DBMDJQPUSJFOF CFUBNFUIBTPOF JT BWBJMBCMF JO UIJT QSFTFOUBUJPO BT B DPMPSMFTT UP TMJHIUMZ PĊ XIJUF BMNPTU DMFBS MJQPQIJMJD TVTQFOTJPO ɨF DBMDJQPUSJFOF DPNQPOFOU JT EJTTPMWFE JO QPMZPYZQSPQZMFOF TUFBSZM FUIFS XIJMF UIF NJDSPOJ[FE CFUBNFUIBTPOF JT QBSUMZ TPMWBUFE BOE QBSUMZ TVTQFOEFE JO B MJRVJE QBSBċO CBTF UIFSFGPSF JU NVTU CF TIBLFO CFGPSF VTF

7JUBNJO % BDUT NBJOMZ PO UIF 7%3 UP SFHVMBUF DFMM HSPXUI EJĊFSFOUJBUJPO BOE JNNVOF GVODUJPO BT XFMM BT DBMDJVN BOE QIPTQIPSVT NFUBCPMJTN *U BMTP JOIJCJUT QSPEVDUJPO PG *- BOE *- CMPDLT USBOTDSJQUJPO PG *'/ γ BOE HSBOVMPDZUF NBDSPQIBHF DPMPOZ TUJNVMBUJOH GBDUPS NFTTFOHFS SJCPOVDMFJD BDJE BOE JOIJCJUT DZUPUPYJD 5 DFMMT BOE OBUVSBM LJMMFS DFMM BDUJWJUZ 7JUBNJO % JOIJCJUT QSPMJGFSBUJPO PG LFSBUJOPDZUFT JO DVMUVSF BOE NPEVMBUFT FQJEFSNBM EJĊFSFOUJBUJPO $BMDJUSJPM TQFDJmDBMMZ IBT JNNVOPNPEVMBUPSZ FĊFDUT PO NPOPDZUFT NBDSPQIBHFT 5 DFMMT BOE FOAMS 'PBN JT B QSPQFMMFE WFIJDMF JO BMDPIPM PS UIFSNPMBCJMF BOE B EFOESJUJD DFMMT 1 MPX SFTJEVF IZESPFUIBOPMJD GPSNVMBUJPO *U TIPXFE JNQSPWFE EFMJWFSZ BOE DPTNFUJD BQQFBM 'PMMPXJOH BQQMJDBUJPO TPNF GPBNT PHARMACOKINETICS ɨF SBUF PG TZTUFNJD BCTPSQUJPO EFQFOET PO GPSNVMBUJPO BOE JOUFSBDU XJUI CPEZ IFBU FOBCMJOH SBQJE EJTTPMVUJPO BOE UIF 12 SPVUF PG BENJOJTUSBUJPO 7JUBNJO % BOE JUT NFUBCPMJUFT BSF BDUJWF DPOTUJUVFOU SFNBJOT PO UIF TLJO XJUI WFSZ MJUUMF SFTJEVF USBOTQPSUFE JO UIF CMPPE CPVOE UP TQFDJmD QMBTNB QSPUFJOT ɨF BDUJWF GPSN DBMDJUSJPM JT SFDZDMFE JO UIF MJWFS BOE FYDSFUFE JO UIF CJMF $BMDJQPUSJFOF 6OJUFE 4UBUFT PS DBMDJQPUSJPM &VSPQF

NFUBCPMJTN GPMMPXJOH TZTUFNJD VQUBLF JT SBQJE BOE PDDVST WJB B TJNJMBS QBUIXBZ UP UIF OBUVSBM IPSNPOF 10 11

CONTRAINDICATIONS/WARNINGS

7JUBNJO % BOE JUT BOBMPHT GPS UPQJDBM VTF TIPVME OPU CF VTFE JO QBUJFOUT XJUI LOPXO PS TVTQFDUFE EJTPSEFST PG DBMDJVN NFUBCPMJTN PS IZQFSDBMDFNJB PS FWJEFODF PG WJUBNJO % UPYJDJUZ 1IPUPTFOTJUJWJUZ DBO PDDVS XJUI BMM UIFTF QSPEVDUT "MTP ɨF VTF PG FBDI NFEJDBUJPO JO UIJT HSPVQ WBSJFT BDDPSEJOH UP QIPUPUIFSBQZ JO UIFTF QBUJFOUT TIPVME CF QSBDUJDFE XJUI DBVUJPO UIF WFIJDMF JO XIJDI JU JT QSFTFOUFE ɨF DIPJDF PG GPSNVMBUJPO EVF UP JODSFBTFE SJTL PG TLJO UVNPST TFFO JO QSFDMJOJDBM USJBMT JO DSFBN PJOUNFOU TPMVUJPO TVTQFOTJPO PS GPBN NBZ EFQFOE PO NJDF 10 11 14 MFTJPO MPDBUJPO 1TPSJBTJT PGUFO JOWPMWFT NVMUJQMF CPEZ BSFBT IBJS BOE OPOoIBJS CFBSJOH BOE NVMUJQMF GPSNVMBUJPOT BSF DPNNPOMZ TOPICAL VITAMIN D ANALOGS QSFTDSJCFE UP BEESFTT TQFDJmD BSFBT ɨJT NVMUJQMF WFIJDMF TDFOBSJP #SBOEFE QSFTFOUBUJPOT BWBJMBCMF JO UIF 6OJUFE 4UBUFT JODMVEF NBZ MFBE UP EFDSFBTFE DPNQMJBODF BOE JODSFBTFE DPTU 12 EPWPOFY DSFBN 4PSJMVY GPBN $BMDJUSJFOF 7FDUJDBM BOE 5BDMPOFY PJOUNFOUT %PWPOFY TPMVUJPO BOE 5BDMPOFY 4DBMQ TVTQFOTJPO

OINTMENTS

0JOUNFOUT BSF VTVBMMZ PJM CBTFE BOE PODF UIPVHIU UP CF UIF NPTU FĊFDUJWF WFIJDMF GPS QTPSJBTJT CFDBVTF PG JUT PDDMVTJWF OBUVSF BOE NPJTUVSJ[JOH BCJMJUZ 0JOUNFOU T TVQFSJPS FĊFDUJWFOFTT IBT CFFO QSPWFO 13 BMUIPVHI OFXFS NPSF FċDJFOU EFMJWFSZ TZTUFNT BSF OPX BWBJMBCMF 1BUJFOU QSFGFSFODF GPS PJOUNFOU JT UZQJDBMMZ MPX TJODF JU JT HSFBTJFS BOE NFTTJFS UIBO PUIFS DIPJDFT $BMDJQPUSJFOF BOE DBMDJUSJPM BOE B DPNCJOBUJPO DBMDJQPUSJFOF CFUBNFUIBTPOF EJQSPQJPOBUF BSF BWBJMBCMF JO UIJT QSFTFOUBUJPO

(FOFSJD WFSTJPOT FYJTU GPS TPNF PG UIFTF GPSNVMBUJPOT

CALCIPOTRIENE

$BMDJQPUSJFOF BT NPOPUIFSBQZ IBT CFFO TIPXO UP JNQSPWF TJHOT BOE TZNQUPNT JO BQQSPYJNBUFMZ UP PG QBUJFOUT XJUI DISPOJD QMBRVF QTPSJBTJT CFHJOOJOH BGUFS XFFLT PG UIFSBQZ 10 21 22 XJUI NBYJNVN FċDBDZ BU XFFLT UP QFS CPUI TIPSU BOE MPOH UFSN EBUB " NFUB BOBMZTJT TIPXFE DBMDJQPUSJFOF UP CF BT FĊFDUJWF JO QTPSJBTJT BT CFUBNFUIBTPOF WBMFSBUF BOE CREAMS NPSF FĊFDUJWF UIBO EJUISBOPM DPBM UBS BOE UBDBMDJUPM 15o "MTP $SFBNT BSF HFOFSBMMZ PJM JO XBUFS FNVMTJPOT BOE UFOE UP CF MFTT XIFO DPNQBSFE XJUI BOUISBMJO JU GBSFE CFUUFS JO UFSNT PG DMJOJHSFBTZ UIBO PJOUNFOUT BOE NPSF BQQFBMJOH DPTNFUJDBMMZ BMCFJU DBM FċDBDZ BOE XBT QSFGFSSFE CZ QBUJFOUT CFDBVTF JU EJE OPU TUBJO PGUFO MFTT FĊFDUJWF $BMDJQPUSJFOF JT BWBJMBCMF JO UIJT QSFTFOUBUJPO BOE XBT MFTT JSSJUBUJOH 1 " ESBXCBDL PG DBMDJQPUSJFOF BOE PUIFS SKINmed. o

5PQJDBM 7JUBNJO % "OBMPHT "WBJMBCMF UP 5SFBU 1TPSJBTJT

3&7*&8

November/December 2012 WJUBNJO % QSPEVDUT JT UIBU UIFZ DBO CF JOIJCJUFE PS JOBDUJWBUFE CZ UPQJDBM BHFOUT TVDI BT IZESPDPSUJTPOF WBMFSBUF BNNPOJVN MBDUBUF TBMJDZMJD BDJE BOE QIPUPUIFSBQZ ɨF UJNJOH PG BQQMJDBUJPO PG UIFTF QSPEVDUT PS UIFSBQFVUJD NPEBMJUJFT TIPVME UIVT CF UBLFO JOUP DPOTJEFSBUJPO BOE EJTDVTTFE XJUI UIF QBUJFOU 20 ɨF NPTU GSFRVFOU BEWFSTF SFBDUJPOT SFQPSUFE XFSF CVSOJOH JUDIJOH BOE TLJO JSSJUBUJPO XIJDI PDDVSSFE JO BQQSPYJNBUFMZ UP PG QBUJFOUT JODMVEJOH FSZUIFNB ESZ TLJO QFFMJOH SBTI EFSNBUJUJT XPSTFOJOH PG QTPSJBTJT TVDI BT EFWFMPQNFOU PG GBDJBM TDBMQ QTPSJBTJT JO UP PG QBUJFOUT &YQFSJFODFT SFQPSUFE JO MFTT UIBO PG QBUJFOUT JODMVEFE TLJO BUSPQIZ IZQFSQJHNFOUBUJPO IZQFSDBMDFNJB BOE GPMMJDVMJUJT 10

CALCITRIOL *O TFWFSBM USJBMT DBMDJUSJPM XBT FĊFDUJWF JO JNQSPWJOH TZNQUPNT PG EJTFBTF JO QBUJFOUT XJUI NJME UP NPEFSBUF QMBRVF QTPSJBTJT 5BCMF * BDIJFWJOH B SFTQPOTF JO BQQSPYJNBUFMZ PG QBUJFOUT BOE iDMFBS PS NJOJNBMw JO BQQSPYJNBUFMZ PG QBUJFOUT 23 24 "MUIPVHI IFBE UP IFBE DPNQBSJTPOT PG DBMDJQPUSJFOF BSF TDBSDF TPNF TUVEJFT TIPX TMJHIUMZ JODSFBTFE FċDBDZ GSPN DBMDJQPUSJFOF 30 BOE PUIFST TIPX DBMDJUSJPM BENJOJTUFSFE UXJDF EBJMZ PWFS B XFFL USFBUNFOU QFSJPE IBWJOH TJNJMBS FċDBDZ UP DBMDJQPUSJFOF EJĊFSFODF XBT OPU TUBUJTUJDBMMZ TJHOJmDBOU IPXFWFS XJUI B CFUUFS TBGFUZ QSPmMF 23

CALCIPOTRIENE/BETAMETHASONE ɨF DPNCJOBUJPO DBMDJQPUSJFOF CFUBNFUIBTPOF IBT CFFO XJEFMZ TUVEJFE JO TFWFSBM MBSHF TUVEJFT EFNPOTUSBUJOH UIBU UIF

D PNQPVOEFE GPSNVMBUJPO IBT CFUUFS FċDBDZ UIBO UIF JOEJWJEVBM DPNQPOFOUT BMPOF 5BCMF ** o "U UIF TBNF UJNF NBJOUBJOJOH B TJNJMBS TBGFUZ QSPmMF UIF NPTU DPNNPO BEWFSTF SFBDUJPOT XFSF QSVSJUVT QTPSJBTJT TLJO BUSPQIZ

GPMMJDVMJUJT CVSOJOH TFOTBUJPO TLJO EFQJHNFOUBUJPO FDDIZNPTJT FSZUIFNB BOE IBOE EFSNBUJUJT 0OF DBTF PG TFSJPVT nBSF VQ PG QTPSJBTJT XBT SFQPSUFE 5PMFSBCJMJUZ XBT BMTP TIPXO UP CF TJNJMBS UP CFUBNFUIBTPOF BMPOF BOE CFUUFS UIBO DBMDJQPUSJFOF XIFO VTFE BT NPOPUIFSBQZ DISCUSSION 5PQJDBM WJUBNJO % BOBMPHT BSF BO JOEJTQFOTBCMF DPNQPOFOU PG UIF DVSSFOU QIZTJDJBO T BSNBNFOUBSJVN GPS QTPSJBTJT USFBUNFOU .BOZ FYQFSUT JODMVEJOH B SFDFOU DPOTFOTVT DPOGFSFODF DMBTTJGZ UPQJDBM WJUBNJO % BHFOUT BT mSTU MJOF UIFSBQZ GPS QTPSJBTJT %FDBEFT PG EBUB TVQQPSU UIF GBDU UIBU UIFTF BHFOUT BSF FċDBDJPVT BOE XFMM UPMFSBUFE FTQFDJBMMZ JO UIF MPOH UFSN NBJOUFOBODF BTQFDU PG EJTFBTF DPOUSPM (FOFSBMMZ TQFBLJOH PJOUNFOUT BQQFBS UP XPSL CFUUFS UIBO DSFBNT UIJT NBZ DIBOHF XJUI UIF BEWFOU PG GPBN PS PUIFS OFXFS GPSNVMBUJPOT DBMDJUSJPM BQQFBST UP CF MFTT JSSJUBUJOH UIBO DBMDJQPUSJFOF 7JUBNJO % QSPEVDUT IBWF B TZOFSHJTUJD DPNQMFNFOUBSZ FĊFDUJWFOFTT XIFO VTFE XJUI UPQJDBM DPSUJDPTUFSPJET 5ZQJDBM UIFSBQFVUJD SFHJNFOT HFOFSBMMZ TUBSU XJUI UPQJDBM WJUBNJO % BOBMPH QSPEVDUT QMVT B UPQJDBM DPSUJDPTUFSPJE UP BDIJFWF SBQJE SFTQPOTF UIFO UIFZ BSF USBOTJUJPOFE UP NPOPUIFSBQZ XJUI UIF UPQJDBM WJUBNJO % BOBMPH BMPOF MPOH UFSN UP NBJOUBJO DMFBSBODF

Table I. Clinical Studies for Calcitriol

STUDY

METHODS

RESULTS/OBSERVATION

B

" SBOEPNJ[FE NVMUJDFOUFS CMJOEFE QBSBMMFM DPNQBSJTPO TUVEZ PG QBUJFOU XJUI NJME UP NPEFSBUF DISPOJD QMBRVF QTPSJBTJT23

$BMDJUSJPM PJOUNFOU WT DBMDJQPUSJFOFb UXJDF EBJMZ GPS XFFLT

*(" GPS DBMDJUSJPM WT " UPUBM PG IBE BU MFBTU GPS DBMDJQPUSJFOF 1(" GPS NBSLFE JNQSPWFNFOU XJUI DBMDBMDJUSJPM WT GPS DBMDJQPUSJFOF DJUSJPM WT XJUI DBMDJQPUSJFOF

BU XFFL

5XP NVMUJDFOUFS SBOEPNJ[FE WFIJDMF DPOUSPMMFE EPVCMF CMJOE QBSBMMFM HSPVQ TUVEJFT JO QBUJFOUT XJUI NJME UP NPEFSBUF DISPOJD QMBRVF QTPSJBTJT XJUI UBLJOH DBMDJUSJPM UBLJOH WFIJDMF

$BMDJUSJPM PJOUNFOU PS WFIJDMF BQQMJFE UXJDF B EBZ GPS XFFLT

$BMDJUSJPM BDIJFWFE iDMFBS PS NJOJNBMw JNQSPWFNFOU XJUI BU MFBTU B HSBEF DIBOHF GSPN CBTFMJOF JO BOE WT BOE PG QBUJFOUT SFTQFDUJWFMZ 0OTFU PG UIFSBQFVUJD FĊFDU BT FBSMZ BT XFFL

4JOHMF DFOUFS PQFO MBCFM JO WJUSP TUVEZ BTTFTTJOH TUBCJMJUZ PG UXP GPSNVMBUJPOT DPOUBJOJOH DMPCFUBTPM QSPQJPOBUF XJUI DBMDJUSJPM PJOUNFOU H H 25

$BMDJUSJPM PJOUNFOU XBT NJYFE JO B UP N- HMBTT DPOUBJOFS JO B X X SBUJP XJUI DMPCFUBTPM 5FTUFE GPS WJTVBM BQQFBSBODF BOE BDUJWF ESVH DPOUFOU CZ IJHI QFSGPSNBODF MJRVJE DISPNBUPHSBQIZ

/P BQQSFDJBCMF EFHSBEBUJPO PG BOZ BDUJWF JOHSFEJFOUT GPMMPXFE UIF DPNCJOBUJPO PG DBMDJUSJPM PJOUNFOU XJUI DMPCFUBTPM PWFS UIF IPVS UFTU QFSJPE

$BMDJUSJPM PJOUNFOU EFNPOTUSBUFE HPPE TZTUFNJD BOE MPDBM TBGFUZ QSPmMF DPNQBSBCMF XJUI JUT WFIJDMF OP FĊFDU PO DBMDJVN IPNFPTUBTJT

"CCSFWJBUJPOT *(" *OWFTUJHBUPS T (MPCBM "TTFTTNFOUT 1(" 1IZTJDJBO T (MPCBM "TTFTTNFOU B$BMDJUSJPM EPTF H H b$BMDJQPUSJFOF EPTF H H SKINmed. o

5PQJDBM 7JUBNJO % "OBMPHT "WBJMBCMF UP 5SFBU 1TPSJBTJT

3&7*&8

November/December 2012

Table II. Clinical Studies for Calcipotriene/Betamethasone

STUDY

METHODS

RESULTS/OBSERVATION

4JY SBOEPNJ[FE EPVCMF CMJOE $BMDJQPUSJFOF CFUBNFUIBTPOF QIBTF *** TUVEJFT PG QBUJFOUT PJOUNFOU WT NPOPUIFSBQZ XJUI XJUI QTPSJBTJT FBDI DPNQPOFOU

5XP NVMUJDFOUFS SBOEPNJ[FE EPVCMF CMJOE TUVEJFT XFSF DPOEVDUFE XJUI BOE QBUJFOUT XJUI NPEFSBUF UP WFSZ TFWFSF TDBMQ QTPSJBTJT SFTQFDUJWFMZ

"GUFS XFFLT 1"4* SFEVDUJPO BQQMJFE PODF PS UXJDF EBJMZ SBOHFE GSPN UP GPS UIF DPNCJOBUJPO QSPEVDU GSPN UP GPS DBMDJQPUSJFOF BOE GSPN UP GPS CFUBNFUIBTPOF

5PMFSBCJMJUZ PG UIF DPNCJOBUJPO QSPEVDU XBT TJNJMBS UP CFUBNFUIBTPOF NPOPUIFSBQZ BOE CFUUFS UIBO DBMDJQPUSJFOF BMPOF

0ODF EBJMZ GPS XFFLT JO UIF EJG- " UPUBM PG QBUJFOUT GFSFOU BSNT XJUI UIF DPNCJOBUJPO BDIJFWFE DMFBS PS BMNPTU DMFBS WT FBDI JOEJWJEVBM ESVH *(" BU XFFLT JO UIF DBMDJQPUSJFOF CFUBNFUIBTPOF HSPVQ GPS CFUIBNFUBTPOF BOE GPS DBMDJQPUSJFOF

&JHIU XFFL NVMUJDFOUFS SBOEPN- $BMDJQPUSJFOF CFUBNFUIBTPOF J[FE EPVCMF CMJOE TUVEZ EJQSPQJPOBUF WT UIF JOEJWJEVBM DPNQPOFOUT JO UIF TBNF WFIJDMF BOE WT WFIJDMF BMPOF

" UPUBM PG QBUJFOUT BDIJFWFE iBCTFOUw PS iWFSZ NJMEw EJTFBTF BU XFFL XJUI DPNCJOBUJPO GPSNVMBUJPO WT (P UBLJOH CFUBNFUIBTPOF P UBLJOH DBMDJQPUSJFOF PS P UBLJOH WFIJDMF

" UPUBM PG QBUJFOUT XJUI BU MFBTU NPEFSBUF EJTFBTF TFWFSJUZ UP BTTFTT TBGFUZ BOE UPMFSBCJMJUZ

.FEJBO VTF XBT H QFS XFFL

$BMDJQPUSJFOF CFUBNFUIBTPOF PJOUNFOU JOUFSNJUUFOUMZ PO BO iBT OFFEFEw CBTJT GPS VQ UP XFFLT

"CCSFWJBUJPOT *(" *OWFTUJHBUPS T (MPCBM "TTFTTNFOU 1"4* 1TPSJBTJT "SFB BOE 4FWFSJUZ *OEFY 4DPSF

REFERENCES 1

Grace K. Kim, DO. The rationale behind topical vitamin D analogs in the treatment of psoriasis. J Clin Aesthet Dermatol. 2010;3:46â&#x20AC;&#x201C;53.

2

Murphy G, Reich K. In touch with psoriasis: topical treatments and cur rent guidelines. J Eur Acad Dermatol Venereol. 2011;25(suppl 4):3â&#x20AC;&#x201C;8.

3

.FOUFS " ,PSNBO /+ &MNFUT $" FU BM (VJEFMJOFT PG DBSF GPS UIF NBO agement of psoriasis and psoriatic arthritis: Section 3. Guidelines of care for the management and treatment of psoriasis with topical thera pies. J Am Acad Dermatol. 2009;60:643â&#x20AC;&#x201C;659.

4

Murphy G, Reich K. In touch with psoriasis: topical treatments and cur rent guidelines. J Eur Acad Dermatol Venereol. 2011;5(suppl 4):3â&#x20AC;&#x201C;8.

5

Nagpal S, Lu J, Boehm MF. Vitamin D analogs: mechanism of action and therapeutic applications. Curr Med Chem. 2001;8:1661â&#x20AC;&#x201C;1679.

6

Guilhou JJ. The therapeutic effects of vitamin D3 and its analogues in psoriasis. Expert Opin Investig Drugs. 1998;7:77â&#x20AC;&#x201C;84.

7

Segaert S, Duvold LB. Calcipotriol cream: a review of its use in the man agement of psoriasis. J Dermatolog Treat. 2006;17:327â&#x20AC;&#x201C;337.

8

Scott LJ, Dunn CJ, Goa KL. Calcipotriol ointment. A review of its use in the management of psoriasis. Am J Clin Dermatol. 2001;2:95â&#x20AC;&#x201C;120.

9

Dam TN, Moller B, Hindkjaer J, Kragballe K. The vitamin D3 analog DBMDJQPUSJPM TVQQSFTTFT UIF OVNCFS BOE BOUJHFO QSFTFOUJOH GVODUJPO PG Langerhans cells in normal human skin. J Investig Dermatol Symp Proc.

1996;1:72â&#x20AC;&#x201C;77.

12 #POJ & &MFXTLJ .% 8JMMJBN "CSBNPWJUT .% FU BM " OPWFM GPBN GPSNVMB tion of ketoconazole, 2%, for the treatment of seborrheic dermatitis on multiple body regions. J Drugs Dermatol. 2007;6:1001â&#x20AC;&#x201C;1008.

13 %VXFC ( "MEFCBOJ 4 &M[PSHIBOZ " #FOHIB[JM . "MIBEEBS + $BMDJQPUSJPM ointment versus cream in psoriasis vulgaris. Int J Clin Pharmacol Res. 2003;23:47â&#x20AC;&#x201C;51.

14 Sorilux foam [package insert]. San Antonio, TX: Stiefel Laboratories, Inc; 2011.

15 Molin L, Cutler TP, Helander I, Nyfors B, Downes N. Comparative efficacy PG DBMDJQPUSJPM .$ DSFBN BOE CFUBNFUIBTPOF WBMFSBUF DSFBN JO UIF USFBUNFOU PG DISPOJD QMBRVF QTPSJBTJT " SBOEPNJ[FE EPVCMF CMJOE parallel group multicentre study. Calcipotriol Study Group. Br J Dermatol.

1997;136:89â&#x20AC;&#x201C;93.

16 Mason J, Mason AR, Cork MJ. Topical preparations for the treatment of psoriasis: a systematic review. Br J Dermatol. 2002;146:351â&#x20AC;&#x201C;364.

17 #FSUI +POFT + $IV "$ %PEE 8" FU BM " NVMUJDFOUSF QBSBMMFM HSPVQ DPNQBSJTPO PG DBMDJQPUSJPM PJOUNFOU BOE TIPSU DPOUBDU EJUISBOPM UIFSBQZ in chronic plaque psoriasis. Br J Dermatol. 1992;127:266â&#x20AC;&#x201C;271.

18 Pinheiro N. Comparative effects of calcipotriol ointment (50 μg/g) and 5% coal tar/2% allantoin/0.5% hydrocortisone cream in treating plaque psoriasis. Br J Clin Pract. 1997;51:16â&#x20AC;&#x201C;19.

19 7FJFO /, #KFSLF +3 3PTTNBO 3JOHEBIM * +BLPCTFO )# 0ODF EBJMZ USFBU ment of psoriasis with tacalcitol compared with twice daily treatment XJUI DBMDJQPUSJPM " EPVCMF CMJOE USJBM Br J Dermatol. 1997;137:581â&#x20AC;&#x201C;586.

10 %PWPOFY $SFBN <QBDLBHF JOTFSU> #BMMFSVQ %FONBSL -&0 1IBSNBDFVUJ cal; 2009.

20 Zeichner JA, Lebwohl MG, Menter A, et al. Optimizing topical therapies for treating psoriasis: a consensus conference. Cutis. 2010;86(suppl 3):5â&#x20AC;&#x201C;31.

11 Vectical ointment [package insert]. Fort Worth, TX: Galderma Laborato ries; 2009.

21 Calcipotriene [package insert]. Hawthorne, NY: Taro Pharmaceuticals USA; 2010.

SKINmed. o

5PQJDBM 7JUBNJO % "OBMPHT "WBJMBCMF UP 5SFBU 1TPSJBTJT

3&7*&8

November/December 2012 22 %PWPOFY 4DBMQ <QBDLBHF JOTFSU> #BMMFSVQ %FONBSL -&0 1IBSNBDFVUJ cal; 2010.

betamethasone dipropionate ointment for the treatment of psoriasis.

JÂ Eur Acad Dermatol Venereol. 2006;20:39â&#x20AC;&#x201C;44.

23 ;IV 9 8BOH # ;IBP ( FU BM "O JOWFTUJHBUPS NBTLFE DPNQBSJTPO PG UIF efficacy and safety of twice daily applications of calcitriol 3 Îźg/g oint ment vs. calcipotriol 50 Îźg/g ointment in subjects with mild to moder BUF DISPOJD QMBRVF UZQF QTPSJBTJT J Eur Acad Dermatol Venereol. 2007; 21:466â&#x20AC;&#x201C;472.

27 5BDMPOFY PJOUNFOU <QBDLBHF JOTFSU> %VCMJO *SFMBOE -&0 1IBSNBDFVUJ cals; 2007.

24 Lebwohl M, Menter A, Weiss J, et al. Calcitriol 3 Îźg/g ointment in the management of mild to moderate plaque type psoriasis: results from 2 QMBDFCP DPOUSPMMFE NVMUJDFOUFS SBOEPNJ[FE EPVCMF CMJOE DMJOJDBM TUVE ies. J Drugs Dermatol. 2007;6:428â&#x20AC;&#x201C;435.

25 Data on file. Fort Worth, TX: Galderma Laboratories, L.P. 26 Kragballe K, van de Kerhof PC. Consistency of data in six phase III DMJOJDBM TUVEJFT PG B UXP DPNQPVOE QSPEVDU DPOUBJOJOH DBMDJQPUSJPM BOE

28 Jemec GB, Ganslandt C, Ortonne JP, et al. A new scalp formulation of cal cipotriene plus betamethasone compared with its active ingredients and UIF WFIJDMF JO UIF USFBUNFOU PG TDBMQ QTPSJBTJT B SBOEPNJ[FE EPVCMF blind, controlled trial. J Am Acad Dermatol. 2008;59:455â&#x20AC;&#x201C;463.

29 Zeichner JA, Lebwohl MG, Menter A, et al. Optimizing topical therapies for treating psoriasis: a consensus conference. Cutis. 2010;86(suppl 3):5â&#x20AC;&#x201C;31.

30 ,Ă&#x161;SWFS +& 7JTTFST 8) WBO 3FOT %8 FU BM " EPVCMF CMJOE SBOEPNJ[FE quantitative comparison of calcitriol ointment and calcipotriol oint ment on epidermal cell populations, proliferation and differentiation.

Br J Dermatol. 2007;156:130â&#x20AC;&#x201C;137.

WAX MOULAGE

Bullous Pemphigoid, Moulage No 25, made by Otto Vogelbacher in Breisgau (Germany) in 1900. Museum of Wax Moulages Zurich.

Courtesy: Michael Geiges, MD SKINmed. o

5PQJDBM 7JUBNJO % "OBMPHT "WBJMBCMF UP 5SFBU 1TPSJBTJT

November/December 2012 Volume 10 Supplement 1

SUPPLEMENT The Safety, EďŹ&#x192;cacy, and Tolerability of a Novel Silicone Gel Dressing Following Dermatological Surgery Sandhofer and Schauer

November/December 2012

EDITORIAL BOARD

EDITOR IN CHIEF

Lawrence Charles Parish, MD, MD (Hon) Philadelphia, PA

DEPUTY EDITORS William Abramovits, MD Dallas, TX

W. Clark Lambert, MD, PhD Newark, NJ

Larry E. Millikan, MD Meridian, MS

Vesna Petronic-Rosic, MD, MSc Chicago, IL

Marcia Ramos-e-Silva, MD, PhD Rio de Janeiro, Brazil

Jennifer L. Parish, MD Philadelphia, PA

EDITORIAL BOARD Mohamed Amer, MD Cairo, Egypt

Howard A. Epstein, PhD Philadelphia, PA

Jasna Lipozencic, MD, PhD Zagreb, Croatia

Noah S. Scheinfeld, MD, JD New York, NY

Robert L. Baran, MD Cannes, France

Ibrahim Hassan Galadari, MD, PhD, FRCP Dubai, United Arab Emirates

Eve J. Lowenstein, MD, PhD New York, NY

Virendra N. Sehgal, MD Delhi, India

Anthony V. Benedetto, DO Philadelphia, PA

Anthony A. Gaspari, MD Baltimore, MD

George M. Martin, MD Kihei, HI

Riccarda Serri, MD Milan, Italy

Brian Berman, MD, PhD Miami, FL

Michael Geiges, MD Zurich, Switzerland

Marc S. Micozzi, MD, PhD Rockport, MA

Charles Steffen, MD Oceanside, CA

Jack M. Bernstein, MD Dayton, OH

Michael H. Gold, MD Nashville, TN

George F. Murphy, MD Boston, MA

Alexander J. Stratigos, MD Athens, Greece

Sarah Brenner, MD Tel Aviv, Israel

Lowell A. Goldsmith, MD, MPH Chapel Hill, NC

Oumeish Youssef Oumeish, MD, FRCP Amman, Jordan

James S. Studdiford III, MD Philadelphia, PA

Joaquin Calap Calatayud, MD Cadiz, Spain

Aditya K. Gupta, MD, PhD, FRCP(C) London, Ontario, Canada

Joseph L. Pace, MD, FRCP Naxxar, Malta

Robert J. Thomsen, MD Los Alamos, NM

Henry H.L. Chan, MB, MD, PhD, FRCP Hong Kong, China

Seung-Kyung Hann, MD, PhD Seoul, Korea

Art Papier, MD Rochester, NY

Julian Trevino, MD Dayton, OH

Noah Craft, MD, PhD, DTMH Torrance, CA

Roderick J. Hay, BCh, DM, FRCP, FRCPath London, UK

Johannes Ring, MD, DPhil Munich, Germany

Snejina Vassileva, MD, PhD Sofia, Bulgaria

Ncoza C. Dlova, MBChB, FCDerm Durban, South Africa

Tanya R. Humphreys, MD Philadelphia, PA

Roy S. Rogers III, MD Rochester, MN

Daniel Wallach, MD Paris, France

Richard L. Dobson, MD Mt Pleasant, SC

Camila K. Janniger, MD Englewood, NJ

Donald Rudikoff, MD New York, NY

Michael A. Waugh, MB, FRCP Leeds, UK

William H. Eaglstein, MD Palo Alto, CA

Abdul-Ghani Kibbi, MD Beirut, Lebanon

Robert I. Rudolph, MD Wyomissing, PA

Wm. Philip Werschler, MD Spokane, WA

Boni E. Elewski, MD Birmingham, AL

Andrew P. Lazar, MD Highland Park, IL

Vincenzo Ruocco, MD Naples, Italy

Joseph A. Witkowski, MD Philadelphia, PA

Charles N. Ellis, MD Ann Arbor, MI

Ronni Wolf, MD Rechovot, Israel

SUPPLEMENT The Safety, EďŹ&#x192;cacy, and Tolerability of a Novel Silicone Gel Dressing Following Dermatological Surgery Sandhofer and Schauer

Publication of this supplement was sponsored by Stratpharma AG, Basel, Switzerland.

TABLE OF CONTENTS /PWFNCFS %FDFNCFS t 7PMVNF t *TTVF

SUPPLEMENT The Safety, Efficacy, and Tolerability of a Novel Silicone Gel Dressing Following Dermatological Surgery ................................................................................................................. S1 Matthias Sandhofer, MD; Patrick Schauer, MD

ABOUT OUR JOURNAL SKINmed: Dermatology for the ClinicianÂŽ, print ISSN 1540-9740, online ISSN 1751-7125, is published bimonthly by Pulse Marketing & Communications, LLC, located at 4 Peninsula Avenue, Sea Bright, NJ 07760.

Printed in the USA. Disclaimer: The Publisher, Editors, and Editorial Board cannot be held responsible for errors or any consequences arising from the use of information contained in this journal; the views and opinions expressed herein do not necessarily reďŹ&#x201A;ect those of the Publisher, Editors, and Editorial Board, neither does the publication of advertisements constitute any endorsement by the Publisher, Editors, and Editorial Board of the products or services advertised. The Publisher, Editors, Editorial Board, Reviewers, Authors, and AďŹ&#x192;liated Agents shall not be held responsible or in any way liable for the continued accuracy of the information or for any errors, inaccuracies, or omissions of any kind in this publication, whether arising from negligence or otherwise, or for any consequences arising thereafter.

Copyright: Š2012 Pulse Marketing & Communications, LLC. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means without the prior permission in writing from the Publisher. Requests should be addressed to the Permissions Editor at: Pulse Marketing & Communications, LLC, 4 Peninsula Avenue, Sea Bright, NJ 07760.

Editorial MANAGING EDITOR Dhayanidhi Karunanidhi skinmed@diacritech.com

COPYEDITOR Elizabeth Holcomb eholcomb@skinmedjournal.com

MEDIA WEB DIRECTOR Joan Osgoodby joan@skinmedjournal.com

Publishing PUBLISHER Art Kalaka

ASSOCIATE PUBLISHER James R. Adams jadams@skinmedjournal.com

Corporate PRESIDENT Arthur Kalaka akalaka@skinmedjournal.com

CHIEF EXECUTIVE OFFICER Jo-Ann Kalaka-Adams jadams@skinmedjournal.com

GENERAL COUNSEL Marianne Mckenzie mmckenzie@skinmedjournal.com

Abstracting & Indexing: The journal is indexed in Index Medicus/ MEDLINE. To submit a manuscript for peer review, send as an e-mail attachment to the Editor in Chief at lparish@skinmedjournal.com. Please visit www.skinmedjournal.com for Information for Authors.

Published by Pulse Marketing & Communications, LLC 1FOJOTVMB "WFOVF t 4FB #SJHIU /+ 5FM t 'BY

7PMVNF t *TTVF t 4VQQMFNFOU

November/December 2012

SUPPLEMENT

The Safety, Efficacy, and Tolerability of a Novel Silicone Gel Dressing Following Dermatological Surgery Matthias Sandhofer, MD; Patrick Schauer, MD ABSTRACT 4JMJDPOF HFM IBT GPS NBOZ ZFBST IBE B QSJNBSZ SPMF JO UIF USFBUNFOU BOE QSFWFOUJPO PG BCOPSNBM TDBST JO UIF GPSN PG IZQFSUSPQIJD TDBST BOE LFMPJET BGUFS FQJUIFMJBMJ[BUJPO ɨF BVUIPST SFQPSU QSFMJNJOBSZ mOEJOHT PO UIF VTF PG B OFX NFEJDBM HSBEF mMN GPSNJOH TJMJDPOF HFM ESFTTJOH BQQSPWFE GPS VTF PO PQFO XPVOET BOE JOKVSFE TLJO BT NPOPUIFSBQZ BOE JO DPNCJOBUJPO XJUI PUIFS USFBUNFOUT QSJPS UP SF FQJUIFMJBMJ[BUJPO "O PCTFSWBUJPOBM TUVEZ JOWPMWJOH QBUJFOUT FYBNJOFE UIF TJMJDPOF HFM T FĊFDUJWFOFTT JO QSPNPUJOH BDDFMFSBUFE FQJUIFMJBMJ[BUJPO SFEVDJOH UIF JOnBNNBUPSZ SFTQPOTF BOE JO UIF QSFWFOUJPO PG TDBSSJOH ɨF TUVEZ XBT DPOEVDUFE PO B SBOHF PG EFSNBUPMPHJDBM TVSHJDBM JOUFSWFOUJPOT ɨF BVUIPST PCTFSWBUJPOT DPOmSNFE TJMJDPOF T SPMF JO QSPNPUJOH BDDFMFSBUFE XPVOE IFBMJOH TDBS QSFWFOUJPO BOE UIF VUJMJUZ PG UIJT OFX mMN GPSNJOH TJMJDPOF ESFTTJOH XIFO VTFE JO DPNCJOBUJPO XJUI WBSJPVT PUIFS USFBUNFOU NPEBMJUJFT SKINmed. 4 o4

W

IFO UIF JOUFHSJUZ PG IVNBO TLJO JT EJTUVSCFE CZ JOKVSZ PS TVSHJDBM JOUFSWFOUJPO UIF SFTVMUJOH TDBST DBO CF FTUIFUJDBMMZ EJTQMFBTJOH PS FWFO EJTmHVSJOH BOE DBO CF BDDPNQBOJFE CZ JUDIJOH QBJO BOE EJTUVSCFE TMFFQ 'VODUJPOBM MJNJUBUJPOT DBVTFE CZ EFGPSNBUJPO DPOUSBDUVSFT BSF BMTP QPTTJCMF EFQFOEJOH PO UIF BSFB BĊFDUFE BOE UIF JOUFOTJUZ PG UIF TDBS GPSNBUJPO ɨF QPUFOUJBM QTZDIPTPDJBM DPOTFRVFODFT JODMVEF EFQSFTTJPO JNQBJSNFOU PG BDUJWJUJFT PG EBJMZ MJWJOH MPX TFMG FTUFFN QPTU USBVNBUJD TUSFTT EJTPSEFS BOE TUJHNBUJ[BUJPO "MM PG UIFTF DPOTFRVFODFT PG BCOPSNBM TDBS GPSNBUJPO MFBE UP B SFEVDFE RVBMJUZ PG MJGF 1 1IZTJDJBOT TQFDJBMJ[JOH JO BFTUIFUJD JOUFSWFOUJPOT FNQMPZ B XJEF SBOHF PG EFSNBUPMPHJDBM TVSHJDBM QSPDFEVSFT XJUI UFDIOPMPHJDBM BEWBODFNFOUT JO UIF UFDIOJRVFT BOE FRVJQNFOU UIBU OPX BMMPX QSFEJDUBCMF WJTVBM BOE GVODUJPOBM PVUDPNF "T B SFTVMU UIF CPVOEBSZ CFUXFFO BDDFQUBCMF BOE VOBDDFQUBCMF SFTVMUT IBT CFDPNF XFMM EFmOFE CPUI GSPN UIF QBUJFOU T QFSTQFDUJWF BT XFMM BT GSPN UIF QIZTJDJBO T ɨJT NFBOT UIBU UIF USFBUJOH QIZTJDJBO NVTU OPU POMZ CF WJHJMBOU EVSJOH UIF QSPDFEVSF CVU BMTP TIPVME CF BDUJWFMZ JOWPMWFE JO UIF IFBMJOH QSPDFTT QPTUPQFSBUJWFMZ UP FOTVSF UIFTF QSFEJDUBCMF SFTVMUT ɨF QVSQPTF PG UIJT FWBMVBUJPO XBT UP PCUBJO QSFMJNJOBSZ EBUB PO UIF FċDBDZ TBGFUZ BOE UPMFSBCJMJUZ PG B OPWFM TJMJDPOF HFM ESFTTJOH GPS XPVOE USFBUNFOU BOE JUT FĊFDU PO BDDFMFSBUFE FQJUIFMJBMJ[BUJPO BOE JO UIF QSFWFOUJPO PG BCOPSNBM TDBSSJOH

USE OF SILICONE IN SCAR TREATMENT AND ABNORMAL SCAR PREVENTION #Z UIF FBSMZ T TJMJDPOF XBT CFJOH VTFE GPS TDBS UIFSBQZ 3 FTQFDJBMMZ GPS USFBUJOH IZQFSUSPQIJD TDBST BOE LFMPJET %VF UP UIF QPTJUJWF SFTVMUT PCUBJOFE 4 5 UIJT USFBUNFOU JO UIF GPSN PG TJMJDPOF HFM TIFFUT SBQJEMZ CFDBNF UIF TUBOEBSE JO QMBTUJD TVSHFSZ 2 *UT FĊFDUJWFOFTT XIFO VTFE GPS TDBS QSFWFOUJPO XBT BMTP SFQFBUFEMZ DPOmSNFE ɨF *OUFSOBUJPOBM $MJOJDBM 3FDPNNFOEBUJPOT PO 4DBS .BOBHFNFOU2 UIVT SFDPNNFOET TJMJDPOF HFM TIFFUT BT UIF mSTU DIPJDF GPS USFBUJOH BOE QSFWFOUJOH IZQFSUSPQIJD TDBST BOE LFMPJET 'VSUIFS EFWFMPQNFOU PG TJMJDPOF UFDIOPMPHZ BOE UIF JOUSPEVDUJPO PG UVCF EJTQFOTFE TFMG ESZJOH QSPEVDUT NBEF JU QPTTJCMF UP PWFSDPNF TJHOJmDBOU EJTBEWBOUBHFT BOE BQQMJDBUJPO MJNJUBUJPOT BTTPDJBUFE XJUI UIF TIFFUT *U CFDBNF FBTJFS UP QSPQFSMZ BQQMZ UIF TJMJDPOF TIFFU FTQFDJBMMZ UP BSFBT PG TLJO FYQPTFE UP JOUFOTJWF NPWFNFOUT BOE UIF DPTNFUJD BQQFBSBODF XBT TJHOJmDBOUMZ JNQSPWFE MFBEJOH UP CFUUFS DPNQMJBODF *O BEEJUJPO UP CFUUFS QBUJFOU DPNQMJBODF TJMJDPOF HFM BMMPXT UPQJDBM BOUJNJDSPCJBMT TVOCMPDL PS NBLFVQ UP CF BQQMJFE PWFS UIF HFM PODF JU ESJFT $VSSFOU DMJOJDBM TUVEJFT BOE QVCMJTIFE DMJOJDBM FYQFSJFODF TIPX UIBU UIF BJS ESZJOH UVCF EJTQFOTFE HFM IBT UIF TBNF FĊFDU GPS QSPNPUJOH XPVOE IFBMJOH JO TDBS USFBUNFOU BOE QSFWFOUJPO PG BCOPSNBM TDBS GPSNBUJPO BT UIF USBEJUJPOBM TJMJDPOF HFM TIFFUT 10 11

'SPN .BUUIJBT 4BOEIPGFS .% 4UBSIFNCFSHTUSBTTF -JO[ t & .BJM ES NBUUIJBT!TBOEIPGFS BU 'PVOEFS BOE )POPSBSZ $IBJSNBO PG "VTUSJBO "DBEFNZ PG $PTNFUJD 4VSHFSZ BOE "FTUIFUJD .FEJDJOF ""$4.

1BUSJDL 4DIBVFS #BIOIPGTUSB F 1BTTBV (FSNBOZ t & .BJM PGåDF!IBVUBS[U QBTTBV DPN

SKINmed. 4 o4

4

ª 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$

4611-&.&/5

November/December 2012 HOW THIS NEW SILICONE GEL WOUND DRESSING WORKS ɨF TJMJDPOF HFM JT BQQMJFE UP UIF BĊFDUFE BSFB PG UIF TLJO GPSNJOH B nFYJCMF QSPUFDUJWF TIFFU UIBU JT HBT QFSNFBCMF CVU TFNJPDDMVTJWF *U CJOET UP UIF JOKVSFE TLJO CVU EPFT OPU QFOFUSBUF JOUP UIF FQJEFSNJT PS EFSNJT "DDPSEJOH UP UIF NPTU SFDFOU TUVEJFT JO BCOPSNBM TDBST UIF QSPUFDUJWF TJMJDPOF TIFFUT SFTUPSF UIF OBUVSBM CBSSJFS GVODUJPO PG UIF FQJEFSNJT BOE SFEVDF USBOTFQJEFSNBM XBUFS MPTT BU UIF JOKVSZ TJUF ɨJT XBUFS MPTT BOE UIF SFTVMUJOH EFIZESBUJPO BSF BTTVNFE UP CF DSJUJDBM GBDUPST CFIJOE FYDFTTJWF QSPEVDUJPO PG DPMMBHFO mCFST BOE UIVT GPS UIF GPSNBUJPO PG BO BCOPSNBM TDBS

XPVOE IFBMJOH 5IF QIZTJDBM FGGFDUT PG UIJT OFX HFM BSF QPUFOUJBMMZ XFMM TVJUFE GPS UIFTF JOEJDBUJPOT BT JU DBO BMTP CF VTFE JNNFEJBUFMZ QPTUQSPDFEVSF METHODS

ɨJT DBTF TFSJFT JMMVTUSBUFT UIF QFSGPSNBODF PG B OFX TJMJDPOF CBTFE QSPEVDU 4USBUBNFE JO B TFSJFT PG TUBOEBSE QSPDFEVSFT QFSGPSNFE BU UIF ;FOUSVN GàS )BVU ­TUIFUJL -BTFS VOE 7FOFO JO -JO[ "VTUSJB BOE %FSNBUPMPHJTDIF (FNFJOTDIBGUTQSBYJT "TUIFUJTDIF .FEJ[JOF JO 1BTTBV (FSNBOZ JODMVEJOH BCMBUJWF BOE TVSHJDBM QSPDFEVSFT 4USBUBNFE JT B UVCF EJTQFOTFE TJMJDPOF HFM 4USBUQIBSNB "( #BTMF 4XJU[FSMBOE XIJDI GPSNT B TFMG ESZJOH QSPUFDUJWF TIFFU *U DPOTJTUT PG JOFSU TJMJDPOF QPMZNFST BOE #FDBVTF TFNJPDDMVTJWF XPVOE ESFTTJOHT XJUIPVU TJMJDPOF IBWF DBO CF BQQMJFE EJSFDUMZ UP PQFO XPVOET BOE UP BSFBT PG UIF TLJO CFFO TIPXO UP CF MFTT FĊFDUJWF JO USFBUJOH TDBST 12 POF DBO BTTVNF XJUI XFBLFOFE JOUFHSJUZ ɨJT TUVEZ EFTDSJCFT PVS PCTFSWBUJPOT UIBU TJMJDPOF QPTTFTTFT PUIFS QSPQFSUJFT UIBU QSPNPUF XPVOE XJUI UIJT QSPEVDU JO B TFSJFT PG QBUJFOUT IFBMJOH ɨF SFTVMUT PG DMJOJDBM TUVEJFT JOEJDBUF UIBU TJMJDPOF HFM NPEVMBUFT UIF MFWFMT PG UIF mCSPCMBTU HSPXUI GBDUPS b ɨF PATIENT SELECTION GPSNBUJPO PG IZQFSUSPQIJD TDBS UJTTVF UIBU DPOUBJOT IJTUPMPHJDBMMZ 'SPN UISPVHI XF NPOJUPSFE UIF QFSGPSNBODF PG OPSNBM mCSPCMBTUT JT QSFWFOUFE CZ NPEVMBUJOH UIF FYQSFTTJPO 4USBUBNFE GPMMPXJOH WBSJPVT JOWBTJWF USFBUNFOUT PO QBUJFOUT PG UIF HSPXUI GBDUPST ɨF EBUB QSPEVDFE TP GBS TVQQPSU UIF JO B DBTF TFSJFT BU UIF BVUIPST DMJOJDT BTTVNQUJPO UIBU UIF QSPQFSUJFT PG UIF TJMJDPOF TVCTUBODFT QSPNPUJOH XPVOE IFBMJOH BSF CBTFE PO UIF UIFPSZ UIBU UIFZ DPSSFDU Table I. The Number and Reason for Intervention (N=105) BO FYJTUJOH TIPSUBHF PS FYDFTT PG HSPXUI IPSNPOFT UIBU DPOUSPM REASON FOR INTERVENTION NO. UIF SFQBJS QSPDFTTFT JO UJTTVFT 13 *O BCMBUJWF BOE SFTVSGBDJOH QSP5BUUPP SFNPWBM 22 DFEVSFT UIF TJMJDPOF HFM XPVOE ESFTTJOH QSPNPUFT B NPJTU BOE )ZQFSUSPQIJD TDBS USFBUNFOU 15 QSPUFDUJWF XPVOE IFBMJOH FOWJSPONFOU ,FMPJE USFBUNFOU

TIME AS A FACTOR IN TREATING WOUNDS WITH SILICONE ɨF LOPXMFEHF HBJOFE GSPN TUVEJFT TVHHFTUT UIBU UIF UJNF BU XIJDI B XPVOE JT USFBUFE IBT B TJHOJmDBOU FĊFDU PO UIF MJLFMJIPPE PG BCOPSNBM TDBS GPSNBUJPO 14 15 UIFSFGPSF UIF HPBM TIPVME CF UP BDIJFWF UIF NPTU SBQJE QPTTJCMF FQJUIFMJBMJ[BUJPO PG UIF XPVOE JO PSEFS UP NJOJNJ[F TDBS GPSNBUJPO ɨJT JT QBSUJDVMBSMZ USVF GPS CVSO XPVOET BOE PUIFS TVSGBDF JOKVSJFT PG UIF FQJEFSNJT XIFSF FQJUIFMJBMJ[BUJPO JT EFMBZFE XJUIPVU BEEJUJPOBM USFBUNFOU IPXFWFS QSJPS UP UIF JOUSPEVDUJPO PG UIJT OFX TJMJDPOF QSFQBSBUJPO TFMG ESZJOH TJMJDPOF HFM QSPEVDUT XFSF OPU JOEJDBUFE VOUJM UIF XPVOE IBE BMSFBEZ IFBMFE BOE UIF FQJUIFMJBM GPSNBUJPO XBT DPNQMFUF EFMBZJOH UIF TUBSU PG USFBUNFOU CZ VQ UP TFWFSBM XFFLT ɨJT OFX TJMJDPOF HFM XPVOE ESFTTJOH JT QPUFOUJBMMZ XFMM TVJUFE GPS TDBS QSFWFOUJPO CFDBVTF JU DBO CF VTFE JNNFEJBUFMZ PO PQFO XPVOET BOE EBNBHFE TLJO *O BEEJUJPO UP FBSMZ USFBUNFOU GPS TDBS QSFWFOUJPO EFSNBUPMPHJDBM BCMBUJWF BOE SFTVSGBDJOH QSPDFEVSFT SFRVJSF B NPJTU QSPUFDUJWF FOWJSPONFOU JNNFEJBUFMZ UP GBDJMJUBUF BDDVSBUF SKINmed. 4 o4

4

2

"DOF TDBS USFBUNFOU

15

8SJOLMF USFBUNFOU

/FWVT SFNPWBM

-FOUJHP SFNPWBM

1

.FMBOPNB SFNPWBM

4

,FSBUPTJT SFNPWBM

3

#BTBM DFMM DBSDJOPNB SFNPWBM

1

4LJO UJHIUFOJOH GBDF

5

&ZFMJE TVSHFSZ

3

-JQPTVDUJPO

3

7FOPVT TVSHFSZ

2

5SBVNBUJD XPVOE USFBUNFOU

2

"CEPNJOBM XBMM UJHIUFOJOH

2

7FSSVDB USFBUNFOU

1

.BNNBQMBTUZ

1

3JOHT VOEFS FZFT USFBUNFOU

1

$JDBUSJDJBM BMPQFDJB

1

*OnBNNBUPSZ MJOFBS WFSSVDPVT FQJEFSNBM OFWVT

1

#VSO USFBUNFOU

1

/PWFM 4JMJDPOF (FM %SFTTJOH

4611-&.&/5

November/December 2012 5BCMF * 5BCMF ** BOE 5BCMF ** EFTDSJCF UIF EJĊFSFOU UZQFT PG QBUIPMPHJFT USFBUFE BOE UIF UFDIOJRVFT VTFE PO UIF TFSJFT PG QBUJFOUT 5BCMF * PVUMJOFT UIF OVNCFS BOE SFBTPOT GPS JOUFSWFOUJPOT PO UIF QBUJFOUT ɨSFF QBUJFOUT IBE NPSF UIBO POF JOUFSWFOUJPO 5BCMF ** EFTDSJCFT UIF GSFRVFODZ BOE UZQFT PG JOUFSWFOUJPOT QFSGPSNFE XJUI OVNFSPVT QBUJFOUT VOEFSHPJOH B DPNCJOBUJPO PG UFDIOJRVFT 5BCMF *** EFTDSJCFT TQFDJmDBMMZ UIF OVNCFS BOE SFBTPOT GPS TVSHJDBM FYDJTJPOT QFSGPSNFE PO QBUJFOUT XIP XFSF Table II. Frequency and Types of Interventions Used

TYPE OF INTERVENTION

NO.

$02 GSBDUJPOBM MBTFS -VUSPOJD

34

2 4XJUDI MBTFS

24

GSBDUJPOBM MBTFS .PTBJD

23

&YDJTJPOT

'6 USJBNDJOPMPOF JOKFDUJPO

'SBDUJPOBM SBEJPGSFRVFODZ *OUSBDFM '",*3

10

%FSNBCSBTJPO

4

$BVUFSJ[BUJPO

1

$IFNJDBM QFFMJOH

1

'PS BMM EFSNBUPMPHJDBM QSPDFEVSFT BGUFS UIF mSTU BQQMJDBUJPO JO UIF DMJOJD QBUJFOUT DPOUJOVFE UP VTF UIF HFM BU IPNF

NO.

/FWVT FYDJTJPO

4LJO UJHIUFOJOH GBDF

3

.FMBOPNB SFNPWBM

3

&ZFMJE TVSHFSZ

2

#BTBM DFMM DBSDJOPNB SFNPWBM

1

.BNNBQMBTUZ

1

-FOUJHP SFNPWBM

1

"GUFS TVSHJDBM FYDJTJPOT BOE SFTVUVSJOH UIF TJMJDPOF HFM XBT GPS UIF mSTU BQQMJFE JNNFEJBUFMZ BGUFS DMPTVSF BOE UIFO PVS TUBOEBSE QPTUoXPVOE DBSF QSPUPDPM XBT BEIFSFE UP JF B DPNCJOBUJPO PG SFHVMBS SFWJFX XJUI PS XJUIPVU XPVOE ESFTTJOHT /P BEEJUJPOBM QSPQIZMBDUJD TDBS UIFSBQJFT XFSF VTFE PO UIJT DBTF TFSJFT *O FBDI DBTF FYDFTT FYVEBUF PS nVJE GSPN UIF XPVOE XBT mSTU QBUUFE ESZ CFGPSF UIF TJMJDPOF HFM BQQMJDBUJPO %FQFOEJOH VQPO UIF TLJO BSFB BOE XPVOE UP CF USFBUFE UIF TJMJDPOF HFM XBT VTFE FJUIFS XJUI PS XJUIPVU B QSPUFDUJWF ESFTTJOH ɨF GBDUPST EFUFSNJOJOH UIF VTF PG B QSPUFDUJWF ESFTTJOH EJE OPU EFWJBUF GSPN PVS TUBOEBSE SFBTPOJOH GPS BQQMZJOH UIF ESFTTJOH JO UIF QPTUPQFSBUJWF QFSJPE 'PS UIF QBUJFOUT SFRVJSJOH USFBUNFOUT PG FYJTUJOH BCOPSNBM TDBST IZQFSUSPQIJD TDBST BOE LFMPJET CPUI BGUFS nVPSP VSBDJM '6 USJBNDJOPMPOF JOKFDUJPOT BT XFMM BT BGUFS UIF VTF PG GSBDUJPOBM MBTFST BOE GSBDUJPOBM SBEJPGSFRVFODZ TZTUFNT XFSF BMM QSFTDSJCFE B QPTUPQFSBUJWF BQQMJDBUJPO PG UIF TJMJDPOF HFM

Table III. Surgical Excisions in Detail (N=17)

SURGICAL EXCISIONS

4PNF QBUJFOUT CBTFE PO DMJOJDBM KVEHNFOU BOE QBUJFOU SJTL GBDUPST XFSF BMTP QSFTDSJCFE BO BOUJCJPUJD PJOUNFOU DPOUBJOJOH UIF BDUJWF JOHSFEJFOU GVTJEJD BDJE UXJDF EBJMZ GPS UIF mSTU UP EBZT UIFSFGPSF PVS NBOBHFNFOU EJE OPU BMUFS FYDFQU GPS UIF BEEJUJPO PG UIF TJMJDPOF HFM BT B mSTU DPOUBDU MBZFS

ɨF BWFSBHF USFBUNFOU UJNF GPS QBUJFOUT VTJOH UIF TJMJDPOF HFM XBT NPOUIT 'PMMPX VQ GPS UIFTF QBUJFOUT SBOHFE GSPN NPOUI UP NPOUIT EFQFOEJOH VQPO UIF QSPDFEVSF QFSGPSNFE CVU JO BDDPSEBODF XJUI PVS TUBOEBSE QBUJFOU GPMMPX VQ "MM QBUJFOUT XFSF QIPUPHSBQIFE EVSJOH UIF DPVSTF PG UIFJS GPMMPX VQ 'JHVSFT o ɨF BVUIPST PCTFSWFE UIF HFOFSBM QFSGPSNBODF PG UIF TJMJDPOF QSPEVDU BOE TVCKFDUJWFMZ FWBMVBUFE UIFTF SFTVMUT CBTFE PO QSFWJPVT DMJOJDBM FYQFSJFODF BOE FYQFDUBUJPOT *O BEEJUJPO QBUJFOUT TVCKFDUJWF PQJOJPOT XFSF SFDPSEFE

SFWJPVTMZ TDBS GSFF QSJPS UP UIFJS QSPDFEVSF 1BUJFOU WBSJBCMFT TVDI Q BT BHF TFY BOE PUIFS JNQPSUBOU DPOGPVOEJOH WBSJBCMFT JODMVEJOH 'JU[QBUSJDL TLJO UZQF IBWF OPU CFFO EFTDSJCFE CFDBVTF UIF QVSQPTF PG UIJT TUVEZ XBT UP PCTFSWF UIF PWFSBMM QFSGPSNBODF PG UIJT OFX TJMJDPOF HFM PO NBOZ UZQFT PG TVSHJDBM JOUFSWFOUJPOT BOE UP HBVHF UIF QBUJFOU T TBUJTGBDUJPO XJUI UIF OFX QSPEVDU *O BEEJUJPO B DPOUSPM HSPVQ XIFSF TUBOEBSE QPTUPQFSBUJWF QSBDUJDFT BSF DPNQBSFE XJUI UIJT OFX USFBUNFOU XBT OPU VOEFSUBLFO *OTUFBE BMM QBUJFOUT SFDFJWFE PVS TUBOEBSE QPTUPQFSBUJWF XPVOE DBSF QSPUPDPM XJUI UIF BEEJUJPO PG UIF OFX HFM

RESULTS AND OBSERVATIONS

'PS UIF DBTFT PG SFTVSGBDJOH QSPDFEVSFT TFWFSBM QPTJUJWF PCTFSWBUJPOT XFSF OPUFE ɨFSF XBT B SFEVDUJPO JO UIF JOnBNNBUPSZ SFTQPOTF JO CPUI UJNF BOE TFWFSJUZ UIF QSFDJTF IFBMJOH PG UIF XPVOE XBT PCTFSWFE BOE UIFSF XFSF OP DBTFT PG JSSJUBUJPO SFEEFOJOH PCTFSWFE 8F BMTP PCTFSWFE B GBTUFS IFBMJOH PS SF FQJUIFMJBMJ[BUJPO PG UIF XPVOE TVSGBDF XJUI WJTJCMZ TBUJTGBDUPSZ SFTVMUT TUBSUJOH BT FBSMZ BT EBZT DPNQBSFE XJUI XIBU XF PCTFSWF XJUI PVS TUBOEBSE DBSF 'JHVSFT BOE ɨF QSPUFDUJWF TIFFU GPSNFE CZ UIF TJMJDPOF HFM JO UIFTF SFTVSGBDJOH DBTFT EJE OPU DESCRIPTION OF PROCEDURES JOUFSGFSF XJUI UIF XPVOE HSBOVMBUJPO *O BEEJUJPO BGUFS UIF 'PS MBTFS SFTVSGBDJOH UIF TJMJDPOF HFM XBT BQQMJFE BT BO BEKVODU SFNPWBM PG UIF JOJUJBM EFUSJUVT UIFSF XBT OP OPUJDFBCMF BCOPSNBM UP PVS TUBOEBSE QPTU MBTFS XPVOE DBSF QSPUPDPM ɨBU JT BMM HSBOVMBUJPO GPSNBUJPO ɨF EFUSJUVT BSJTJOH GSPN GSBDUJPOBM $02 QBUJFOUT XFSF QSFTDSJCFE B NPJTUVSJ[JOH QFUSPMFVN CBTFE HFM USFBUNFOU XFSF FYGPMJBUFE BGUFS UP EBZT 1BUJFOUT TVCKFDUJWFMZ SKINmed. 4 o4

4

/PWFM 4JMJDPOF (FM %SFTTJOH

4611-&.&/5

November/December 2012

Figure 1. 4DBS JNNFEJBUFMZ BGUFS UIF JODJTJPO BOE BGUFS XFFLT PG 4USBUBNFE USFBUNFOU BT NPOPUIFSBQZ 'JSTU QVCMJTIFE JO PO XXX TUSBUBNFE DPN

Figure 2. &YJTUJOH IZQFSUSPQIJD TDBS GPMMPXJOH UIPSBDJD TVSHFSZ CFGPSF EVSJOH BOE BGUFS B XFFL 4USBUBNFE USFBUNFOU BT DPNCJOBUJPO UIFSBQZ XJUI GSBDUJPOBM $02 NPTBJD MBTFS BOE SBEJP GSFRVFODZ USFBUNFOU 'JSTU QVCMJTIFE JO PO XXX TUSBUBNFE DPN

SFQPSUFE B TJHOJmDBOU SFEVDUJPO JO SFEEFOJOH JUDIJOH BOE GFFMJOHT PG UJHIUOFTT JO UIFTF TFNJ BCMBUJWF BOE BCMBUJWF QSPDFEVSFT DBTFT ɨF TJMJDPOF HFM XBT SFQPSUFE UP CF OPOEJTSVQUJWF BOE FTUIFUJDBMMZ UPMFSBCMF GPS QBUJFOUT QBSUJDVMBSMZ XJUI GBDJBM BQQMJDBUJPOT *O POF QBUJFOU XJUI OP SFQPSUFE QFSTPOBM IJTUPSZ PG herpes JOGFDUJPO VTJOH USFBUNFOU XJUI B GSBDUJPOBM $02 MBTFS B XJEF BSFB herpetic FSVQUJPO PDDVSSFE XIJDI XBT TVDDFTTGVMMZ USFBUFE XJUI TZTUFNJD BDZDMPWJS 'SPN PVS FYQFSJFODF JU JT OPU SBSF UP FYQFSJFODF B IFSQFUJD FSVQUJPO TVCTFRVFOU UP B TFWFSF TLJO USBVNB TVDI BT GSPN B GSBDUJPOBM $02 MBTFS USFBUNFOU SKINmed. 4 o4

4

/P PUIFS TJEF FĊFDUT VTJOH UIF TJMJDPOF HFM GSPN UIF MBTFS QSPDFEVSFT XFSF PCTFSWFE *O UIF DBTFT PG TVSHJDBM FYDJTJPOT XF PCTFSWFE B SF FQJUIFMJBMJ[BUJPO BOE TDBS GPSNBUJPO UIBU TVQFSTFEFE PVS DMJOJDBM FYQFDUBUJPOT 'JHVSF ɨF BQQMJDBUJPO PG UIF TJMJDPOF HFM SFQSFTFOUFE B XFMDPNF FOIBODFNFOU PG UIF QPTUPQFSBUJWF NBOBHFNFOU QSPDFTT GPS QBUJFOUT BOE UIFZ XFSF BCMF UP EP UIF BQQMJDBUJPO JOEFQFOEFOUMZ NBLJOH BEEJUJPOBM WJTJUT UP PVS DMJOJDT FYDFQU GPS UIF NBOEBUPSZ GPMMPX VQ VOOFDFTTBSZ $PNQMJBODF JO UIFTF DBTFT XBT SFDPSEFE BT $PNQMJBODF XBT EFmOFE BT VTJOH UIF TJMJDPOF HFM BU MFBTU EBZT PG UIF XFFL /PWFM 4JMJDPOF (FM %SFTTJOH

4611-&.&/5

November/December 2012

Figure 3. &YJTUJOH IZQFSUSPQIJD TDBS GPMMPXJOH FYDJTJPO PG B NFMBOPNB CFGPSF USFBUNFOU BOE BGUFS BOE XFFLT PG 4USBUBNFE USFBUNFOU JO DPNCJOBUJPO UIFSBQZ XJUI '6 DPSUJDPTUFSPJE JOKFDUJPOT 'JSTU QVCMJTIFE JO PO XXX TUSBUBNFE DPN

Figure 4. %FSNBCSBTJPO EVSJOH USFBUNFOU BOE BGUFS XFFL 4USBUBNFE USFBUNFOU BT NPOPUIFSBQZ 'JSTU QVCMJTIFE JO PO XXX TUSBUBNFE DPN SKINmed. 4 o4

4

/PWFM 4JMJDPOF (FM %SFTTJOH

4611-&.&/5

November/December 2012

"MM QPTUPQFSBUJWF BQQMJDBUJPO SFDPNNFOEBUJPOT XFSF GPMMPXFE XJUIPVU FYDFQUJPO *O POF TVSHJDBM FYDJTJPO DBTF BGUFS FYDJTJPO PG B KVWFOJMF NFMBOPNB JO UIF DIFTU BSFB XF PCTFSWFE EFWFMPQNFOU PG B IZQFSUSPQIJD TDBS UIBU XBT TVDDFTTGVMMZ USFBUFE XJUI JOKFDUJPO USFBUNFOU XJUI '6 USJBNDJOPMPOF JO DPNCJOBUJPO XJUI UIF TJMJDPOF HFM DISCUSSION ɨF HFOFSBM PCTFSWBUJPOT GSPN PVS DBTF FYQFSJFODF JOEJDBUF UIBU UIJT OFX TJMJDPOF HFM XPVOE ESFTTJOH JT XFMM TVJUFE GPS B XJEF SBOHF PG EFSNBUPMPHJDBM TVSHFSZ JOEJDBUJPOT OBNFMZ UIF USFBUNFOU PG PQFO XPVOET QPTU SFTVSGBDJOH QSPDFEVSFT BOE UIF FBSMZ VTF JO BCOPSNBM TDBS QSFWFOUJPO ɨF HFM ESFTTJOH JT BMTP XFMM TVJUFE BT B DPNCJOBUJPO UIFSBQZ XJUI PVS TUBOEBSE QPTUPQFSBUJWF XPVOE DBSF QSPUPDPMT ɨF TJMJDPOF HFM QSPWFE QBSUJDVMBSMZ IFMQGVM JO UIF QPTUPQFSBUJWF GSBDUJPO TZTUFN USFBUNFOU XIFSF XF PCTFSWFE UIBU FSPTJWF BOE BCMBUJWF XPVOET BSF CFUUFS QSPUFDUFE UIBO XJUI UIF QFUSPMFVN CBTFE NPJTUVSJ[JOH BHFOUT UIBU XF DPNNPOMZ VTF ɨF IFBMJOH QSPDFTT XBT BMTP PCTFSWFE UP CF NPSF TUSPOHMZ TVQQPSUFE 8F QSPQPTF UIBU UIJT JT EVF UP UIF TJMJDPOF QPMZNFST IBWJOH OP NFBTVSBCMF Q) WBMVF BOE UIFSFGPSF UIFTF QPMZNFST EP OPU BĊFDU UIF QSPUFDUJWF BDJE NBOUMF PG UIF TLJO BOE EP OPU SFBDU XJUI UIF OFXMZ GPSNJOH FQJUIFMJBM UJTTVFT ɨF SFTVMU JT B GBWPSBCMF FOWJSPONFOU GPS UIF TLJO IFBMJOH QSPDFTT XIJDI XF TVCKFDUJWFMZ PCTFSWFE UP MFBE UP GBTUFS FQJUIFMJBM GPSNBUJPO 'SPN PVS USJBM FYQFSJFODF XF DPODMVEF UIBU UIFSF JT OP OFFE UP BEBQU GVSUIFS PVS FYJTUJOH XPVOE USFBUNFOU DPODFQUT XIFO TJMJDPOF HFM JT VTFE CFDBVTF JU JT BO BEE PO UIFSBQZ ɨF QSFQBSBUJPO XBT XFMM UPMFSBUFE XJUIPVU FYDFQUJPO BOE OP DPOUBDU TFOTJUJ[BUJPO PS HFM SFMBUFE JOGFDUJPOT XFSF PCTFSWFE *O OP JOTUBODF XBT JU OFDFTTBSZ UP SFNPWF UIF QSFQBSBUJPO (JWFO UIBU UIF HFM JT JOFSU BOE UIBU OP BEWFSTF UPQJDBM TJMJDPOF HFM SFBDUJPOT IBWF CFFO QVCMJTIFE UP EBUF QSFEJDUFE UIJT SFTVMU 1BUJFOU DPNQMJBODF XBT WFSZ IJHI BOE XF QSPQPTF UIBU UIF GBDUPST UIBU DPOUSJCVUFE UP UIJT SFTVMU XFSF JO QBSUJDVMBS UIF TJNQMJDJUZ PG BQQMJDBUJPO XIJDI DPVME CF QFSGPSNFE CZ BMM QBUJFOUT BU IPNF XJUIPVU EJċDVMUZ BOE UIF UZQF PG DMJFOUFMF USFBUFE BU UIF DMJOJD ɨF QBUJFOUT TFFO BSF IJHIMZ iDPTNFUJDBMMZ DPOTDJPVT w QBSUJDVMBSMZ XJUI SFHBSET UP QSFWFOUJPO PG BCOPSNBM TDBSSJOH BOE UIF BVUIPST CFMJFWF UIJT MFBET UP B NBYJNVN MFWFM PG QPTUPQFSBUJWF DPNQMJBODF UIFSFGPSF UIF DPNQMJBODF SBUF PCTFSWFE XJUI UIF TVSHJDBM FYDJTJPOT JT OPU TVSQSJTJOH LIMITATIONS

Figure 5. -BTFS XSJOLMF USFBUNFOU CFGPSF EVSJOH EBZ

BOE BGUFS EBZT USFBUNFOU XJUI 4USBUBNFE BT DPNCJOBUJPO UIFSBQZ XJUI UIFSNBHF GSBDUJPOBM $02 MBTFS BOE #PUPY 'JSTU QVCMJTIFE JO PO XXX TUSBUBNFE DPN SKINmed. 4 o4

ɨJT PCTFSWBUJPOBM TUVEZ IBT TFWFSBM JNQPSUBOU MJNJUBUJPOT UIBU OFFE UP CF UBLFO JOUP BDDPVOU XIFO JOUFSQSFUJOH SFTVMUT ɨF TUVEZ XBT OPU SBOEPNJ[FE BOE MBDLFE B DPOUSPM HSPVQ

4

/PWFM 4JMJDPOF (FM %SFTTJOH

4611-&.&/5

November/December 2012

Figure 6. -BTFS SFTVSGBDJOH PG BDOF TDBST CFGPSF EVSJOH EBZ BOE BGUFS EBZT PG USFBUNFOU XJUI 4USBUBNFE BT DPNCJOBUJPO UIFSBQZ XJUI UIFSNBHF BOE GSBDUJPOBM $02 MBTFS 'JSTU QVCMJTIFE JO PO XXX TUSBUBNFE DPN

T UBOEBSEJ[FE JOEJDBUJPOT GPS USFBUNFOU BOE QSFEFmOFE FOEQPJOUT *O UIF BCTFODF PG SJHPSPVT FYQFSJNFOUBM NFUIPEPMPHZ JU JT OPU QPTTJCMF UP DPODMVEF TDJFOUJmDBMMZ UIBU PVS PCTFSWBUJPOT BSF QSFEJDUJWF PG UIF SFTVMUT PG B SBOEPNJ[FE DPOUSPMMFE USJBM *O PSEFS UP WBMJEBUF BOE RVBOUJGZ UIF QPTJUJWF SFTVMUT GSPN UIFTF JOJUJBM PCTFSWBUJPOT XF SFDPNNFOE DPOEVDUJOH BEEJUJPOBM SJHPSPVT DMJOJDBM TUVEJFT XJUI PCKFDUJWF BOE SFMJBCMF NFBTVSFNFOU UPPMT CMJOEFE QBUJFOUT BOE BTTFTTPST BOE B DPOUSPM HSPVQ

4

$SV[ ,PSDIJO /* &GGFDUJWFOFTT PG TJMJDPOF TIFFUT JO UIF QSFWFOUJPO PG IZQFSUSPQIJD CSFBTU TDBST Ann Plast Surg. o

5

"IO 45 .POBGP 88 .VTUPF 5" 5PQJDBM TJMJDPOF HFM GPS UIF QSFWFOUJPO BOE USFBUNFOU PG IZQFSUISPQIJD TDBS Arch Surg. o

6

(PME .) 'PTUFS 5% "EBJS ." #VSMJTPO , -FXJT 5 1SFWFOUJPO PG IZQFS USPQIJD TDBST BOE LFMPJET CZ UIF QSPQIZMBDUJD VTF PG UPQJDBM TJMJDPOF HFM TIFFUT GPMMPXJOH B TVSHJDBM QSPDFEVSF JO BO PG├еDF TFUUJOH Dermatol Surg. o

7

#PSHPHOPOJ - #JPMPHJDBM FGGFDUT PG TJMJDPOF HFM TIFFUJOH Wound Repair Regen. o

8

$IBO ,: -BV $- "EFFC 4. 4PNBTVOEBSBN 4 /BTJS ;BIBSJ . " SBO EPNJ[FE QMBDFCP DPOUSPMMFE EPVCMF CMJOE QSPTQFDUJWF DMJOJDBM USJBM PG TJMJDPOF HFM JO QSFWFOUJPO PG IZQFSUSPQIJD TDBS EFWFMPQNFOU JO NFEJBO TUFSOPUPNZ XPVOE Plast Reconstr Surg o

9

.VTUPF 5" &WPMVUJPO PG TJMJDPOF UIFSBQZ BOE NFDIBOJTN PG BDUJPO JO TDBS NBOBHFNFOU Aesthetic Plast Surg o

CONCLUSIONS ╔иF QSFMJNJOBSZ PCTFSWBUJPOT TVHHFTU UIBU UIJT TFMG ESZJOH UPQJDBM TJMJDPOF HFM XPVOE ESFTTJOH JT BO F─КFDUJWF USFBUNFOU UIBU DPOUSJCVUFT UP GBTUFS FQJUIFMJBMJ[BUJPO SFEVDFE JOnBNNBUPSZ SFTQPOTF BOE SFEVDUJPO JO BCOPSNBM TDBS GPSNBUJPO ╔иF FBTF PG BQQMJDBUJPO BOE VUJMJUZ PG UIJT OFX GPSN PG TJMJDPOF ESFTTJOH 4USBUBNFE

BMTP NBLFT JUT VTF JO DPNCJOBUJPO XJUI PUIFS QSPEVDUT TJNQMF )JHI QBUJFOU DPNQMJBODF XJUI UIF VTF PG UIF HFM DBO CF FYQFDUFE GPMMPXJOH B XJEF SBOHF PG EFSNBUPMPHJDBM TVSHJDBM JOUFSWFOUJPOT Disclosures: This clinical investigation was conducted with the support of Stratpharma AG, Switzerland. The authors do not have any ямБnancial interest in Stratpharma AG or Stratamed.

11 5PCPMB + 8JULPXTLB 5PCP┬ТB " 8┬ТPEBSLJFXJD[ " 4JMJDPOF HFM JO QSFWFO UJPO BOE USFBUNFOU PG IZQFSUSPQIJD TDBST BOE LFMPJET Dermatologia Estetyczna o 12 4BVMJT "4 $IBP +% 5FMTFS " .PHGPSE +& .VTUPF 5" 4JMJDPOF PDDMVTJWF USFBUNFOU PG IZQFSUSPQIJD TDBS JO UIF SBCCJU NPEFM Aesthet Surg J 2002; o 13 )BOBTPOP .. -VN + $BSSPMM -" .JLVMFD "" ,PDI 3+ 5IF FGGFDU PG TJMJDPOF HFM PO CBTJD ├еCSPCMBTU HSPXUI GBDUPS MFWFMT JO ├еCSPCMBTU DFMM DVMUVSF Arch Facial Plastic Surg o 14 5BOEBSB "" .VTUPF 5" 5IF SPMF PG UIF FQJEFSNJT JO UIF DPOUSPM PG TDBS SJOH FWJEFODF GPS NFDIBOJTN PG BDUJPO GPS TJMJDPOF HFM J Plast Reconstr Surg o

REFERENCES 1

#BZBU " .D(SPVUIFS %" 'FSHVTPO .8 4LJO TDBSSJOH BMJ. 2003; o

2

.VTUPF 5" $PPUFS 3% (PME .) FU BM *OUFSOBUJPOBM DMJOJDBM SFDPNNFOEB UJPOT PO TDBS NBOBHFNFOU Plast Reconstr Surg o

3

1FSLJOT , %BWFZ 3# 8BMMJT ," 4JMJDPOF HFM B OFX USFBUNFOU GPS CVSO TDBST BOE DPOUSBDUVSFT Burns Incl Therm Inj o

SKINmed. 4 o4

10 4JHOPSJOJ . $MFNFOUPOJ .5 $MJOJDBM FWBMVBUJPO PG B OFX TFMG ESZJOH TJMJDPOF HFM JO UIF USFBUNFOU PG TDBST B QSFMJNJOBSZ SFQPSU Aesthetic Plast Surg. o

15 6QUPO ; -ZOBN & 5SFBUNFOU JOOPWBUJPOT JO IZQFSUSPQIJD BOE LFMPJE TDBST Wounds International o

4

16 (BVHMJU[ (( ,PSUJOH )$ 1BWJDJD 5 3V[JDLB 5 +FTDILF .( )ZQFSUSPQIJD TDBSSJOH BOE LFMPJET QBUIPNFDIBOJTNT DVSSFOU BOE FNFSHJOH USFBU NFOU TUSBUFHJFT Mol Med o

/PWFM 4JMJDPOF (FM %SFTTJOH

Publication of this supplement was sponsored by Stratpharma AG, Basel, Switzerland.

Stratpharma AG, Centralbahnplatz 8, CH-4051 Basel, Switzerland

7PMVNF t *TTVF

November/December 2012

CORE CURRICULUM Virendra N. Sehgal, MD, Section Editor

Pathophysiology of Adverse Cutaneous Drug Reactions—Applied Perceptions: Part II Virendra N. Sehgal, MD; Prashant Verma, MD; Sambit N. Bhattacharya, MD "EWFSTF DVUBOFPVT ESVH SFBDUJPOT BSF B HSPVQ XJUI DPNNPO NPSQIPMPHZ .VDI SFTFBSDI IBT CFFO QFSGPSNFE PO TVDI SFBDUJPOT CVU UIFJS QBUIPQIZTJPMPHZ JT MBSHFMZ VOLOPXO ɨF BVUIPST QSPWJEF B DSJUJDBM BQQSBJTBM PG UIF WBSJPVT BTQFDUT PG UIFJS EJBHOPTJT BOE USFBUNFOU 4PNF PG UIF DPNNPO SFBDUJPO QBUUFSOT BSF JODMVEFE XJUI UIF QSJNF PCKFDUJWF PG IJHIMJHIUJOH UIFJS QBUIPQIZTJPMPHZ SKINmed. o

T

IF QBUIPQIZTJPMPHZ PG BEWFSTF DVUBOFPVT ESVH SFBDUJPOT $%3T IBT CFFO XJEFMZ JOWFTUJHBUFE 5P GVMMZ VOEFSTUBOE TVDI ESVH SFBDUJPOT JU JT OFDFTTBSZ UP IBWF B DMFBS DVU VOEFSTUBOEJOH PG UIFJS QBUIPHFOPTJT BOE UIF TVCTFRVFOU TVJUBCJMJUZ JO UIF NBOBHFNFOU PG SFBDUJPO FQJTPEFT )FSF XF EJTDVTT UIF DVSSFOU JNQMJDBUJPOT PG BEWFSTF $%3T APPLIED PATHOPHYSIOLOGY OF ADVERSE CDRS ɨF OVNCFS PG ESVH TQFDJmD DZUPUPYJD 5 DFMMT BOE UJTTVF EFTUSVDUJPO JT SFMBUFE UP UIF QSPQPSUJPO PG DZUPUPYJD $% WT DZUPUPYJD $% 5 DFMMT CFDBVTF DZUPUPYJD $% 5 DFMMT IBWF B CSPBEFS UBSHFU DFMM SFQFSUPJSF *O BEEJUJPO BMM OVDMFBUFE DFMMT FYQSFTT NBKPS IJTUPDPNQBUJCJMJUZ DPNQMFY .)$ * XIJDI JT SFDPHOJ[FE CZ $% 5 DFMMT XIJMF $% 5 DFMMT SFRVJSF BO FYQSFTTJPO PG .)$ ** XIJDI JT GPVOE POMZ PO UIF JNNVOPDPNQFUFOU DFMMT "OPUIFS EFUFSNJOBOU PG UIF DMJOJDBM QJDUVSF JT UIF UZQF PG BTTPDJBUFE FĊFDUPS NFDIBOJTN JODMVEJOH UIPTF JOWPMWJOH FPTJOPQIJMT OFVUSJPQIJMT BOE NPOPDZUFT 1 MACULOPAPULAR DRUG REACTION

" EFMBZFE UZQF PG DFMM NFEJBUFE IZQFSTFOTJUJWJUZ SFBDUJPO JT MBSHFMZ JNQMJDBUFE JO NBDVMPQBQVMBS ESVH FSVQUJPOT 'JHVSF *NNVOPIJTUPMPHZ SFWFBMT B ESVH TQFDJmD $%

5 DFMM JOmMUSBUJPO $-" $$3

JO UIF QFSJWBTDVMBS BSFBT PG UIF EFSNJT 2 3 4PNF 5 DFMMT NJHSBUF UP UIF EFSNPFQJEFSNBM KVODUJPO BOE UIF FQJEFSNJT QSPCBCMZ EVF UP B HSBEJFOU PG DIFNPLJOFT QSPEVDFE CZ LFSBUJOPDZUFT BOE NFMBOPDZUFT FH $$- CJOEJOH UP $$3 *O UIF EFSNJT BOE UIF FQJEFSNJT UIFZ NBZ FODPVOUFS UIF ESVH BOUJHFO BHBJO BOE HFU SFBDUJWBUFE UIFZ FYQSFTT .)$ DMBTT ** BOE $%

BOE NBZ

VMUJNBUFMZ LJMM UIF BDUJWBUFE LFSBUJOPDZUFT EJSFDUMZ JO B DPOUBDU EFQFOEFOU NBOOFS CZ SFMFBTJOH QFSGPSJO HSBO[ZNF # 4PNF LFSBUJOPDZUFT NBZ VOEFSHP IZESPQJD EFHFOFSBUJPO CVU UIJT BQPQUPTJT JT OPU BT FYUFOTJWF BT UIBU TFFO XJUI $% 5 DFMMo NFEJBUFE LJMMJOH CFDBVTF OPU BMM UIF LFSBUJOPDZUFT FYQSFTT .)$ DMBTT ** *O BEEJUJPO UIF JNNJHSBUJOH $% 5 DFMMT FYIJCJU B IFUFSPHFOFPVT DZUPLJOF QSPmMF JODMVEJOH UZQF JOUFSGFSPO <*'/> γ BOE UZQF JOUFSMFVLJO <*-> *- DZUPLJOFT XIJDI TVHHFTUT UIBU CPUI ɨ BOE ɨ DFMMT JOmMUSBUF UIF TLJO ɨF DZUPLJOF *- JT BMTP EFUFDUBCMF JO TJUV BT XFMM BT JO UIF TFSVN ɨFTF QBUIPHFOJD GFBUVSFT IBWF CFFO NBEF VTF PG JO JO WJUSP ESVH TQFDJmD MZNQIPDZUF USBOTGPSNBUJPO BOE DZUPLJOF SFMFBTF BTTBZT BT B EJBHOPTUJD UPPM 5JTTVF BT XFMM BT CMPPE FPTJOPQIJMJB NBZ CF GPVOE 7 *O BEEJUJPO UIF SFDSVJUNFOU PG FPTJOPQIJMT JT FOIBODFE CZ UIF FYQSFTTJPO PG UIF DIFNPLJOFT BOE SFHVMBUFE PO BDUJWBUJPO OPSNBM 5 DFMM FYQSFTTFE BOE TFDSFUFE JO UIF NBDVMPQBQVMBS MFTJPOT 8 8PNFO PG DIJMECFBSJOH BHF NBZ IBWF B IJHIFS SJTL PG FYBOUIFNB TVHHFTUJOH UIF JOnVFODF PG FTUSPHFOT 9 7BDVPMBS JOUFSGBDF EFSNBUJUJT XJUI MZNQIPDZUF UBHHJOH BMPOH UIF EFSNPFQJEFSNBM KVODUJPO BOE EZTLFSBUPUJD DFMMT BSF JUT TBMJFOU IJTUPQBUIPMPHJD GFBUVSFT " TQBSTF TVQFSmDJBM MZNQIPDZUJD QFSJWBTDVMBS JOmMUSBUF BDDPNQBOJFE JO TPNF DBTFT CZ QBQJMMBSZ FEFNB BOE UJTTVF FPTJOPQIJMJB BSF DPNQMJNFOUBSZ 10 ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS " TQFDJmD NFNPSZ 5 DFMM QIFOPUZQF XJUI BO *- oQSFEPNJOBOU DZUPLJOF QBUUFSO VOEFSMJOFT UIF BDVUF HFOFSBMJ[FE FYBOUIFNBUPVT QVTUVMPTJT QBUIPHFOFTJT XIJDI NBZ CF SFTQPOTJCMF GPS

From the Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Panchwati-Delhi, Department of Dermatology and STD, University College of Medical Sciences, and associated Guru Teg Bahadur Hospital, Shahdara, Delhi, India Address for Correspondence: Virendra N. Sehgal, MD, Dermato Venerology (Skin/VD) Center, Sehgal Nursing Home, A/6 Panchwati, %FMIJ *OEJB t & NBJM ESTFIHBM!OEG WTOM OFU JO

SKINmed. 2012;10:373–383

373

ª 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$

$03& $633*$6-6.

November/December 2012

TQPOHJGPSN PS OPU PUIFSXJTF TQFDJmFE QVTUVMF T XJUI PS XJUIPVU QBQJMMBSZ FEFNB FIXEDDRUG ERUPTION 'JYFE ESVH FSVQUJPOT BSF DIBSBDUFSJ[FE CZ B QFDVMJBS TVEEFO POTFU PG SPVOE BOE PS PWBM FEFNBUPVT EVTLZ SFE NBDVMFT QMBRVFT PO UIF TLJO 'JHVSF BOE PS NVDPVT NFNCSBOFT BDDPNQBOJFE CZ CVSOJOH BOE PS JUDIJOH *UT EJBHOPTUJD IBMMNBSL IPXFWFS JT UIF SFBQQFBSBODF PG UIF MFTJPOT QSFDJTFMZ PWFS UIF QSFWJPVTMZ BĊFDUFE TJUF T XIFO UIF PĊFOEJOH BHFOU JT SFVTFE QSPWPDBUJPO 1SFGFSFOUJBM MPDBMJ[BUJPO BOE SFDVSSFODF BU mYFE TJUFT JO UIF DPOEJUJPO JT EFCBUBCMF OFWFSUIFMFTT BO BCOPSNBM TVCQPQVMBUJPO PG LFSBUJOPDZUFT DIBSBDUFSJ[FE CZ QFSTJTUFOU FYQSFTTJPO PG JOUFSDFMMVMBS BEIFTJPO NPMFDVMF GBDJMJUBUFT BEIFTJPO PG B MZNQIPDZUJD TVCQPQVMBUJPO UIBU FYQSFTTFT MZNQIPDZUF GVODUJPOoBTTPDJBUFE BOUJHFO ɨFTF MZNQIPDZUFT MJCFSBUF MZNQIPLJOFT UIBU EBNBHF UIF FQJEFSNBM DFMMT 17 *OUSBFQJEFSNBM $% 5 DFMMT XJUI BO FĊFDUPS NFNPSZ QIFOPUZQF SFTJEFOU JO mYFE ESVH FSVQUJPO MFTJPOT IBWF B NBKPS DPOUSJCVUJOH SPMF JO UIF EFWFMPQNFOU PG MPDBMJ[FE UJTTVF EBNBHF "DUJWBUJPO PG UIFTF $% 5 DFMMT JT TVċDJFOU GPS USJHHFSJOH UIF MFTJPO IPXFWFS JU JT OPU TVċDJFOU UP DBVTF FYUFOTJWF UJTTVF EBNBHF PCTFSWFE JO UIF GVMMZ FWPMWFE MFTJPOT "EEJUJPOBM SFDSVJUNFOU PG $% BOE $% 5 DFMMT UP B TQFDJmD UJTTVF TJUF NBZ BMTP DPOUSJCVUF UP UIF MBUF TUBHF PG MFTJPO EFWFMPQNFOU ɨF JOnVY PG SFHVMBUPSZ 5 DFMMT JOUP UIF FQJEFSNJT JO UIF GVMMZ FWPMWFE MFTJPOT NBZ PO UIF PUIFS IBOE TFSWF UP MJNJU IBSNGVM JNNVOF SFBDUJPOT $POTJTUFOU XJUI UIJT QPTJUJWF QBUDI UFTU SFBDUJPOT BSF BQQBSFOU POMZ BU UIF TJUF PG QSFWJPVT MFTJPOT UIBU IBSCPS TJHOJmDBOU OVNCFST PG JOUSBFQJEFSNBM $% 5 DFMMT 18

Figure 1. Maculopapular eruption, nonreactive VDRL, and Treponema palliidum ITAL hemagglutination.

OFVUSPQIJM JOmMUSBUJPO BOE UIF SFTVMUBOU JOnBNNBUJPO 11 *NNVOPIJTUPMPHZ PG BO BDVUF MFTJPO SFWFBMT TVCDPSOFBM PS JOUSBFQJEFSNBM QVTUVMFT XIJDI BSF mMMFE XJUI OFVUSPQIJMJD HSBOVMPDZUFT BOE BSF TVSSPVOEFE CZ BDUJWBUFE )-" %3oFYQSFTTJOH $%

BOE $% 5 DFMMT ,FSBUJOPDZUFT TIPX BO FMFWBUFE FYQSFTTJPO PG UIF OFVUSPQIJM BUUSBDUJOH DIFNPLJOF *- $9$- BOE FWFO UIF 5 DFMMT NJHSBUJOH JOUP UIF FQJEFSNJT FYQSFTT $9$- BOE HSBOVMPDZUF NBDSPQIBHF DPMPOZ TUJNVMBUJOH GBDUPS "OBMZTJT PG TFRVFOUJBM QBUDI UFTU SFBDUJPOT BU UP IPVST TVHHFTUT UIBU ESVH TQFDJmD DZUPUPYJD 5 DFMMT NJHSBUF mSTU BOE DBVTF GPSNBUJPO PG WFTJDMFT CZ LJMMJOH LFSBUJOPDZUFT 4VCTFRVFOUMZ 5 DFMMT BOE LFSBUJOPDZUFT TUJNVMBUFE CZ *'/ γ UVNPS OFDSPTJT GBDUPS <5/'> α SFMFBTF $9$- XIJDI SFDSVJUT HSBOVMPDZUFT JOUP UIF WFTJDMFT BOE BSF VMUJNBUFMZ USBOTGPSNFE JOUP QVTUVMFT 12 The WBMVF PG JO WJWP UFTUT NBJOMZ QBUDI UFTUT BOE PS JO WJUSP UFTUT UIF MZNQIPDZUF USBOTGPSNBUJPO UFTU BOE DZUPLJOF SFMFBTF UFTUT

GPS UIF JEFOUJmDBUJPO PG DBVTBUJWF ESVHT IBT CFFO EFNPOTUSBUFE JO JUT EJBHOPTJT 13–

)JTUPQBUIPMPHJDBMMZ mYFE ESVH FSVQUJPOT BSF DIBSBDUFSJ[FE CZ B MJDIFOPJE UJTTVF SFBDUJPO JOUFSGBDF EFSNBUJUJT 17 BDDPNQBOJFE CZ EFHFOFSBUJWF FQJUIFMJBM BMUFSBUJPOT JODMVEJOH WBDVPMJ[BUJPO BOE CBTJMBS BOE TVQSBCBTJMBS EZTLFSBUPTJT ɨFSF NBZ CF BTTPDJBUFE BDBOUIPTJT IZQFSHSBOVMPTJT BOE IZQFSLFSBUPTJT 5JTTVF

)JTUPQBUIPMPHZ JT WBSJBCMF BOE NBZ FJUIFS DPOGPSN UP FYPDZUPTJT PG QPMZNPSQIPOVDMFBS DFMMT TVCDPSOFBM BOE PS JOUSBFQJEFSNBM SKINmed. 2012;10:373–383

Figure 2. Fixed-drug eruption, round and/or oval, edematous, dusky red macules/plaques on the skin.

1BUIPQIZTJPMPHZ PG "EWFSTF $VUBOFPVT %SVH 3FBDUJPOT

$03& $633*$6-6.

November/December 2012

F PTJOPQIJMJB OFVUSPQIJMJB BOE UIF QSFTFODF PG JOUSBFQJUIFMJBM UP JOGFDUJPO XIFSFJO UIF TLJO SFBDUJPO JT DIBSBDUFSJ[FE CZ QVSQVSB HSBOVMPDZUJD BCTDFTTFT DPNQMFUF UIF QJDUVSF CVMMBF BOE BUZQJDBM UBSHFU MFTJPOT BĊFDUJOH MFTT UIBO PG UIF CPEZ TVSGBDF BSFB 0QQPTFE UP UIJT JO UPYJD FQJEFSNBM OFDSPMZTJT URTICARIA 5&/ UIF TLJO SFBDUJPO SBQJEMZ DPBMFTDFT UP USBOTGPSN JOUP B XJEF6SUJDBSJB NBZ CF PG FJUIFS JNNVOPMPHJDBM PS OPOJNNVOPMPHJ- TQSFBE EVTLZ FSZUIFNB JOUFOTF OFDSPTJT BOE FQJEFSNBM EFUBDINFOU DBM PSJHJO 19 20 ɨF GPSNFS JT B IZQFSTFOTJUJWJUZ SFBDUJPO NFEJBUFE JO TIFFUT 'JHVSF BĊFDUJOH NPSF UIBO PG UIF CPEZ TVSGBDF 2 30 CZ BOUJCPEJFT BOE PS 5 DFMMT UIBU SFTVMU JO NBTU DFMM BDUJWBUJPO BSFB "MUIPVHI *H&oNFEJBUFE UZQF * IZQFSTFOTJUJWJUZ JT BDDMBJNFE UP CF UIF NBKPS QBUIXBZ NBTU DFMM BDUJWBUJPO CFJOH UIF NPTU QFSDFQUJCMF BDDPNQBOJNFOU JU JT OPX XFMM FTUBCMJTIFE UIBU VSUJDBSJB NBZ SFTVMU GSPN UZQF ** IZQFSTFOTJUJWJUZ BT XFMM .BTU DFMM BDUJWBUJPO DBO SFTVMU GSPN UZQF *** IZQFSTFOTJUJWJUZ UISPVHI UIF CJOEJOH PG DJSDVMBUJOH JNNVOF DPNQMFYFT UP UIF NBTU DFMMo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–

1BUIPHFOFTJT SFWPMWFT BSPVOE NBTTJWF BQPQUPTJT QSPHSBNNFE DFMM EFBUI PG UIF FQJEFSNBM LFSBUJOPDZUFT 31 ɨF CVMMBF DPOUBJO 5 DFMMT DPNQPTFE QSJNBSJMZ PG $% BOE $% BOE IBWF OBUVSBM LJMMFS /, DFMMoMJLF GFBUVSFT 32 33 %SVH TQFDJmD MZNQIPDZUF USBOTGPSNBUJPO BOE DZUPLJOF SFMFBTF BTTBZT EFWJTFE PO UIF CBTJT PG UIF QBUIPQIZTJPMPHZ PG 4+4 5&/ NBZ QSPWF UP CF B VTFGVM EJBHOPTUJD BEKVODU ɨF QBUIPHFOJD QSPDFTT PG 4+4 5&/ NBZ BMTP CF USJHHFSFE CZ UIF QSPEVDUJPO PG UIF BDUJWF MJHBOE GPS 'BT SFDFQUPS 'BT3 $% ɨF DFMMVMBS TPVSDF PG TPMVCMF 'BT MJHBOE T'BT- JT DPOUSPWFSTJBM IPXFWFS XJUI CPUI QFSJQIFSBM MZNQIPDZUFT BOE LFSBUJOPDZUFT BT QPUFOUJBM DBOEJEBUFT $ZUPLJOFT QSPEVDFE CZ 5 MZNQIPDZUFT NBDSPQIBHFT PS LFSBUJOPDZUFT NBZ QBSUJDJQBUF JO UIF

ACE INHIBITORINDUCED ANGIODEMA "OHJPFEFNB JT BO BCOPSNBM WBTDVMBS SFTQPOTF JOWPMWJOH UIF EFFQ EFSNJT PS TVCDVUBOFPVT PS TVCNVDPTBM UJTTVFT DIBSBDUFSJ[FE CZ MPDBMJ[FE FEFNB B SFTVMU PG EJMBUBUJPO BOE JODSFBTFE QFSNFBCJMJUZ PG UIF DBQJMMBSJFT ɨF GBDF MJQT FZFT HFOJUBMJB IBOET GFFU BOE MBSZOY BSF UIF VTVBM TJUFT PG BČJDUJPO 7BSJPVT NFEJDBUJPOT JODMVEJOH BOHJPUFOTJO DPOWFSUJOH FO[ZNF "$&

JOIJCJUPST IBWF CFFO JNQMJDBUFE *O WJFX PG UIF GBDU UIBU UIF DPOEJUJPO NBZ CF MJGF UISFBUFOJOH EVF UP FEFNB PG UIF VQQFS BJSXBZ BOE JT MBSHFMZ SFTJTUBOU UP USFBUNFOU JU SFRVJSFT BTUVUF BUUFOUJPO FTQFDJBMMZ JO DBTFT DBVTFE CZ "$& JOIJCJUPST ɨF NFDIBOJTN PG BOHJPFEFNB JO QBUJFOUT UBLJOH "$& JOIJCJUPST JOWPMWFT UIF JOIJCJUJPO PG "$& XIJDI SFEVDFT UIF DBUBCPMJTN PG CSBEZLJOJO BOE JODSFBTFT JUT MFWFMT %FDSFBTFE BNJOPQFQUJEBTF 1 "11 BDUJWJUZ BOE EJQFQUJEZM QFQUJEBTF 1 JO UIF TVCTUBODF 1 EFHSBEBUJPO QBUIXBZT JT ZFU BOPUIFS QPTUVMBUFE NFDIBOJTN 27 " QPMZNPSQIJTN PG 91/1&1 UIF " WBSJBOU BTTPDJBUFE XJUI SFEVDFE "11 BDUJWJUZ JT TQFDVMBUFE 28 The VTF PG UIF CSBEZLJOJO JOIJCJUPS JDBUJCBOU UIFSFGPSF NBZ QSPWF UP CF FĊFDUJWF JO "$& JOIJCJUPSoJOEVDFE BOHJPFEFNB 29 STEVENSJOHNSON SYNDROME/TOXIC EPIDERMAL NECROLYSIS 4UFWFOT +PIOTPO TZOESPNF 4+4 JT B TFWFSF FQJTPEJD NVDPDVUBOFPVT SFBDUJPO MBSHFMZ DBVTFE CZ JOHFTUJPO PG ESVHT BOE PS PDDBTJPOBMMZ SKINmed. 2012;10:373–383

Figure 3. Toxic epidermal necrolysis, depicting widespread dusky erythema, intense necrosis, and epidermal detachment in sheets.

1BUIPQIZTJPMPHZ PG "EWFSTF $VUBOFPVT %SVH 3FBDUJPOT

$03& $633*$6-6.

November/December 2012 QSPDFTT CZ BDUJWBUJOH LFSBUJOPDZUFT BOE FOIBODJOH UIF FYQSFTTJPO PG 'BT3 BOE T'BT- PS CZ QSPNPUJOH UIF TLJO SFDSVJUNFOU PG MZNQIPDZUFT CZ VQSFHVMBUJOH DFMM BEIFTJPO NPMFDVMFT 4JODF CMPDLJOH BOUJ 'BT BOUJCPEJFT BSF GPVOE JO JNNVOPHMPCVMJO QSFQBSBUJPOT JU IBT CFFO QSPQPTFE UIBU QBUJFOUT XJUI 5&/ NBZ CF USFBUFE XJUI JNNVOPHMPCVMJOT IPXFWFS UIF FċDJFODZ PG UIJT USFBUNFOU JT DPOUSPWFSTJBM BOE UIF DPOUFOU PG TVDI BOUJ 'BT BOUJCPEJFT JO JNNVOPHMPCVMJO QSFQBSBUJPOT JT IJHIMZ WBSJBCMF )JTUPQBUIPMPHZ PG 5&/ NBZ SFWFBM B TVCFQJEFSNBM CVMMB CFOFBUI B DPOnVFOU FQJEFSNBM OFDSPTJT -ZNQIPDZUJD JOmMUSBUF JT TQBSTF BOE QFSJWBTDVMBS 4XFBU EVDUT BSF PGUFO JOWPMWFE BOE NBZ TIPX B CBTBM DFMM BQPQUPTJT FWFO SFTVMUJOH JO OFDSPTJT 37

5ZQF ** JNNVOF IZQFSTFOTJUJWJUZ TFFNT UP CF SFTQPOTJCMF GPS UIF DPOEJUJPO 5IF ESVH NBZ FJUIFS BDU BT B IBQUFO CZ CJOEJOH UP UIF MBNJOB MVDJEB GPSNJOH B OFPBOUJHFO XIJDI JO UVSO NBZ JOEVDF BVUPBOUJCPEZ GPSNBUJPO PS JU NBZ IBWF B EJSFDU FGGFDU PO UIF JNNVOPSFHVMBUPSZ NFDIBOJTNT FOBCMJOH QSPMJGFSBUJPO PG GPSCJEEFO # DFMMT UP QSPEVDF CVMMPVT QFNQIJHPJE BOUJCPEJFT 5IFTF BOUJCPEJFT DBO CF EFUFDUFE CZ JOEJSFDU JNNVOPGMVPSFTDFODF CVU BSF JOEJTUJOHVJTIBCMF GSPN UIPTF JO JEJPQBUIJD GPSNT 4VCFQJEFSNBM CMJTUFST DPOUBJOJOH UZQJDBM QPMZNPSQIPVT JOGMBNNBUPSZ JOGJMUSBUF XJUI BO FPTJOPQIJM QSFEPNJOBODF BSF JUT IBMMNBSL %FNPOTUSBUJPO PG NBTU DFMMT BOE CBTPQIJMT NBZ CF B QSPNJOFOU GFBUVSF FBSMZ JO UIF DPVSTF

PSEUDOPORPHYRIA 1TFVEPQPSQIZSJB JT DIBSBDUFSJ[FE CZ QPSQIZSJB MJLF CMJTUFSJOH PO UIF FYUSFNJUJFT JO UIF BCTFODF PG BCOPSNBM QPSQIZSJO NFUBCPMJTN 'VSPTFNJEF OBQSPYFO BOE PUIFS OPOTUFSPJEBM BOUJ JOnBNNBUPSZ ESVHT OBMJEJYJD BDJE UFUSBDZDMJOFT BOE TVMGPOZMVSFBT BSF JUT LOPXO DBVTFT ɨ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m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

LINEAR IGA BULLOUS DISEASE *EJPQBUIJD BT XFMM BT ESVH JOEVDFE MJOFBS *H" CVMMPVT EJTFBTF -"% IBT B WBSJFE DMJOJDBM QSFTFOUBUJPO XIJDI NBZ TJNVMBUF FSZUIFNB NVMUJGPSNF CVMMPVT QFNIJHPJE BOE EFSNBUJUJT IFSQFUJGPSNJT *NNVOPFMFDUSPO NJDSPTDPQJD mOEJOHT IPXFWFS BSF JOEJTUJOHVJTIBCMF %SVH JOEVDFE -"% EJĊFST GSPN UIF JEJPQBUIJD GPSN CZ BO BCTFODF PG NVDPTBM JOWPMWFNFOU TQPOUBOFPVT SFNJTTJPO PO XJUIESBXBM PG UIF PĊFOEJOH ESVH BOE EJTBQQFBSBODF PG UIF JNNVOF EFQPTJUT PODF UIF MFTJPOT IBWF SFTPMWFE *NNVOPQBUIPHFOFTJT JOWPMWFT UZQF ** JNNVOF IZQFSTFOTJUJWJUZ BOE JT TJNJMBS UP ESVH JOEVDFE CVMMPVT QFNQIJHPJE QFNQIJHVT OFPBOUJHFO GPSNBUJPO CZ IBQUFOBUJPO PG UIF CBTFNFOU NFNCSBOF BOE SFTVMUBOU JOEVDUJPO PG BVUPBOUJCPEZ QSPEVDUJPO CZ # DFMMT " IFUFSPHFOFPVT HSPVQ PG BOUJHFOT IBT CFFO FMVDJEBUFE BT UBSHFUT JO UIF JEJPQBUIJD GPSN PG UIF EJTFBTF ɨFTF BOUJHFOJD UBSHFUT BSF MPDBMJ[FE UP UIF CBTFNFOU NFNCSBOF [POF #.; *OUFSFTUJOHMZ UIF ,E FDUPEPNBJO PG UIF ,E CVMMPVT QFNQIJHPJE BOUJHFO BOE UZQF 7** DPMMBHFO BSF UXP PG UIF NPTU DPNNPOMZ JEFOUJmFE BOUJHFOT BOE NBZ QMBZ B QBUIPHFOJD SPMF (JWFO UIF SBSF JODJEFODF PG ESVH JOEVDFE -"% GBS GFXFS TUVEJFT IBWF CFFO BCMF UP DIBSBDUFSJ[F UIF UBSHFU BOUJHFOT JOWPMWFE JO UIJT TVCTFU 4UVEJFT IBWF GPVOE BOUJCPEJFT UP UIF L% BOUJHFO UIF L% BOUJHFO BOE UIF UZQF 7** DPMMBHFO JO OPOWBODPNZDJO ESVH JOEVDFE -"% "OPUIFS TUVEZ EFTDSJCFE QBUJFOUT XJUI WBODPNZDJO JOEVDFE -"% XJUI BVUPBOUJCPEJFT EJSFDUFE BHBJOTU #1 BOE -"% BOUJHFOT )JTUPMPHJDBMMZ -"% TIPXT TVCFQJEFSNBM CMJTUFST XJUI BO JOmMUSBUF DPOTJTUJOH QSJNBSJMZ PG OFVUSPQIJMT %JSFDU JNNVOPnVPSFTDFODF PG QFSJMFTJPOBM TLJO UZQJDBMMZ TIPXT EFQPTJUJPO PG *H" BMPOH UIF #.; VTVBMMZ JO B IPNPHFOPVT MJOFBS QBUUFSO

DRUG-DEPENDENT PEMPHIGUS

%SVH JOEVDFE CVMMPVT QFNQIJHPJE JO DPOUSBTU UP JEJPQBUIJD %SVH EFQFOEFOU QFNQIJHVT DBO CF EJWJEFE JOUP UIF GPMMPXJOH CVMMPVT QFNQIJHPJE UFOET UP PDDVS JO ZPVOHFS QBUJFOUT HSPVQT %SVH EFQFOEFOU QFNQIJHVT JT QSFDJQJUBUFE CZ JOHFTUJPO SKINmed. 2012;10:373–383

1BUIPQIZTJPMPHZ PG "EWFSTF $VUBOFPVT %SVH 3FBDUJPOT

$03& $633*$6-6.

November/December 2012 PG UIJPM 4) DPOUBJOJOH ESVHT TVDI BT % QFOJDJMMBNJOF BOE DBQUPQSJM ɨF MFTJPOT VTVBMMZ EJTBQQFBS BT UIF ESVH JT EJTDPOUJOVFE ɨJPM ESVHT BSF QPTUVMBUFE UP JOEVDF BDBOUIPMZTJT UISPVHI CJPDIFNJDBM NFDIBOJTNT XJUIPVU BOUJCPEZ GPSNBUJPO &YQFSJNFOUT XJUI TLJO FYQMBOUT IBWF EFNPOTUSBUFE UIBU UIJPM ESVHT DBO JOEVDF BDBOUIPMZTJT EJSFDUMZ 4FWFSBM IZQPUIFTFT GPS UIJT IBWF CFFO QSPQPTFE OBNFMZ UIJPM ESVHT NBZ JOUFSGFSF XJUI DSJUJDBM FO[ZNFT TVDI BT LFSBUJOPDZUF USBOTHMVUBNJOBTF SFTVMUJOH JO MPTT PG FQJEFSNBM DFMM DPIFTJPO ɨJPM ESVHT NBZ BDUJWBUF FOEPHFOPVT QSPUFPMZUJD FO[ZNFT TVDI BT QMBTNJOPHFO BDUJWBUPST XJUI TVCTFRVFOU DMFBWBHF PG EFTNPTPNBM BOUJHFOT ɨFZ NBZ CJOE EFTNPHMFJO PS EFTNPHMFJO DSFBUJOH B OFPBOUJHFO XIJDI NBZ UIFO FMJDJU BO JNNVOF SFTQPOTF -BTUMZ UIJPM ESVHT NBZ CJOE UP UIF QFNQIJHVT BOUJHFOT BOE JOUFSGFSF XJUI UIFJS OPSNBM GVODUJPO SFTVMUJOH JO BDBOUIPMZTJT

DRUG-TRIGGERED TRUE PEMPHIGUS ɨJT NBZ PDDVS JO JOEJWJEVBMT XIP IBWF B HFOFUJD QSFEJTQPTJUJPO ɨ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ɨJT BMTP FYQMBJOT UIF JODSFBTFE NVDPTBM JOWPMWFNFOU TFFO JO UIFTF QBUJFOUT *O GBDU UIJT HSPVQ UFOET UP IBWF DMJOJDBM IJTUPMPHJD JNNVOPMPHJD BOE QSPHOPTUJD GFBUVSFT UIBU NJNJDL JEJPQBUIJD QFNQIJHVT WVMHBSJT DRUG ERUPTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS DRESS ɨJT IZQFSTFOTJUJWJUZ TZOESPNF JT DIBSBDUFSJ[FE CZ GFWFS GBDJBM FEFNB JOmMUSBUFE QBQVMFT BOE HFOFSBMJ[FE QBQVMPQVTUVMBS BOE FYBOUIFNBUPVT FSVQUJPOT *U JT BMTP SFDPHOJ[FE BT ESVH JOEVDFE EFMBZFE NVMUJPSHBO IZQFSTFOTJUJWJUZ TZOESPNF The EJBHOPTJT PG ESVH FSVQUJPO XJUI FPTJOPQIJMJB BOE TZTUFNJD TZNQUPNT %3&44 TIPVME CF CBTFE PO UISFF DSJUFSJB DVUBOFPVT FSVQUJPO IFNBUPMPHJD BCOPSNBMJUJFT XJUI FJUIFS FPTJOPQIJMJB PG QBUJFOUT PS BUZQJDBM MZNQIPDZUPTJT o PG QBUJFOUT EFQFOEJOH PO UIF DBVTBUJWF ESVH BOE TZTUFNJD TJHOT BEFOPQBUIZ IFQBUJUJT JOUFSTUJUJBM OFQISJUJT JOUFSTUJUJBM QOFVNPOJUJT PS DBSEJUJT 'FWFS BDDPNQBOJFE CZ WBSJPVT TLJO MFTJPOT NBZ CF UIF QSFTFOUJOH TJHOT &SZUIFNBUPVT BOE NBDVMPQBQVMBS SKINmed. 2012;10:373–383

MFTJPOT UZQJDBMMZ BQQFBS mSTU PO UIF USVOL GBDF BOE VQQFS FYUSFNJUJFT BOE NBZ QSPHSFTT UP CMJTUFST WFTJDMFT QVTUVMFT PS QVSQVSB &YGPMJBUJWF EFSNBUJUJT NBZ SFTVMU ɨF MBUF POTFU BOE MPOH EVSBUJPO PG %3&44 BMPOHT XJUI UIF QSFTFODF PG IFNBUPMPHJDBM BCOPSNBMJUJFT EJĊFSFOUJBUFT JU GSPN PUIFS IZQFSTFOTJUJWJUZ SFBDUJPOT OBNFMZ UPYJD FQJEFSNBM OFDSPMZTJT " MPOH MBTUJOH DMJOJDBM DPVSTF EFTQJUF XJUIESBXBM PG UIF DBVTBUJWF ESVH JT JUT VODPNNPO GFBUVSF *UT QSFDJTF QBUIPHFOFTJT JT TUJMM TQFDVMBUJWF " HFOFUJD NFUBCPMJD EFGFDU EFmDJFOU FQPYJEF IZESPMBTF SFRVJSFE GPS UIF EFUPYJmDBUJPO PG BSFOF PYJEF IBT CFFO JEFOUJmFE ɨF NFUBCPMJD EFGFDU JT DPNNPO UP UIF BSPNBUJD BOUJDPOWVMTBOUT XIFSF UIF QBUJFOU JT GSFRVFOUMZ DSPTT SFBDUJWF UP UIF ESVHT "SFOF PYJEFT BSF GPSNFE JO UIF MJWFS CZ PYJEBUJPO PG UIF ESVHT XIJDI CJOE UP UIF NBDSPNPMFDVMFT PG LFSBUJOPDZUFT BOE JNNVOF DFMMT MFBEJOH UP JNNVOF QFSUVSCBUJPOT UIBU NBOJGFTU BT UZQF *7 IZQFSTFOTJUJWJUZ %SVH TQFDJmD 5 DFMMT NBZ CF EJSFDUMZ TUJNVMBUFE CZ UIF SFTQFDUJWF ESVH Q * DPODFQU BOE UIFO TFDSFUF MBSHF BNPVOUT PG *- BOE *'/ γ 3FDFOUMZ IVNBO IFSQFTWJSVT ))7 SFBDUJWBUJPO JO %3&44 IBT BMTP CFFO JNQMJDBUFE *U JT QSPQPTFE UIBU BHBJOTU B HFOFUJD CBDLHSPVOE TPNF ESVHT NBZ JOEVDF UIF QSPEVDUJPO PG SFBDUJWF NFUBCPMJUFT UIBU NBZ QSPWPLF ))7 SFBDUJWBUJPO BOE QSPQBHBUJPO CZ UIF XBZ PG DZUPLJOF QSPEVDUJPO ɨF SPMF PG ))7 NBZ OPU CF MJNJUFE UP UIF JOJUJBM EFWFMPQNFOU PG %3&44 ))7 SFQMJDBUJPO DBO MFBE UP TZTUFNJD WJSBM EJTTFNJOBUJPO UP UBSHFU PSHBOT *U NBZ BMTP CF EJSFDUMZ JNQMJDBUFE JO TZTUFNJD NBOJGFTUBUJPOT JO %3&44 PSEUDOLYMPHOMATOUS SYNDROME ɨF QTFVEPMZNQIPNBUPVT TZOESPNF VTVBMMZ EFWFMPQT XFFLT UP ZFBST BGUFS JOJUJBUJOH ESVHT TVDI BT QIFOZUPJO TPEJVN *U QSFTFOUT BT B TPMJUBSZ MPDBMJ[FE QBQVMF QMBRVF BOE PS OPEVMF TFWFSBM MPDBMJ[FE QMBRVFT NVMUJQMF QMBRVFT PS OPEVMFT PO EJĊFSFOU QBSUT PG UIF TLJO PS BT B HFOFSBMJ[FE FSVQUJPO ɨFTF GFBUVSFT BSF JO TUSJLJOH DPOUSBTU UP PUIFS ESVH SFBDUJPOT XIJDI NBZ EFWFMPQ JO B TIPSUFS JODVCBUJPO QFSJPE BOE SFTPMWF RVJDLMZ PO DFTTBUJPO PG UIF ESVH UIFSBQZ ɨF DPVSTF PG UIF ESVH JOEVDFE QTFVEPMZNQIPNB TZOESPNF JT QSPMPOHFE BOE TVHHFTUT B EJTUJODU CJPMPHJD NFDIBOJTN *U JT QPTUVMBUFE UIBU ESVH JOEVDFE JNNVOPEZTSFHVMBUJPO SFTVMUT JO B MZNQIPQSPMJGFSBUJWF QSPDFTT "COPSNBMMZ GVODUJPOJOH MZNQIPDZUFT NBZ QSPMJGFSBUF JO SFTQPOTF UP BO BOUJHFO GSPN UIF ESVH JUTFMG BO BOUJHFO VONBTLFE CZ ESVH NFUBCPMJTN PS BOPUIFS OPOQIBSNBDPMPHJD BOUJHFO "MUFSBUJPOT JO JNNVOF GVODUJPO IBWF CFFO EFNPOTUSBUFE JO WJWP PS JO WJUSP GPS NBOZ PG UIF DBVTBUJWF BHFOUT %FGFDUJWF TVQQSFTTPS 5 DFMM GVODUJPO IBT BMTP CFFO JNQMJDBUFE XIJDI NBZ MFBE UP B QBSBEPYJDBM IFJHIUFOFE IFMQFS 5 DFMM SFTQPOTF

377

1BUIPQIZTJPMPHZ PG "EWFSTF $VUBOFPVT %SVH 3FBDUJPOT

$03& $633*$6-6.

November/December 2012 PHOTOSENSITIVITY 1IPUPBMMFSHJD BOE QIPUPUPYJD SFBDUJPOT BSF JUT WJBCMF JOHSFEJFOUT ɨF DPOEJUJPO JT DIBSBDUFSJ[FE CZ MPDBMJ[BUJPO PG UIF MFTJPOT UP UIF TVO FYQPTFE BSFBT PG UIF CPEZ JODMVEJOH UIF GBDF EPSTBM BTQFDU PG UIF GPSFBSNT 7 PG UIF OFDL 'JHVSF BOE CBDL PG UIF IBOET TQBSJOH UIF QPTUBVSJDVMBS BSFB TVCNFOUBM SFHJPO BOE UIF TLJO GPMET

CZ OBUVSF UIF EJĊFSFODF CFJOH UIBU QIPUPEZNBNJD SFBDUJPOT SFRVJSF PYZHFO ɨF QIPUPUPYJD SFBDUJPO SFTFNCMFT TVOCVSO BOE JT DIBSBDUFSJ[FE CZ FSZUIFNB FEFNB BOE CMJTUFSJOH 1IPUPUPYJD TVCTUBODFT BSF OPU OFDFTTBSJMZ QIPUPBMMFSHJD XIFSFBT BMM QIPUPBMMFSHJD TVCTUBODFT NBZ BMTP CF QIPUPUPYJD )JTUPMHJDBMMZ UIFSF BSF OFDSPUJD LFSBUJOPDZUFT BU BMM MBZFST PG FQJEFSNJT XJUI BSDIJUFDUVSBM EJTBSSBZ BOE EZTNBUVSBUJPO WBSJBCMF FQJEFSNBM IZQFSQMBTJB BOE WBSJBCMF FYPDZUPTJT PG OFVUSPQIJMT UP BSFBT PG LFSBUJOPDZUF OFDSPTJT )ZQFSLFSBUPTJT IZQFSHSBOVMPTJT NFMBOPDZUJD IZQFSQMBTJB NBZ TVCTFRVFOUMZ EFWFMPQ 3FUJGPSN FĊBDFNFOU XJUI NFMBOJO JODPOUJOFODF DPNQMFUFT UIF QJDUVSF $ISPOJD QIPUPTFOTJUJWJUZ JT NBOJGFTUFE CZ JOUSBFQJUIFMJBM DPMMFDUJPOT PG BUZQJDBM MZNQIPDZFT SFTFNCMJOH 1BVUSJFST NJDSPBCDFTTFT CVU EFWJBUF JO CFJOH TQPOHJPUJD BOE IBWJOH B HSFBU BENJYUVSF PG JOnBNNBUPSZ DFMM FMFNFOUT

1IPUPBMMFSHJD DPOUBDU EFSNBUJUJT JT B UZQF *7 IZQFSTFOTJUJWJUZ SFBDUJPO UP ESVHT JO UIF QSFTFODF PG SBEJBOU FOFSHZ 8BWFMFOHUIT JO UIF 67 " SBOHF BSF NBJOMZ SFTQPOTJCMF GPS TVDI SFBDUJPOT ɨF FMFDUSPNBHOFUJD FOFSHZ NBZ DPOWFSU BO JNNVOPMPHJDBMMZ JOBDUJWF GPSN PG UIF QIPUPTFOTJUJ[JOH DPNQPVOE UP JUT BDUJWF GPSN ɨF IBQUFO GPSNFE JT VTVBMMZ B TUBCMF QIPUP BEEVDU PG UIF ESVH XIJDI DPNCJOFT XJUI B QSPUFJO JO UIF TLJO UP QSPEVDF GVMM BOUJHFO ɨF OFPBOUJHFO UIVT GPSNFE NBZ FMJDJU B DFMM NFEJBUFE JNNVOF SFTQPOTF XIJDI NBZ NBOJGFTU DMJOJDBMMZ BT FSZUIFNB FEFNB PP[JOH WFTJDVMBUJPO BOE QSVSJUVT PIGMENTATION REACTIONS ɨF QIPUPBMMFSHJD SFBDUJPOT EP OPU PDDVS EVSJOH mSTU FYQPTVSF UP UIF QIPUPBMMFSHFO CVU SFRVJSF B MBUFOU QFSJPE EVSJOH XIJDI TFOTJUJ[BUJPO PDDVST )JTUPQBUIPMPHJDBMMZ UIFSF JT BO BOHJPDFOUSJD MZNQIPDZUJD BOE FPTJOPQIJMJD JOmMUSBUF UIBU EJTTJQBUFT UPXBSET UIF CBTF PG UIF CJPQTZ ɨF FQJEFSNBM DIBOHFT JODMVEF TQPOHJPTJT XJUI FYPDZUPTJT PG MZNQIPDZUFT BOE FPTJOPQIJMT BOE UIF GPSNBUJPO PG WFTJDMFT DPOUBJOJOH OVNFSPVT -BOHFSIBOT DFMMT 7BTDVMBS FDUBTJB FOEPUIFMJBM TXFMMJOH BOE NVSBM FEFNB BSF DPOTQJDVPVT JO TVQFSmDJBM EFSNJT ɨFSF JT B WBSJBCMF QBQJMMBSZ EFSNBM FEFNB

1JHNFOUBUJPO SFBDUJPOT BSF EFmOFE CZ ESVH JOEVDFE BMUFSBUJPO JO TLJO DPMPS *UT QBUIPHFOFTJT NBZ CF ESVH PS ESVH NFUBCPMJUF EFQPTJUJPO JO UIF EFSNJT BOE FQJEFSNJT FOIBODFE NFMBOJO QSPEVDUJPO XJUI XJUIPVU BO JODSFBTF JO UIF OVNCFS PG BDUJWF NFMBOPDZUFT BOE ESVH JOEVDFE QPTU JOnBNNBUPSZ DIBOHFT JO TLJO 4JNJMBSMZ DIFNJDBM IZQPQJHNFOUBUJPO JT BMTP UIPVHIU UP PDDVS UISPVHI B WBSJFUZ PG QBUIPMPHJD NFDIBOJTNT JODMVEJOH B SFEVDFE OVNCFS PG TLJO NFMBOPDZUFT FO[ZNBUJD CMPDLBEF PG NFMBOPHFOFTJT BOE JOIJCJUJPO PG NFMBOPTPNF USBOTGFS

ɨF QIPUPUPYJD SFBDUJPO PO UIF PUIFS IBOE JT OPOJNNVOPMPHJDBM BOE DBO PDDVS PO mSTU FYQPTVSF UP UIF QIPUPUPYJD TVCTUBODF JG FOPVHI PG UIF DISPNPQIPSF BCTPSCT BEFRVBUF BNPVOUT PG UIF BQQSPQSJBUF SBEJBUJPO JO UIF SFBDUJWF UJTTVF ɨF QIPUPUPYJD SFBDUJPO NBZ CF QIPUPEZOBNJD PS OPOQIPUPEZOBNJD

ACNEIFORM ERUPTION

Figure 4. Localization of the lesions on the V of the neck.

SKINmed. 2012;10:373–383

%JWFSTF QBUIPNFDIBOJTNT IBWF CFFO FMVDJEBUFE GPS BDOFJGPSN FSVQUJPOT $PSUJDPTUFSPJE BTTPDJBUFE BDOFJGPSN FSVQUJPOT BSF JEFOUJmFE CZ FBSMZ IJTUPMPHJD DIBOHFT DIBSBDUFSJ[FE CZ OFDSPTJT BOE SVQUVSF PG UIF XBMM PG UIF TFCBDFPVT HMBOE XIJDI VMUJNBUFMZ SFTVMUT JO QFSJGPMMJDVMBS BCTDFTT NBOJGFTUJOH BT NPOPNPSQIJD JOnBNNBUPSZ QBQVMFT BOE QVTUVMFT 5PQJDBM DPSUJDPTUFSPJET NBZ JOEVDF DPNFEP GPSNBUJPO CZ SFOEFSJOH UIF QJMPTFCBDFPVT VOJU NPSF SFTQPOTJWF UP DPNFEPHFOFTJT $PNFEP GPSNBUJPO JO EVF DPVSTF NBZ FWPMWF JOUP UIF EPNJOBOU MFTJPO *ODSFBTF JO GSFF GBUUZ BDJE DPOUFOU PG TLJO TVSGBDF MJQJET BOE JODSFBTFE OVNCFST PG CBDUFSJB JO UIF QJMPTFCBDFPVT EVDU NBZ CF BO PVUDPNF PG UPQJDBM DPSUJDPTUFSPJE BQQMJDBUJPO "DOFJGPSN FSVQUJPOT IBWF CFFO SFQPSUFE UP PDDVS JO QBUJFOUT DPOTVNJOH FQJEFSNBM HSPXUI GBDUPSoSFDFQUPS JOIJCJUPST &(' 3*T

Q B DFMM DZDMF JOIJCJUPS NBZ CF SFTQPOTJCMF CFDBVTF JU JT VQSFHVMBUFE CZ UIF VTF PG &(' 3*T *U JT SFMFWBOU UP FNQIBTJ[F UIBU Q JT B SFHVMBUPS UIBU JOIJCJUT UIF BDUJPOT PG DZDMJO EFQFOEFOU LJOBTF $%, QSFWFOUJOH QSPHSFTTJPO GSPN ( QIBTF UP 4 QIBTF JO UIF DFMM DZDMF $POTFRVFOUMZ BO JODSFBTFE FYQSFTTJPO PG Q NBZ SFTVMU JO BMUFSBUJPOT JO DFMM HSPXUI BOE

378

1BUIPQIZTJPMPHZ PG "EWFSTF $VUBOFPVT %SVH 3FBDUJPOT

$03& $633*$6-6.

November/December 2012 JĊFSFOUJBUJPO MFBEJOH UP DIBOHFT JO UIF TUSBUVN DPSOFVN PG E UIF GPMMJDVMBS JOGVOEJCVMVN .POPDMPOBM BOUJCPEZ JOIJCJUPST NBZ JOEVDF BO JOnBNNBUPSZ SFBDUJPO CZ UIF BDUJWBUJPO PG OFVUSPQIJMT BOE DPNQMFNFOU UISPVHI UIF CJOEJOH PG JUT 'D EPNBJO ɨF NFDIBOJTN PG BDOFJGPSN MFTJPO EFWFMPQNFOU TFDPOEBSZ UP VTF PG TJSPMJNVT JT MJLFMZ UP B SFTVMU PG JUT FĊFDUT PO FQJEFSNBM HSPXUI GBDUPS &(' BOE UFTUPTUFSPOF TZOUIFTJT *O BEEJUJPO TJSPMJNVT JOIJCJUT &(' BDUJPO CZ DVSCJOH UIF N503 QBUIXBZ 5FTUPTUFSPOF VQSFHVMBUFT &(' SFDFQUPS TZOUIFTJT XIFSFBT TJSPMJNVT EPXOSFHVMBUFT UFTUPTUFSPOF TZOUIFTJT ɨF NFDIBOJTN PG BOUJo5/' αoJOEVDFE BDOFJGPSN FSVQUJPO JT VODMFBS IPXFWFS *- B 5/' α BOE *'/ γ NBZ QMBZ B SPMF JO UIF IZQFSDPSOJmDBUJPO PG UIF JOGVOEJCVMVN BOE USJHHFSJOH PG JOOBUF JNNVOF SFTQPOTF MFBEJOH UP JOnBNNBUPSZ BDOF MFTJPOT $ZDMPTQPSJOF UPP IBT CFFO JNQMJDBUFE *UT QPTTJCMF SPVUF PG FMJNJOBUJPO NBZ CF UISPVHI UIF TFCBDFPVT HMBOE IFODF UIF ESVH NBZ NPEJGZ UIF QJMPTFCBDFPVT VOJUT "OESPHFOT BSF LOPXO UP TUJNVMBUF UIF TFCBDFPVT HMBOET XIJDI NBZ MFBE UP JODSFBTFE GPMMJDVMBS LFSBUJOJ[BUJPO SFTVMUJOH JO DPNFEPOF GPSNBUJPO )JHI EPTBHFT PG UFTUPTUFSPOF BOE BOBCPMJD BOESPHFOJD TUFSPJET BSF LOPXO UP JODSFBTF TLJO TVSGBDF MJQJET BOE UIF Propianebacterium acnes PSHBOJTN QPQVMBUJPO ɨF BNPVOU PG GSFF BOESPHFO JO TFSVN NBZ IBWF BO JNQPSUBOU BTTPDJBUJPO XJUI EFWFMPQNFOU PG BDOF MFTJPOT TVHHFTUFE CZ TUSPOHFS FO[ZNBUJD DPOWFSTJPO UP UIF NPSF BDUJWF EJIZESPUFTUPTUFSPOF PS JODSFBTFE SFDFQUPS TFOTJUJWJUZ UPXBSET BOESPHFOT JO UIF TLJO 70 -JUIJVN BDUJOH BT B USJHHFSJOH PS BHHSBWBUJOH GBDUPS NBZ QSFEJTQPTF UP UIF EFWFMPQNFOU PG BDOF WVMHBSJT CFDBVTF JU JT VTVBMMZ BTTPDJBUFE XJUI QSPNJOFOU OFVUSPQIJMJD JOmMUSBUJPO 71 ɨF VOEFSMZJOH QBUIPQIZTJPMPHJD NFDIBOJTN PG UIF BDOFJGPSN SFBDUJPO UP JTPUSFUJOPJO JT VODMFBS 4LJO GSBHJMJUZ BTTPDJBUFE XJUI UIF MPTT PG EFTNPTPNFT BOE EFTNPTPNBM BUUBDINFOUT BOE XJUI UIF BDDVNVMBUJPO PG BO BNPSQIPVT NBUFSJBM XJUIJO UIF FQJEFSNJT JT JUT QPTTJCMF QBUIPNFDIBOJTN 72

UIF PSJHJO PG # # JOEVDFE BDOF NBZ CF TJNJMBS UP UIBU PG JTPOJB[JE JOEVDFE BDOF LICHENOID TISSUE REACTION -JDIFOPJE UJTTVF SFBDUJPO -53 PS JOUFSGBDF EFSNBUJUJT *'%

BSF TPNF PG UIF DPNNPOMZ FODPVOUFSFE DMJOJDBM BOE IJTUPMPHJDBM QSFTFOUBUJPOT *'% SFGFST UP UIF IJTUPQBUIPMPHJDBM mOEJOH PG BO JOnBNNBUPSZ JOmMUSBUF UIBU BCVUT PS PCTDVSFT UIF EFSNPFQJEFSNBM KVODUJPO ɨF UFSN lichenoid SFGFST UP QBQVMBS MFTJPO PG DFSUBJO TLJO EJTPSEFST PG XIJDI MJDIFO QMBOVT JT UIF QSPUPUZQF 'JHVSF

-53 DBVTBUJPO NBZ EJĊFS *O NPTU JOTUBODFT UIF QSFDJTF NFDIBOJTN PG UIF EJTFBTF JT OPU BNCJHVPVT *U JT VTVBMMZ CFMJFWFE UP CF B DFMM NFEJBUFE IZQFSTFOTJUJWJUZ SFBDUJPO JO OBUVSF XIFSF B DZUPUPYJD 5 DFMM DMPOF JT GPSNFE BHBJOTU B ESVH .)$ ** DPNQMFY -BOHFSIBOT DFMMT BOE LFSBUJOPDZUFT BSF SFDPHOJ[FE BT OPO TFMG CZ UIFTF DMPOFT .BOZ PG UIF MFTJPOT BSF TFMG MJNJUFE BOE POMZ SFRVJSF TZNQUPNBUJD USFBUNFOU BMUIPVHI DPSUJDPTUFSPJET DBO IBTUFO SFTPMVUJPO 77 PSORIASIFORM ERUPTION ɨJT WBSJBOU PG ESVH FSVQUJPO NBOJGFTUT DMJOJDBMMZ BT DMBTTJD QBQVMPTRVBNPVT MFTJPOT PG QTPSJBTJT "MUIPVHI UIF FYBDU QBUIPHFOFTJT PG QTPSJBTJGPSN FSVQUJPO JT VODFSUBJO JU JT CFMJFWFE UIBU UIF FWFOUT UIBU QSFDJQJUBUF QTPSJBTJGPSN DIBOHFT BSF GSFRVFOUMZ JOnBNNBUPSZ ɨFZ BQQFBS UP JOWPMWF B EZTSFHVMBUJPO PG DZUPLJOFT BOE HSPXUI GBDUPST XIJDI BSF WJUBM UP UIF NBJOUFOBODF PG OPSNBM FQJEFSNBM QSPMJGFSBUJPO 78 1TPSJBTJGPSN FSVQUJPOT PDDVS JO BTTPDJBUJPO XJUI BOUJo5/' α USFBUNFOUT JO BVUPJOnBNNBUPSZ EJTFBTFT ɨF NBKPS SFQPSUFE DMJOJDBM

*TPOJB[JE JT BMTP LOPXO GPS JOEVDJOH BDOFJGPSN FSVQUJPOT JO QBUJFOUT SFDFJWJOH B DPNCJOBUJPO PG JTPOJB[JE BOE BNJOPTBMJDZDMJD BDJE .BOZ PG UIFTF BDOF QBUJFOUT BSF TMPX JOBDUJWBUPST PG JTPOJB[JE 73 )JTUPMPHJDBMMZ PQFO BOE DMPTFE DPNFEPOFT BOE BO BCTFODF PG BO JOnBNNBUPSZ JOmMUSBUF BSF DIBSBDUFSJTUJD PG UIF FBSMZ QIBTF PG JTPOJB[JE JOEVDFE BDOF ɨF MBUFS QIBTF PG UIF FSVQUJPO NBZ FYIJCJU QSPNJOFOU JOnBNNBUPSZ JOmMUSBUF OP DPNFEPOFT BOE IZQFSQMBTUJD GPMMJDVMBS FQJUIFMJVN &YBDFSCBUJPO PS POTFU PG JOnBNNBUPSZ BDOF SFMBUFE UP WJUBNJOT # SJCPnBWJO # QZSJEPYJOF BOE # DZBOPDPCBMBNJO BSF BMTP LOPXO ɨF MFTJPOT PG WJUBNJO #oJOEVDFE BDOF NBZ PDDVS FJUIFS BT FYBDFSCBUJPOT PG QSF FYJTUJOH BDOF WVMHBSJT BT OFX POTFU PG NVMUJQMF QBQVMFT BOE QBQVMPQVTUVMFT PS BT BO FYQMPTJWF QVTUVMBS FSVQUJPO JOWPMWJOH UIF GBDF *U IBT CFFO QPTUVMBUFE UIBU SKINmed. 2012;10:373–383

379

Figure 5. Lichenoid tissue reaction illustrating violaceous flattopped papules over the dorsa of the hands with compatible histopathology.

1BUIPQIZTJPMPHZ PG "EWFSTF $VUBOFPVT %SVH 3FBDUJPOT

$03& $633*$6-6.

November/December 2012 QSFTFOUBUJPO JT QBMNPQMBOUBS QVTUVMPTJT TPNFUJNFT BDDPNQBOJFE XJUI QMBRVF MJLF QTPSJBTJT "O JODSFBTFE FYQSFTTJPO PG UZQF * *'/T JOEVDFE CZ BOUJo5/' α IBT CFFO SFQPSUFE JO CJPQTZ TQFDJNFOT 79 $SPTT SFHVMBUJPO CFUXFFO 5/' BOE *'/ JOEVDFE CZ QMBTNBDZUPJE EFOESJUJD DFMMT PS UIF IPNJOH PG ɨ MZNQIPDZUFT UP UIF TLJO IBT CFFO QPTUVMBUFE BT B QPTTJCMF VOEFSMZJOH NFDIBOJTN 80 81 -JUIJVN JT BOPUIFS JNQPSUBOU ESVH GSFRVFOUMZ JNQMJDBUFE JO JOEVDJOH QTPSJBTJT "O BMUFSBUJPO PG DBMDJVN IPNFPTUBTJT EVF UP JOIJCJUJPO PG JOPTJUPM SFDZDMJOH UP GPSN UIF 1*1 UIF QSFDVSTPS GPS UIF QIPTQIBUJEZM JOPTJUPM QBUIXBZ XIJDI MFBET UP DBMDJVN SFMFBTF JT UIF NPTU BDDFQUFE NFDIBOJTN GPS MJUIJVN JOEVDFE BOE FYBDFSCBUFE QTPSJBTJT 82

PG UIF DBTFT PG BDVUF DVUBOFPVT WBTDVMJUJT BSF CFMJFWFE UP CF ESVH JOEVDFE 87 %FQPTJUJPO PG BOUJHFO ESVH BOUJCPEZ DPNQMFYFT JO UIF WFTTFM XBMM JT UIF CFTU EFTDSJCFE QBUIPNFDIBOJTN JO ESVH JOEVDFE TNBMM WFTTFM WBTDVMJUJT UZQF *** IZQFSTFOTJUJWJUZ ɨF "H "C DPNQMFY BDUJWBUFT UIF DPNQMFNFOU TZTUFN XIJDI JO UVSO MFBET UP NBTU DFMM EFHSBOVMBUJPO ɨF NBTU DFMM SFMFBTFT WBTPBDUJWF BNJOFT XIJDI CSJOH BCPVU JODSFBTFE NJDSPWFTTFM QFSNFBCJMJUZ BOE WBTPEJMBUBUJPO ɨF FOEPUIFMJBM DPOUSBDUJPO CSPVHIU BCPVU CZ UIF BDUJPO PG WBTPBDUJWF BNJOFT JODSFBTFT UIF FYQSFTTJPO PG & TFMFDUJO BOE 1 TFMFDUJO PO UIF FOEPUIFMJBM DFMMT XIJDI GVSUIFS SFDSVJUT OFVUSPQIJMT JOUP UIF WFTTFM XBMM MFBEJOH UP JOnBNNBUJPO 88

ɨF MFBEJOH UIFPSZ GPS UIF SPMF PG β CMPDLFST JO USJHHFSJOH BOE FYBDFSCBUJOH QTPSJBTJT JT UIF OPSNBM β BHPOJTUT BUUBDINFOU UP β SFDFQUPST JO UIF TLJO SFTVMUJOH JO JODSFBTFE DZDMJD BEFOPTJOF NPOPQIPTQIBUF D".1 MFWFMT JT CMPDLFE CZ UIF β BOUBHPOJTN PG UIF ESVHT D".1 BO JOUSBDFMMVMBS NFTTFOHFS JT QBSU PG B QBUIXBZ UIBU TUJNVMBUFT QSPUFJOT SFTQPOTJCMF GPS EJĊFSFOUJBUJPO BOE JOIJCJUJPO PG QSPMJGFSBUJPO 83 " EFDSFBTF JO D".1 MFWFMT MFBET UP B EFDSFBTF JO DBMDJVN BOE BO VQ SFHVMBUJPO PG LFSBUJOPDZUF QSPMJGFSBUJPO EFDSFBTFE EJĊFSFOUJBUJPO BOE JODSFBTFE MZNQIPDZUF NPUJMJUZ "OUJNBMBSJBMT BOPUIFS JNQMJDBUFE DMBTT PG ESVHT NBZ JOIJCJU DIPMFTUFSPM CJPTZOUIFTJT CZ UIFJS USBOTHMVUBNJOBTF JOIJCJUJPO DPOUSJCVUJOH UP UIF FQJEFSNBM CBSSJFS EZTGVODUJPO XIJDI DBO FYBDFSCBUF QTPSJBTJT JO HFOFUJDBMMZ QSFEJTQPTFE JOEJWJEVBMT CZ USJHHFSJOH FQJEFSNBM IZQFSQSPMJGFSBUJPO

3FDFOUMZ NJOPDZDMJOF JOEVDFE QFSJOVDMFBS BOUJOFVUSPQIJMJD DZUPQMBTNJD BOUJCPEZ "/$" oQPTJUJWF DVUBOFPVT QPMZBSUFSJUJT OPEPTB IBT CFFO EFTDSJCFE 5XP ZPVOH XPNFO EFWFMPQFE MJWFEP SFUJDVMBSJT BOE TVCDVUBOFPVT OPEVMFT BGUFS UBLJOH NJOPDZDMJOF GPS BOE NPOUIT SFTQFDUJWFMZ 89 "OPUIFS QBUJFOU EFWFMPQFE B DVUBOFPVT WBTDVMJUJT BMPOH XJUI B OFDSPUJ[JOH VUFSJOF DFSWJDBM WBTDVMJUJT BGUFS UBLJOH NJOPDZDMJOF GPS ZFBST 90 *U IBT CFFO QPTUVMBUFE UIBU NZFMPQFSPYJEBTF BO FO[ZNF GPVOE JO OFVUSPQIJMT PYJEJ[FT NJOPDZDMJOF UP SFBDUJWF NFUBCPMJUFT UIBU NBZ JOEVDF UIF GPSNBUJPO PG QFSJOVDMFBS "/$" 91

"/$" QPTJUJWF WBTDVMJUJT IBT BMTP CFFO EFTDSJCFE XJUI BOUJUIZSPJE NFEJDBUJPOT JODMVEJOH QSPQZMUIJPVSBDJM BOE MFTT DPNNPOMZ NFUIJNB[PMF BOE DBSCJNB[PMF 92– ɨF NFDIBOJTN PG QSPQZMUIJPVSBDJM JOEVDFE WBTDVMJUJT JT OPU DMFBS CVU JU JT TQFDVMBUFE UIBU QSPQZMUIJPVSBDJM NBZ BMUFS UIF FOEPHFOPVT NZFMPQFSDRUGINDUCED LUPUS ERYTHEMATOSUS PYJEBTF JO TVDI B XBZ TP BT UP TUJNVMBUF UIF BOUJNZFMPQFSPYJEBTF %SVH JOEVDFE MVQVT FSZUIFNBUPTVT %*-& JT EFmOFE BT BO BOUJCPEJFT XIJDI NBZ DBVTF OFVUSPQIJM EFHSBOVMBUJPO BOE WBTFOUJUZ DIBSBDUFSJ[FE CZ DMJOJDBM NBOJGFTUBUJPOT BOE JNNVOP- DVMBS EBNBHF 93 QBUIPMPHJDBM TFSVN mOEJOHT TJNJMBS UP UIPTF PG JEJPQBUIJD -& CVU JT UFNQPSBMMZ SFMBUFE UP DPOUJOVPVT ESVH FYQPTVSF BOE DRUGINDUCED LIPODYSTROPHY SFTPMWFT BGUFS EJTDPOUJOVBUJPO PG UIF PĊFOEJOH ESVH 4JNJMBS -JQPBUSPQIZ SFQSFTFOUT B GPSN PG ESVH UPYJDJUZ TQFDJmDBMMZ UP JEJPQBUIJD -& %*-& DBO CF EJWJEFE JOUP TZTUFNJD MVQVT JOWPMWJOH UIF TVCDVUBOFPVT GBU UJTTVF SFTVMUJOH JO QBUIPMPHJDBM FSZUIFNBUPTVT TVCBDVUF DVUBOFPVT MVQVT FSZUIFNBUPTVT BOE GBU MPTT UIBU QSFGFSFOUJBMMZ BĊFDUT UIF MJNCT BOE GBDF /VDMFPTJEF DISPOJD DVUBOFPVT MVQVT FSZUIFNBUPTVT ɨF ESVHT UIBU DBVTF BOBMPHVF SFWFSTF USBOTDSJQUBTF JOIJCJUPS /35* oJOEVDFE IPTU -& JOIJCJU 5 DFMM %/" NFUIZMBUJPO UIFSFCZ QSPWPLJOH BVUPSF- UPYJDJUZ JT QSPQPTFE UP JOWPMWF DFMMVMBS NJUPDIPOESJBM %/" BDUJWJUZ BOE HFOFSBUJOH BOUJCPEJFT BHBJOTU IJTUPOF %/" DPN- NU%/" EFQMFUJPO SFTVMUJOH JO BEJQPDZUF EFBUI "EJQPDZUPQMFY %SVH JOEVDFE -& JT IJTUPMPHJDBMMZ JOEJTUJOHVJTIBCMF GSPN LJOFT TFDSFUFE CZ BEJQPTF UJTTVF NBZ SFHVMBUF GBU NFUBCPMJTN JEJPQBUIJD -& MJQJE BOE HMVDPTF IPNFPTUBTJT BOE JOTVMJO TFOTJUJWJUZ ɨFZ VASCULITIS

ɨF UFSN WBTDVMJUJT SFGFST UP JOnBNNBUJPO PG UIF CMPPE WFTTFMT ɨF WBTDVMJUJEFT DPNQSJTF B EJWFSTF HSPVQ PG DPOEJUJPOT UIBU NBZ NBOJGFTU NBJOMZ BT B TZTUFNJD PS DVUBOFPVT EJTPSEFS XIFSFJO CPUI UZQFT NBZ CF EVF UP ESVH UIFSBQZ 4FWFSBM ESVHT DBO JOEVDF CPUI TZTUFNJD WBTDVMJUJT XJUI DVUBOFPVT NBOJGFTUBUJPOT BOE DVUBOFPVT WBTDVMJUJT XJUIPVU PUIFS PSHBO JOWPMWFNFOU "CPVU SKINmed. 2012;10:373–383

JODMVEF BEJQPOFDUJO MFQUJO *- BOE 5/' α *U IBT CFFO TVHHFTUFE UIBU BEJQPOFDUJO MFQUJO DPSSFMBUFT QPTJUJWFMZ BOE 5/' α OFHBUJWFMZ XJUI MJQPEZTUSPQIZ ɨF DIPJDF BOE EVSBUJPO PG UIFSBQZ TUBWVEJOF [JEPWVEJOF JT UIF EPNJOBOU SJTL GBDUPS GPS DMJOJDBM MJQPBUSPQIZ BT XFMM BT GPS UIF QBUIPMPHJDBM DIBOHFT UP BEJQPTF UJTTVF UIBU VOEFSMJF UIF DMJOJDBM TZOESPNF 97 )PTU GBDUPST IBWF BMTP FNFSHFE BT JNQPSUBOU NPEVMBUPST PG MJQPBUSPQIZ JO QBUJFOUT SFDFJWJOH UIFTF /35* ESVHT JODMVEJOH BHF SBDF BOE

380

1BUIPQIZTJPMPHZ PG "EWFSTF $VUBOFPVT %SVH 3FBDUJPOT

$03& $633*$6-6.

November/December 2012 TFWFSJUZ PG JNNVOPEFmDJFODZ 97 )JTUPMPHJDBM GFBUVSFT EJTDMPTF B QFDVMJBS UZQF PG JOWPMVUJPOBM MJQPEZTUSPQIZ 4LJO CJPQTJFT HFOFSBMMZ TIPX UIJOOJOH PG UIF TVCDVUBOFPVT GBU BTTPDJBUFE XJUI mCSPTJT MJQPHSBOVMPNB BOE TPNFUJNFT WFTTFM QSPMJGFSBUJPO 98 CONCLUSIONS ɨF QBUIPQIZTJPMPHZ PG $%3T JT MBSHFMZ PCTDVSF *U IBT HFOFSBMMZ CFFO UIPVHIU UP SFWPMWF BSPVOE UIF 5 DFMM XJUI UIF IBQUFO NPEFM CFJOH UIF XJEFMZ LOPXO DPODFQU ɨF SFDFOU EFmOJUJPO PG UIF Q J DPODFQU BOE UIF TVCDMBTTJm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

Hausmann O, Schnyder B, Pichler WJ. Drug hypersensitivity reactions involving skin. Handb Exp Pharmacol. 2010;196:29â&#x20AC;&#x201C;55.

2

Pichler WJ. Delayed drug hypersensitivity reactions. Ann Intern Med. 2003;139:683â&#x20AC;&#x201C;693.

3

:BXBMLBS / &HMJ ' )BSJ : FU BM *OĂĽMUSBUJPO PG DZUPUPYJD 5 DFMMT JO ESVH induced cutaneous eruptions. Clin Exp Allergy. 2000;30:847â&#x20AC;&#x201C;855

4

Schnyder B, Frutig K, Mauri-Hellweg D, Yawalkar N, Pichler WJ. T-cellmediated cytotoxicity against keratinocytes in sulfamethoxazol-induced skin reaction. Clin Exp Allergy. 1998;28:1412â&#x20AC;&#x201C;1417.

5

Hari Y, Urwyler A, Hurni M, et al. Distinct serum cytokine levels in drug- and measles-induced exanthema. Int Arch Allergy Immunol.

1999;120:225â&#x20AC;&#x201C;229

6

Porebski G, Gschwend-Zawodniak A, Pichler WJ. In vitro diagnosis of T cell-mediated drug allergy. Clin Exp Allergy. 2011;41:461â&#x20AC;&#x201C;470.

7

Hari Y, Frutig-Schnyder K, Hurni M, et al. T-cell involvement in cutaneous drug eruptions. Clin Exp Allergy. 2001;31:1398â&#x20AC;&#x201C;1408.

8

Gerber BO, Zanni MP, Uguccioni M, et al. Functional expression of the eotaxin receptor CCR3 in T lymphocytes co-localizing with eosinophils.

Curr Biol. 1997;7:836â&#x20AC;&#x201C;843.

9

Schmid DA, Campi P, Pichler WJ. Hypersensitivity reactions to quinolones. Curr Pharm Des. 2006;12:3313â&#x20AC;&#x201C;3326.

10 Crowson AN, Magro CM. Recent advances in the pathology of cutaneous drug eruptions. Dermatol Clin. 1999;17:537â&#x20AC;&#x201C;560.

11 Sidoroff A, Halvey S, Bavinck JN, Vaillant L, Roujeau JC. Acute generalJ[FE FYBOUIFNBUPVT QVTUVMPTJT "(&1 B DMJOJDBM SFBDUJPO QBUUFSO J Cut Pathol. 2001;28:113â&#x20AC;&#x201C;119.

12 Britschgi M, Steiner UC, Schmid S, et al. T-cell involvement in druginduced acute generalized exanthematous pustulosis. J Clin Invest.

2001;107:1433â&#x20AC;&#x201C;1441.

13 Wolkenstein P, Chosidow O, FlĂŠchet ML, et al. Patch testing in severe cutaneous adverse drug reactions, including Stevens-Johnson

SKINmed. 2012;10:373â&#x20AC;&#x201C;383

381

syndrome and toxic epidermal necrolysis. Contact Dermatitis. 1996; 35:234â&#x20AC;&#x201C;236.

14 Watsky KL. Acute generalized exanthematous pustulosis induced by metronidazole: the role of patch testing. Arch Dermatol. 1999;135:93â&#x20AC;&#x201C;94.

15 Halevy S. Acute generalized exanthematous pustulosis. Curr Opin Allergy Clin Immunol. 2009;9:322â&#x20AC;&#x201C;328.

16 Korkij W, Soltani K. Fixed drug eruption. Arch Dermatol. 1984;120:520â&#x20AC;&#x201C; 524.

17 4FIHBM 7/ 4SJWBTUBWB ( 'JYFE ESVH FSVQUJPO '%& DIBOHJOH TDFOBSJP of incriminating drugs. Int J Dermatol. 2006;45:897â&#x20AC;&#x201C;908.

18 Shiohara T. Fixed drug eruption: pathogenesis and diagnostic tests. Curr Opin Allergy Clin Immunol. 2009;9:316â&#x20AC;&#x201C;321.

19 Sehgal VN, Jain S, Bhattachrya SN. Cutaneous drug reactions. J Eur Acad Dermatol. 1993;2:281â&#x20AC;&#x201C;295.

20 Hennino A, Be´rard F, Guillot I, et al. Pathophysiology of urticaria. Clin Rev Allergy Immunol. 2006;30:3â&#x20AC;&#x201C;11.

21 Shipley D, Ormerod AD. Drug-induced urticaria. Recognition and treatment. Am J Clin Dermatol. 2001;2:151â&#x20AC;&#x201C;158.

22 Dibbern, DA Jr, Dreskin SC. Urticaria and angioedema: an overview.

Immunol Allergy Clin North Am. 2004;24:141â&#x20AC;&#x201C;162.

23 Baxi S, Dinakar C. Urticaria and angioedema. Immunol Allergy Clin North Am. 2005;25:353â&#x20AC;&#x201C;367.

24 Kaplan AP, Greaves MW. Angioedema. J Am Acad Dermatol.

2005;53:373â&#x20AC;&#x201C;388; quiz 389â&#x20AC;&#x201C;392.

25 SĂĄnchez-Borges M, GonzĂĄlez-Aveledo LA. Angiotensin-converting enzyme inhibitors and angioedema. Allergy Asthma Immunol Res. 2010;2:195â&#x20AC;&#x201C;198.

26 Mlynarek A, Hagr A, Kost K. Angiotensin-converting enzyme inhibitor inhibitor-induced unilateral tongue angioedema. Otolaryngol Head Neck Surg. 2003;129:593â&#x20AC;&#x201C;595.

27 Byrd JB, Touzin K, Sile S, et al. Dipeptidyl peptidase IV in angiotensinconverting enzyme inhibitor associated angioedema. Hypertension.

2008;51:141â&#x20AC;&#x201C;147.

28 %VBO 2- /JLQPPS # %VCF .1 FU BM " WBSJBOU JO 91/1&1 JT BTTPDJBUFE with angioedema induced by angiotensin I-converting enzyme inhibitors.

Am J Hum Genet. 2005;77:617â&#x20AC;&#x201C;626.

29 Weber MA, Messerli FH. Angiotensin-converting enzyme inhibitors and angioedema: estimating the risk. Hypertension. 2008;51:1465â&#x20AC;&#x201C;1467.

30 #SFBUIOBDI 4. &SZUIFNB NVMUJGPSNF 4UFWFOT +PIOTPO TZOESPNF BOE UPYJD FQJEFSNBM OFDSPMZTJT *O #VSOT 5 #SFBUIOBDI 4. $PY / (SJGĂĽUI $ eds. Rookâ&#x20AC;&#x2122;s Textbook of Dermatology. 7th ed, vol 4. Oxford: Blackwell 4DJFOUJĂĽD 1VCMJDBUJPO o 31 Paul C, Wolkenstein P, Adle H, et al. Apoptosis as a mechanism of keratinocyte death in toxic epidermal necrolysis. Br J Dermatol.

1996;134:710â&#x20AC;&#x201C;714.

32 /BTTJG " #FOTVTTBO " %PSPUIFF ( FU BM %SVH TQFDJĂĽD DZUPUPYJD 5 DFMMT in the skin lesions of a patient with toxic epidermal necrolysis. J Invest Dermatol. 2002;118:728â&#x20AC;&#x201C;733.

33 Nassif A, Bensussan A, Boumsell L, et al. Toxic epidermal necrolysis: FGGFDUPS DFMMT BSF ESVH TQFDJĂĽD DZUPUPYJD 5 DFMMT J Allergy Clin Immunol.

2004;114:1209â&#x20AC;&#x201C;1215.

34 Abe R, Shimizu T, Shibaki A, et al. Toxic epidermal necrolysis and Stevensâ&#x20AC;&#x201C;Johnson syndrome are induced by soluble Fas ligand. Am J Pathol. 2003;162:1515â&#x20AC;&#x201C;1520.

35 Viard I, Wehrli P, Bullani R, et al. Inhibition of toxic epidermal necrolysis by blockade of CD95 with human intravenous immunoglobulin. Science.

1998;282:490â&#x20AC;&#x201C;493.

36 Bachot N, Revuz J, Roujeau JC. Intravenous immunoglobulin treatment for Stevensâ&#x20AC;&#x201C;Johnson syndrome and toxic epidermal necrolysis: B QSPTQFDUJWF OPODPNQBSBUJWF TUVEZ TIPXJOH OP CFOFĂĽU PO NPSUBMJUZ PS progression. Arch Dermatol. 2003;139:33â&#x20AC;&#x201C;36.

1BUIPQIZTJPMPHZ PG "EWFSTF $VUBOFPVT %SVH 3FBDUJPOT

$03& $633*$6-6.

November/December 2012 37 4FIHBM 7/ 4SJWBTUBWB ( 5PYJD FQJEFSNBM OFDSPMZTJT 5&/ -ZFMM T TZOdrome. J Dermatolog Treat. 2005;16:278â&#x20AC;&#x201C;286.

59 $SBJH ,4 &EXBSE 8$ "OUIPOZ "( $VUBOFPVT %SVH 3FBDUJPOT Pharmacol Rev. 2000;53:357â&#x20AC;&#x201C;379.

38 Keane JT, Pearson RW, Malkinson FD. Nalidixic acid-induced photosensitivity in mice: a model for pseudoporphyria. J Invest Dermatol.

1984;82:210â&#x20AC;&#x201C;213.

60 Wills I, Kligman AM. The mechanism of photoallergic dermatitis. J Invest Dermatol. 1968;51:378.

39 %BCTLJ $ #FVUOFS &) 4UVEJFT PG MBNJOJO BOE UZQF *7 DPMMBHFO JO CMJTUFST of porphyria cutanea tarda and drug-induced pseudoporphyria. J Am Acad Dermatol. 1991;25:28-32.

40 Breathnach SM. Drug reactions. In: Burns T, Breathnach SM, Cox N, (SJGĂĽUI $ FET Rookâ&#x20AC;&#x2122;s Textbook of Dermatology. 8th ed, vol 4. Oxford: #MBDLXFMM 4DJFOUJĂĽD 1VCMJDBUJPO o 41 Friedmann PS, Lee MS, Friedmann AC, Barnetson RS. Mechanisms in cutaneous drug hypersensitivity reactions. Clin Exp Allergy. 2003; 33:861â&#x20AC;&#x201C;872.

42 Wojnarowska F, Marsden RA, Bhogal B, Black MM. Chronic bullous disease of childhood, childhood cicatricial pemphigoid, and linear IgA disease of adults. A comparative study demonstrating clinical and immunopathologic overlap. J Am Acad Dermatol. 1988;19:792â&#x20AC;&#x201C;805.

43 ,VFDIMF ., 4UFHFNFJS & .BZOBSE # FU BM %SVH JOEVDFE MJOFBS *H" CVMlous dermatosis: Report of six cases and review of the literature. J Am Acad Dermatol. 1994;30:187â&#x20AC;&#x201C;192.

44 Nousari HC, Kimyai-Asadi A, Caeiro JP, Anhalt GJ. Clinical, demographic, and immunohistologic features of vancomycin-induced linear IgA bullous disease of the skin. Report of 2 cases and review of the literature. Medicine (Baltimore). 1999;78:1â&#x20AC;&#x201C;8.

45 Wakelin SH, Allen J, Zhou S, Wojnarowska F. Drug-induced linear IgA disease with antibodies to collagen VII. Br J Dermatol. 1998;138:310â&#x20AC;&#x201C;314.

46 Paul C, Wolkenstein P, Prost C, et al. Drug-induced linear IgA disease: target antigens are heterogeneous. Br J Dermatol. 1997;136:406â&#x20AC;&#x201C;411.

47 Palmer RA, Ogg G, Allen J, et al. Vancomycin-induced linear IgA disease with autoantibodies to BP 180 and LAD 285. Br J Dermatol.

2001;145:816â&#x20AC;&#x201C;820.

48 Wolf R, Brenner S. An active amide group in the molecule of drugs that induce pemphigus: a casual or causal relationship? Dermatology.

1994;189:1â&#x20AC;&#x201C;4.

49 Brenner S, Bialy-Golan A, Anhalt GJ. Recognition of pemphigus antigens in drug-induced pemphigus vulgaris and pemphigus foliaceus. J Am Acad Dermatol. 1997;36:919â&#x20AC;&#x201C;923.

50 Sullivan JR, Shear NH. The drug hypersensitivity syndrome: what is the pathogenesis? Arch Dermatol. 2001;137:357â&#x20AC;&#x201C;364.

51 Peyriere H, Derreure O, Bretton H, et al. Variability in clinical patterns of DVUBOFPVT TJEF FGGFDUT PG ESVHT XJUI TZTUFNJD TZNQUPNT %PFT %3&44 syndrome really exist? Br J Dermatol. 2006;155:422â&#x20AC;&#x201C;428.

52 Sontheimer RD, Houpt KR. DIDMOHS: a proposed consenus nomenclature for the drug-induced delayed multiorgan hypersensitivity syndrome.

Arch Dermatol. 1998;134:874â&#x20AC;&#x201C;875.

53 (SFFG %& .FOOJF , .VJTF " %SVH SFBDUJPO XJUI FPTJOPQIJMJB BOE TZTtemic systems. CMAJ. 2010;182:481.

54 Peyriere H, Dereure O, Breton H, et al. Variability in the clinical pattern of DVUBOFPVT TJEF FGGFDUT PG ESVHT XJUI TZTUFNJD TZNQUPNT EPFT B %3&44 syndrome really exist? Br J Dermatol. 2006;155:422â&#x20AC;&#x201C;428.

55 /BJTCJUU %+ 'BSSFMM + 8POH ( FU BM $IBSBDUFSJ[BUJPO PG ESVH TQFDJĂĽD T cells in lamotrigine hypersensitivity. J Allergy Clin Immunol. 2003; 111:1393â&#x20AC;&#x201C;1403.

56 %FTDBNQT 7 $PMMPU 4 .BIĂ? & FU BM "DUJWF IVNBO IFSQFTWJSVT JOGFDtion in a patient with drug rash with eosinophilia and systemic symptoms.

J Invest Dermatol. 2003;121:215â&#x20AC;&#x201C;216.

57 Shear NH, Spielberg SP. Anticonvulsant hypersensitivity syndrome.

In vitro assessment of risk. J Clin Invest. 1988;82:1826â&#x20AC;&#x201C;1832.

58 Magro CM, Crowson AN, Kovatich AJ, Burns F. Drug-induced reversible lymphoid dyscrasia: a clonal lymphomatoid dermatitis of memory and activated T cells. Hum Pathol. 2003;34:119â&#x20AC;&#x201C;129.

SKINmed. 2012;10:373â&#x20AC;&#x201C;383

382

61 Crowson AN, Magro CM. Recent advances in the pathology of cutaneous drug eruptions. Dermatol Clin. 1999;17:537.

62 Halder RM, Nandedkar MA, Neal KW. Pigmentary disorders in ethnic skin.

Dermatol Clin. 2003;21:617â&#x20AC;&#x201C;628.

63 Kaidbey KH, Kligman AM. The pathogenesis of topical steroid acne.

J Invest Dermatol. 1974;62:31â&#x20AC;&#x201C;36.

64 0MJFU &+ &TUFT 4" 1FSJBOBM DPNFEPOFT BTTPDJBUFE XJUI DISPOJD UPQJDBM fluorinated steroid use. J Am Acad Dermatol. 1982;7:405â&#x20AC;&#x201C;407.

65 Gloor M, Mildenberger KH. On the influence of an external therapy with dexamethasone-21-sodium-m-sulfobenzoate on the amount of free fatty acids in the skin surface lipids. Arch Dermato Res. 1978;261: 33â&#x20AC;&#x201C;38.

66 %F8JUU $" 4JSPZ "& 4UPOF 41 "DOFJGPSN FSVQUJPOT BTTPDJBUFE XJUI epidermal growth factor receptor-targeted chemotherapy. J Am Acad Dermatol. 2007;56:500â&#x20AC;&#x201C;505.

67 .BIĂ? & .PSFMPO & -FDIBUPO 4 FU BM "DOF JO SFDJQJFOUT PG SFOBM USBOTplantation treated with sirolimus: clinical, microbiologic, histologic, therapeutic, and pathogenic aspects. J Am Acad Dermatol. 2006;55: 139â&#x20AC;&#x201C;142.

68 #BTTJ & 1PMJ ' $IBSBDIPO " 3FWV[ + *OĂ˝JYJNBC JOEVDFE BDOF SFQPSU PG two cases. Br J Dermatol. 2007;156:402â&#x20AC;&#x201C;403.

69 Bencini PL, Montagnino G, Sala F, et al. Cutaneous lesions in 67 cyclosporin-treated renal transplant recipients. Dermatologica.

1986;172:24â&#x20AC;&#x201C;30.

70 Fyrand O, Fiskaadal HJ, Trygstad O. Acne in pubertal boys undergoing treatment with androgens. Acta Derm Venereol. 1992;72:148â&#x20AC;&#x201C;149.

71 Chan HH, Wing Y, Su R, Van Krevel C, Lee S. A control study of the cutaneous side effects of chronic lithium therapy. J Affect Disord.

2000;57:107â&#x20AC;&#x201C;113.

72 &YOFS +) %BIPE 4 1PDIJ 1& 1ZPHFOJD HSBOVMPNB MJLF BDOF MFTJPOT EVSing isotretinoin therapy. Arch Dermatol. 1983;119:808â&#x20AC;&#x201C;811.

73 #FSFTUPO &4 3FBDUJPOT UP BOUJUVCFSDVMPVT ESVHT J Invest Dermatol.

1959;33:427â&#x20AC;&#x201C;439.

74 Cohen LK, George W, Smith R. Isoniazid-induced acne and pellagra.

Occurrence in slow inactivators of isoniazid. Arch Dermatol. 1974; 109:377â&#x20AC;&#x201C;381.

75 4IFSFSU[ &' "DOFJGPSN FSVQUJPO EVF UP iNFHBEPTFw WJUBNJOT # BOE B12. Cutis. 1991;48:119â&#x20AC;&#x201C;120.

76 Sontheimer RD. Lichenoid tissue reaction/interface dermatitis: clinical and histological perspectives. J Invest Dermatol. 2009;129:1088â&#x20AC;&#x201C;1099.

77 Sehgal VN, Srivastava G, Sharma S, Sehgal S, Verma P. Lichenoid tisTVF SFBDUJPO JOUFSGBDF EFSNBUJUJT 3FDPHOJUJPO DMBTTJĂĽDBUJPO FUJPMPHZ and clinicopathological overtones. Indian J Dermatol Venereol Leprol.

2011;77:418â&#x20AC;&#x201C;430.

78 Sehgal VN, Dogra S, Srivastava G, Aggarwal AK. Psoriasiform dermatoses. Indian J Dermatol Venereol Leprol. 2008;74:94â&#x20AC;&#x201C;99.

79 Seneschal J, Milpied B, Vergier B, Lepreux S, Schaeverbeke T, TaĂŻeb A. Cytokine imbalance with increased production of interferon-alpha in psoriasiform eruptions associated with antitumour necrosis factor-alpha treatments. Br J Dermatol. 2009;161:1081â&#x20AC;&#x201C;1088.

80 Devos SA, Van Den Bossche N, De Vos M, Naeyaert JM. Adverse skin reactions to anti-TNF-alpha monoclonal antibody therapy. Dermatology.

2003;206:388â&#x20AC;&#x201C;390.

81 Aeberli D, Oertle S, Mauron H, Reichenbach S, Jordi B, Villiger PM. Inhibition of the TNF-pathway: use of infliximab and etanercept as remission-inducing agents in cases of therapy-resistant chronic inflammatory disorders. Swiss Med Wkly. 2002;132:414â&#x20AC;&#x201C;422.

1BUIPQIZTJPMPHZ PG "EWFSTF $VUBOFPVT %SVH 3FBDUJPOT

$03& $633*$6-6.

November/December 2012 82 Gill R, Mohammed F, Badyal R, et al. High-resolution structure of myoinositol monophosphatase, the putative target of lithium therapy. Acta Crystallogr D Biol Crystallogr. 2005;61:545â&#x20AC;&#x201C;555.

91 4IBQJSP -& 6FUSFDIU + 4IFBS /) .JOPDZDMJOF QFSJOVDMFBS BOUJOFVUSPphilic cytoplasmic antibody, and pigment: the biochemical basis. J Am Acad Dermatol. 2001;45:787â&#x20AC;&#x201C;789.

83 Karvonen SL, Korkiamaki T, Yla-Outinen H, et al. Psoriasis and altered calcium metabolism: downregulated capacitative calcium influx and defective calcium-mediated cell signaling in cultured psoriatic keratinocytes. J Invest Dermatol. 2000;114:693â&#x20AC;&#x201C;700.

92 (VOUPO +& 4UJFM + $BUFSTPO 3+ .D&MEVGG " $MJOJDBM DBTF TFNJOBS "OUJ thyroid drugs and antineutrophil cytoplasmic antibody positive vasculitis. A case report and review of the literature. J Clin Endocrinol Metab.

1999;84:13â&#x20AC;&#x201C;16.

84 Takahashi H, Honma M, Miyauchi Y, et al. Cyclic AMP differentially SFHVMBUFT DFMM QSPMJGFSBUJPO PG OPSNBM IVNBO LFSBUJOPDZUFT UISPVHI &3, activation depending on the expression pattern of B-Raf. Arch Dermatol Res. 2004;296:74â&#x20AC;&#x201C;82.

93 Otsuka S, Kinebuchi A, Tabata H, Yamakage A, Yamazaki S. Myeloperoxidase-antineutrophil cytoplasmic antibody-associated vasculitis following propylthiouracil therapy. Br J Dermatol. 2000;142:828â&#x20AC;&#x201C;830.

85 Wolf R, Schiavo AL, Lombardi ML, et al. The in vitro effect of hydroxychloroquine on skin morphology in psoriasis. Int J Dermatol. 1999;38:154â&#x20AC;&#x201C;157.

86 Marzano AV, Vezzoli P, Crosti C. Drug-induced lupus: an update on its dermatologic aspects. Lupus. 2009;18:935â&#x20AC;&#x201C;940.

87 Jain KK. Drug-induced cutaneous vasculitis. Adverse Drug React Toxicol Rev. 1993;12:263â&#x20AC;&#x201C;276.

88 Lotti T, Ghersetich I, Comacchi C, Jorizzo JL. Cutaneous small-vesselvasculitis. J Am Acad Dermatol. 1998;39:667â&#x20AC;&#x201C;687.

89 Schaffer JV, Davidson DM, McNiff JM, Bolognia JL. Perinuclear antineutrophilic cytoplasmic antibody-positive cutaneous polyarteritis nodosa associated with minocycline therapy for acne vulgaris. J Am Acad Dermatol. 2001;44:198â&#x20AC;&#x201C;206.

90 Schrodt BJ, Kulp-Shorten CL, Callen JP. Necrotizing vasculitis of the skin and uterine cervix associated with minocycline therapy for acne vulgaris.

South Med J. 1999;92:502â&#x20AC;&#x201C;504.

94 Helfgott SM, Smith RN. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 21-2002. A 21-year-old man with arthritis during treatment for hyperthyroidism. N Engl J Med. 2002;347:122â&#x20AC;&#x201C;130.

95 Nolan D, Mallal S. Antiretroviral-therapy-associated lipoatrophy: current status and future directions. Sex Health. 2005;2:153â&#x20AC;&#x201C;163.

96 Lassalle S, Cervera P, Hofman V, et al. Antiretroviral treatments-relatFE MJQPEZTUSPQIZ TZOESPNF DMJOJDP QBUIPMPHJDBM ĂĽOEJOHT Ann Pathol.

2005;25:309â&#x20AC;&#x201C;317.

97 Buffet M, Schwarzinger M, Amellal B, et al. Mitochondrial DNA depletion in adipose tissue of HIV-infected patients with peripheral lipoatrophy.

J Clin Virol. 2005;33:60â&#x20AC;&#x201C;64.

98 Vigourox C, Maachi M, Nguyen TH, et al. Serum adipocytokines are related to lipodystrophy and metabolic disorders in HIV-infected men under antiretroviral therapy. AIDS. 2003;17:1503â&#x20AC;&#x201C;1511.

VINTAGE LABEL

$PVSUFTZ PG #VZ&OMBSHF 1IJMBEFMQIJB 1" SKINmed. 2012;10:373â&#x20AC;&#x201C;383

383

1BUIPQIZTJPMPHZ PG "EWFSTF $VUBOFPVT %SVH 3FBDUJPOT

PROGRAM OVERVIEW Friday, Feb. 15 8:00 AM – 2:00 PM Lasers 101 2:30 PM – 5:00 PM Laser Workshops

Saturday, Feb. 16 8:00 AM – 4:00 PM Toxins, Fillers, and Laser Sessions from the experts 4:30 PM – 6:00 PM Filler/Toxin Workshops

Sunday, Feb. 17 8:00 AM – 12:00 PM Practice Management Workshops

Plus, don’t miss exhibits showcasing the best in our industry!

Hutton Hotel 1808 West End Avenue | Nashville, TN 37203 (615) 340-9333 Phone | (615) 340-0010 Fax www.huttonhotel.com

$179 TSLMS room rate Our room block is limited so book NOW to receive the group rate!

REGISTER NOW or become a supporter, visit tnlasersociety.com or contact Meeting Designs at (781) 793-0088.

November/December 2012

Volume 10 • Issue 6

PERILS OF DERMATOPATHOLOGY W. Clark Lambert, MD, PHD, Section Editor

On Bossing: Taking Charge Without the Facts Cindy Wassef, BA; Cristian Serna-Tamayo, BS; Patrick McDonough, BA; Gizem Tumer, MD; W. Clark Lambert, MD, PhD Ours is not to reason why, Ours is but to do, or die.

—Alfred, Lord Tennyson, The Charge of the Light Brigade (1854)

I

t is common practice in many dermatopathology reports to include a section beyond the diagnosis, which provides surgical recommendations for lesions. Such recommendations often raise a dispute regarding the role of dermatopathologists in the treatment plan of such cases. Are dermatopathologists, as Glogau1 described, “pretending” to be dermatologists? Or do such recommendations provide a necessary and reliable facet to treating dermatologists?

“OURS IS NOT TO REASON WHY” In determining the usefulness of dermatopathologists’ recommendations, it is important to keep in mind factors involved in choosing treatment. While the value of clinical presentation is often debated, with differing opinions from dermatologists and dermatopathologists,2–4 other factors, such as surgical and medical history as well as family history of cutaneous malignancy, influence the treatment plan. This information, in addition to other knowledge gained only through contact and conversation with the patient, is most often absent from histological requisition forms1,5 and, thus, the dermatopathologist who makes treatment recommendations may do so without all of the relevant facts. In addition, dermatologists also have noted that often terse diagnoses given in dermatopathology reports such as “basal cell carcinoma, nose” are of very little benefit to their treatment plans.1 Basing a treatment plan on such information can be challenging for dermatologists who at least have access to the clinical presentation; however, dermatopathologists often do not have access to this clinical information and thus offer blinded treatment suggestions.

The information received through requisition forms that dermatopathologists base their diagnosis and treatment plans on is often incomplete as well. In a study conducted in 2008, dermatopathol-

ogy requisition forms received from private dermatology offices for 100 consecutive melanocytic lesions were assessed. While all 100 requisition forms included information about patient age, sex, and site of lesion, no morphological characteristics were provided for 67 of the 100 lesions. Other clinical data were also reported at low frequency, including asymmetry (4% reported), border irregularity (8%), color (39%), and diameter/size (22%). No requisition form included any mention of prior history, family history of melanoma, or past treatment at the site and whether the biopsy was a partial or complete specimen. Only 1% included dermatoscopic conclusions and a clinical photograph, which are the mainstay findings used for diagnosis to many dermatologists.5 Rendering a treatment with such limited and inconsistent information is without clinical basis and is both unreliable and imprecise. Diagnosis and treatment is based on a correlation between clinical presentation and histopathology, and if either of these factors is missing, an accurate conclusion cannot be reached.6 DERMATOPATHOLOGISTS’ RECOMMENDATIONS Dermatopathologists’ recommendations are also controversial given that many dermatopathologists have scant clinical dermatologic training.7 Dermatopathologists who complete a residency in pathology receive only 6 months of clinical dermatology training, compared with dermatologists who spend the bulk of their 3-year residency on clinical dermatology. Pathology residents with 6 months of clinical dermatologic training cannot be expected to have the same level of knowledge about surgical and pharmacologic interventions as dermatologists.

ILLUSTRATIVE CASES A reciprocal scenario can also arise: A 45-year-old woman presented to her dermatologist with an 8-month history of an

From the Departments of Pathology and Dermatology, UMDNJ-New Jersey Medical School, Newark, NJ Address for Correspondence: W. Clark Lambert, MD, PhD, Room C520 MSB, UMDNJ-NJMS, 185 South Orange Avenue, Newark, NJ 07101 • E-mail: lamberwc@umdnj.edu

SKINmed. 2012;10:385–386

385

© 2012 Pulse Marketing & Communications, LLC

November/December 2012

PERILS OF DERMATOPATHOLOGY

Figure. (A) Pseudoepitheliomatous hyperplasia with fibrosis and chronic inflammation (hematoxylin-eosin stain, original magnification ×20). (B) Granulomatous inflammation with brown pigment deposition (black arrows) (hematoxylin-eosin stain, original magnification ×40).

annular erythematous eruption around areas of red tattoo pigment from a tattoo performed in Puerto Rico 3 years previously.

A punch biopsy was taken to differentiate between granulomatous tattoo hypersensitivity and chronic infection. The ordering clinician specified that an acid-fast bacilli test be performed to rule out tuberculosis infection; however, when a granulomatous lesion was observed by a pathologist, many conditions were considered within the differential diagnosis. Microscopic examination dictated to the dermatopathologist whether an acid-fast bacilli test was appropriate (Figure 1A and 1B). In this case, demand for an acid-fast bacilli test by the clinician was made based on clinical suspicion, but on microscopic examination, it was not justified. The granulomatous appearance was altered by overlying pseudoepitheliomatous hyperplasia. As expected, results from the acid-fast bacilli test were negative.

Another example encountered by one of us (WCL) involved treatment of parapsoriasis. This author had published in many textbooks, and in order to promote appropriate treatment of parapsoriasis, he thought that treatment must be undertaken.

An astute reader from India sent him a letter describing one of his patients who traveled 3 days per week to receive UV radiation twice a week. While treatment of parapsoriasis is recommended, other factors, such as access to medical care, which our author could not have known about in this case, must also be factored into the treatment plan.

dermatopathologists to supplement their macroscopic findings with a precise diagnosis that only microscopic findings can provide.4 Dermatopathologists, in turn, rely on dermatologists for clinical evidence and further clues to guide their assessment. In the case of treatment planning, dermatologists have more intimate knowledge of the patient and often a greater knowledge of potential therapeutic options; thus, it is the responsibility of the dermatologist to formulate the treatment plan. Similarly, dermatologists should make requests of the dermatopathologist, and textbook authors should give advice, with care and humility, because only the recipient knows the true situation. All parties involved should continue to make suggestions but be aware that the individual situation will ultimately dictate the best measures to be taken.

REFERENCES 1

Glogau RG. Collegiality and dermatology. J Am Acad Dermatol. 2005; 53:701–702.

2

Ackerman AB. Dermatologist not equal to dermatopathologist: no place in a profession for pretenders. J Am Acad Dermatol. 2005;53:698–699.

3

Gromet MA. Dermatopathologist/academic not equal arbiter of competence/ethics/morality: no place in a profession for sanctimony. J Am Acad Dermatol. 2006;55:170–172.

4

Conrad N, Haque R, Cockerell CJ. Delivery of dermatopathologic health care in the twenty-first century. Dermatol Clin. 2000;18:241–249.

5

Waller JM, Zedek DC. How informative are dermatopathology requisition forms completed by dermatologists? A review of the clinical information provided for 100 consecutive melanocytic lesions. J Am Acad Dermatol.

2010;62:257–261.

“OURS IS BUT TO DO, OR DIE”

6

It is important not to lose sight of the complementary nature of dermatology and dermatopathology. Dermatologists rely on

Sellheyer K, Bergfield WF. “Lesion”, Rule out…,” and other vagaries of filling out pathology requisition forms. J Am Acad Dermatol. 2005;52:914–915.

7

Boyd AS, Fang F. A survey-based evaluation of dermatopathology in the United States. Am J Dermatopathol. 2011;33:173–176.

SKINmed. 2012;10:385–386

386

On Bossing: Taking Charge Without the Facts

Grand Wailea | January 19-23, 2013

Register Now for the 9th Annual Conference!

'RAND 7AILEA -AUI (AWAII

January 19-23, 2013

0LAN TO ATTEND THE TH !NNUAL -AUI $ERM #ONFERENCE h#UTTING EDGE A GREAT BLEND OF SCIENCE AND CLINICAL MEDICINE AND A WORLD CLASS FACULTYv DESCRIBE -AUI $ERM /UR FACULTY WILL SHARE WITH YOU THE MOST IMPORTANT DEVELOPMENTS IN MEDICAL AND COSMETIC DERMATOLOGY VITAL TO YOUR PRACTICE /UR LIVE PATIENT DEMONSTRATION WORKSHOPS IN LASERS BOTULINUM TOXINS AND l LLERS HAVE SET THE STANDARD FOR hHANDS ONv WORKSHOPS /UR FORMAT HAS BEEN SPECIl CALLY DESIGNED TO ALLOW OPTIMAL TIME FOR DISCUSSION WITH OUR FACULTY 7E ARE CERTAIN THAT YOU WILL l ND THIS TO BE AN OUTSTANDING AND MEMORABLE EDUCATIONAL EVENT THAT YOU WILL NOT WANT TO MISS "E SURE TO PUT -AUI $ERM ON YOUR CALENDAR FOR

Featured Lectures

Hot Topics s Cases for the Panel s Seminars s Workshops s Basic Science

Medical Dermatology: Basic Science, Hot Topics, Cases for the Panel, Point:Counterpoint, Seminars, â&#x20AC;&#x153;Outside the Boxâ&#x20AC;?, â&#x20AC;&#x153;How I Do Itâ&#x20AC;? #UTANEOUS /NCOLOGY s !CNE 2OSACEA s 0EDIATRIC $ERMATOLOGY s )NFECTIOUS $ISEASES s 0SORIASIS s 0HOTOAGING 3UNSCREENS #OSMECEUTICALS s -ASTER S #0# s 3URGICAL 0EARLS s 0RACTICE -ANAGEMENT

Cosmetic Dermatology: From Basic Science to Case-based Discussion and â&#x20AC;&#x153;How I Do Itâ&#x20AC;?

"OTULINUM 4OXINS AND &ILLERS s ,ASERS s 3CLEROTHERAPY

â&#x20AC;&#x153;Lunch with the Facultyâ&#x20AC;? â&#x20AC;&#x201C; Controversial Topics, Case-based Discussions Interactive Workshops 3MALL 'ROUP ,IVE 0ATIENT (ANDS /N $EMONSTRATIONS "OTULINUM 4OXINS &ILLERS

Sclerotherapy

2013 Faculty * 2 2OX !NDERSON -$ 0H$ -ATHEW !VRAM -$ *$ (ILARY "ALDWIN -$ *EFFREY "ENABIO -$ .EAL "HATIA -$ !NDREW "LAUVELT -$ *OEL #OHEN -$ #URTIS #OLE -$ ,AWRENCE %ICHENl ELD -$ 3HEILA &ALLON &RIEDLANDER -$ )LONA &RIEDEN -$ "ARBARA 'ILCHREST -$ -ICHAEL 'OLD -$ -ITCHEL 'OLDMAN -$ +ENNETH 'ORDON -$ /MAR )BRAHIMI -$ 0H$ $EREK *ONES -$ !RTHUR +AVANAUGH -$ 3UZANNE +ILMER -$ $ANIELA +ROSHINSKY -$ 2ICHARD ,ANGLEY -$ $AVID ,AUB -$ 0HILIP ,E"OIT -$

#HAIRMAN $R 'EORGE -ARTIN #RAIG ,EONARDI -$ 3TUART -ADDIN -$ !SHFAQ -ARGHOOB -$ 3TUART .ELSON -$ 0H$ 3HELDON 0OLLACK -$ +EVIN 0INSKI -$ !LAIN 2OOK -$ 4ED 2OSEN -$ % 6IC 2OSS -$ !LAN 3HALITA -$ !VA 3HAMBAN -$ %GGERT 3TOCKm ETH -$ "RUCE 3TROBER -$ 0H$ .EIL 3WANSON -$ +ENNETH 4ANABE -$ *AMES 4REAT -$ (ENSIN 4SAO -$ 0H$ 3ANDY 4SAO -$ *OHN 6ORHEES -$ 'UY 7EBSTER -$ 0H$ 7M 0HILIP 7ERSCHLER -$ *OHN :ONE -$ * Subject to Change

MAUI DERM 2013 HAS SPECIAL/REDUCED RATES AT THE

Grand Wailea and the Wailea Marriott &OR MORE DETAILS VISIT OUR WEBSITE AT

www.acmd-derm-hawaii.com

November/December 2012

Volume 10 • Issue 6

HISTORY OF DERMATOLOGY SOCIETY NEWSLETTER Eve J. Lowenstein, MD, PhD, Section Editor

Mosquito Wars: Malaria and Bioterrorism in Italy, 1943–1945 Frank M. Snowden, PhD

B

y July 1943, Italian hopes for victory in World War II lay in ruins. Axis armies were in disarray on all fronts, the Allies had landed in Sicily, and bombs were falling on Italian cities. In this impending disaster, Mussolini’s dictatorship collapsed on July 25. On September 8, the successor government of Pietro Badoglio reversed sides, declaring war on Germany as a “cobelligerent” of the Allies.1

Immediately after this volte-face, the German army occupied Italy, imposing a brutal policy of recruiting forced labor, plundering resources, and punishing Italians for their betrayal. German troops also carried out a series of massacres, killing unarmed men, women, and children in a “war against civilians.” The distinction between the eastern and western fronts was blurred in the Italian theater.2 VENGEANCE The Pontine Marshes south of Rome also experienced a war crime. The German army used malaria as an instrument of bioterrorism in violation of the Hague Treaty3 and the Geneva Convention.4 The signatories, including Germany, had pledged to inflict no unnecessary harm on civilians and to renounce chemical and biological weapons.

Nazi policy had a special focus in the Pontine Marshes because its reclamation and settlement was a celebrated accomplishment of Italian Fascism. Undoing this project, restoring the swamps, and unleashing malaria were means of inflicting humiliation as well as suffering. Furthermore, a substantial malaria epidemic could slow the Allied armies and complicate the task of governing the liberated territories. Finally, the project was an experiment in Nazi medical science whose goal was to cause rather than alleviate suffering. The result between 1944 and 1946 was a great malaria epidemic in which nearly all of the 150,000 settlers contracted malaria, and especially the virulent form caused

by Plasmodium falciparum, despite the fact that the Littoria province was declared malaria-free in 1939.5

THE NAZI SCIENCE OF TERROR The architect of this project was Erich Martini, one of the leading malariologists in Europe. Martini was Professor of Medicine at Hamburg, an early member of the Nazi Party, a protégé of Heinrich Himmler, and a biological warfare specialist.6 He was also an expert on the sanitary infrastructure of the Pontine Marshes who had worked there with his Italian colleague and fellow malariologist Alberto Missiroli. Their work had contributed to understanding an outstanding malaria puzzle—the natural history and speciation of anopheles mosquitoes.

One aspect of their discoveries was directly relevant: the role of the malariavector Anopheles labranchiae. Alone of mosquitoes in the former Pontine Marshes, A labranchiae could breed in both fresh and brackish water. Martini’s experiment, therefore, involved two steps. The first was to stop the powerful pumps installed by Mussolini’s regime to discharge runoff from the hills into the sea. This act, taken in the autumn of 1943, caused the reclaimed land to revert to marshland as it had been before the Fascist bonification program.7 The flooding has been understood as a legitimate act of war intended to slow the advancing Allied armies.

This first step, however, was followed by a second step that was useless for military purposes but had dire health consequences.

This second step was to put the pumps into reverse action, drawing seawater to heighten the level of salinity. One result was to blight the crops and to harm domestic and farm animals. The most important consequence, however, was to modify the environment in order not only to increase the numbers of mosquitoes exponentially but also to ensure that nearly all were A labranchiae, the highly efficient vector. This was “species sanitation” in reverse. The Italian malariologist Alberto Coluzzi, who played a leading role in combating the resulting epidemic, conducted on-site inspections and concluded that the epidemic was “man-made malaria.”8 One clue was geographical. Extensive zones were flooded, he discovered, that had no military value. Furthermore, increasing

From the Program in History of Science and History of Medicine, History Department, Yale University, New Haven, CT Address for Correspondence: Frank M. Snowden, PhD, Andrew Downey Orrick Professor of History, Chair, Program in History of Science and History of Medicine, Yale University, History Department, P.O. Box 208324, New Haven, CT 06520-8324 • E-mail: frank.snowden@yale.edu

SKINmed. 2012;10:388–389

388

© 2012 Pulse Marketing & Communications, LLC

November/December 2012

HISTORY OF DERMATOLOGY

the salinity was a procedure whose consequences were known best of all to Martini, the expert on A labranchiae and on biological warfare. Furthermore, before departing, the German army took additional measures that maximized the impact on public health. These measures included destroying the sanitary infrastructure by removing as many water pumps as possible and transporting them to Germany while dynamiting the ones they were unable to move. This action had no purpose except to make certain that the impact on the civilian population was lasting and maximally difficult to repair, particularly when the Wehrmacht planted mine fields surrounding the former pumping stations. There was also a sinister logic in the decisions to confiscate the supplies of the antimalarial medication quinine from the Department of Health in Rome and to destroy the boats used to keep the drainage canals free-flowing and clear of vegetation.9

REFERENCES

ITALIAN SCIENTIFIC COMPLICITY Mussolini’s foreign policy comprehensively destroyed his most celebrated domestic program when his Axis partner carried out the only instance of biological warfare in 20th-century Europe, at the expense of the Italian civilian population. Surprisingly, however, the extent of the epidemic was magnified by Missiroli, the Italian High Commissioner of Health and Martini’s former colleague. He wrote in his own hand that he and other Italians had beseeched the Germans to have due regard for Italian civilians and for international law. Once the experiment had begun, however, Missiroli was anxious to see whether DDT was a weapon potent enough to contain malaria. He, therefore, systematically withheld antimalarial medication from the population to observe the power of DDT alone.10

1

Deakin FW. The Brutal Friendship: Mussolini, Hitler, and the Fall of Italian Fascism. London: Weidelfeld and Nicolson, 1962; Lamb R. War in Italy, 1943–1945: A Brutal Story.London: Murray, 1993); and Plehwe F von, The End of an Alliance: Rome’s Defection from the Axis in 1943. London and New York: Oxford; 1971.

2 Battini M, Pezzini P. Guerra aicivili: occupazionetedesca e politica del massacro. Toscana 1944.Venice: Marsilio, 1997); Collotti E, Klinkhammer L. L’occupazionetedesca, 1943–1945. Rome, 1996; and Schreiber G. La vendetta tedesca, 1943–1945: le rappresaglienaziste in Italia, trans. M. Buttarelli. Milan: Mondadori, 2000.

3 The text of the Hague Convention. http://avalon.law.yale.edu/ 20th_century/hague04.asp. Accessed June 5, 2010.

4 Protocol for the prohibition of the use in war of asphyxiating, poisonous or other gases, and of bacteriological methods of warfare. http://www.fas.harvard.edu/~hsp/1925.html. Accessed June 5, 2010.

5 Snowden FM. The Conquest of Malaria: Italy, 1900–1962. New Haven: Yale; 2006: chap 7.

6 Hering R. Nazi Persecution and the Pursuit of Science: Correspondence between Erich Martini and Otto Hecht, 1946–1947.

Jewish Culture Hist. 2000;3:95–124.

7 McCormic AO. Abroad: undoing the German campaign of the mosquito. New York Times. September 13, 1944; Kumm HW. Malaria Control West of Rome during the Summer of 1944, 26 January 1945. Rockefeller Archive Center, Record Group 1.2, 700 Europe, box 12, Folder 102.

8 Private Archive of Mario Coluzzi. Rome, Italy, Coluzzi, A. Diary, 18-24.

9 Missiroli A. La malaria nella zona di Maccarese. January 24, 1947. Central State Archive, Rome, Italy. Ms, ISS, Laboratorio di Parassitologia, b. 6, fasc. 19, sottofasc. Maccarese: Difesa antimalarica..

10 Missiroli A. La malaria nellazfona di Maccarese. January 24, 1947. Archivio Centrale dello Stato, Rome. MS, ISS, Laboratorio di Parassitologia, b. 6, fasc. 19, sottofasc. Maccarese: Difesa antimalarica.

HISTORY OF DERMATOLOGY SOCIETY

Courtesy of BuyEnlarge, Philadelphia, PA SKINmed. 2012;10:388–389

389

Mosquito Wars: Malaria and Bioterrorism in Italy, 1943–1945

7PMVNF t *TTVF

November/December 2012

CASE STUDY Vesna Petronic-Rosic, MD, MSc, Section Editor

Radiation Port Erythema Multiforme: Erythema Multiforme Localized to the Radiation Port in a Patient With Non–Small Cell Lung Cancer Hubert M. Chodkiewicz, MD;1 Philip R. Cohen, MD2,3,4, " ZFBS PME NBO XBT USFBUFE XJUI TUFSFPUBDUJD SBEJBUJPO UP HSBZ VOJUT JO GSBDUJPOT GPS TUBHF *# OPOoTNBMM DFMM MVOH DBODFS 3BEJPUIFSBQZ XBT EJSFDUFE BU UIF SJHIU MPXFS MPCF TFHNFOU PG UIF MVOH BOE MBTUFE EBZT )F EFWFMPQFE SBEJPEFSNBUJUJT XIJDI DPNQMFUFMZ SFTPMWFE XJUIJO B GFX XFFLT BGUFS SBEJPUIFSBQZ XBT mOJTIFE ɨSFF NPOUIT BGUFS DPNQMFUJOH SBEJBUJPO UIFSBQZ IF EFWFMPQFE B QSVSJUJD SFE MFTJPO XJUIJO IJT SBEJBUJPO QPSU PO IJT SJHIU NJE CBDL XJUI UIF GPSNBUJPO PG CMJTUFST B XFFL MBUFS 5XP XFFLT BGUFS UIF POTFU PG UIF QBUJFOU T CMJTUFST DVUBOFPVT FYBNJOBUJPO TIPXFE JOEJWJEVBM BOE DPOWFSHFOU FSZUIFNBUPVT QBQVMFT BOE QMBRVFT XJUI TVQFSmDJBM TDBMJOH BU TJUFT PG SFTPMWJOH WFTJDMFT MPDBUFE XJUIJO UIF SBEJBUFE BSFB 'JHVSFT BOE ɨF QBUJFOU IBE OFJUIFS TZNQUPNT PG NZDPQMBTNB QOFVNPOJBF OPS MFTJPOT PS IJTUPSZ PG QSFTFOU PS QBTU IFSQFUJD JOGFDUJPO "MTP IF IBE OPU SFDFOUMZ CFFO QMBDFE PO BOZ OFX NFEJDBUJPOT BOE IF EJE OPU IBWF BOZ PUIFS FSZUIFNB NVMUJGPSNFoBTTPDJBUFE SJTL GBDUPST " CJPQTZ GSPN UIF FSZUIFNBUPVT MFTJPOT TIPXFE B CBOE MJLF JOmMUSBUF PG MZNQIPDZUFT JO UIF EFSNJT ɨF PWFSMZJOH FQJEFSNJT DPOUBJOFE OFDSPUJD LFSBUJOPDZUFT BOE UIFSF XBT BMUFSBUJPO PG UIF CBTBM MBZFS $PSSFMBUJPO PG UIF DMJOJDBM QSFTFOUBUJPO BOE QBUIPMPHJD DIBOHFT FTUBCMJTIFE B EJBHOPTJT PG FSZUIFNB NVMUJGPSNF MPDBMJ[FE UP UIF SBEJBUJPO QPSU ɨF QBUJFOU XBT USFBUFE XJUI UPQJDBM USJBNDJOPMPOF BDFUPOJEF DSFBN UXJDF EBJMZ GPS EBZT BOE PODF EBJMZ GPS EBZT )JT MFTJPOT SFTPMWFE BOE UIFSF XBT NJME IZQFSQJHNFOUBUJPO PG UIF BĊFDUFE BSFB

DISCUSSION &SZUIFNB NVMUJGPSNF B EJTPSEFS PG TLJO BOE NVDPVT NFNCSBOFT JT PGUFO EVF UP B QSFDJQJUBUJOH GBDUPS BOE IBT B UFOEFODZ GPS SFDVSSFODF ɨF MFTJPOT DBO CF NBDVMBS QBQVMBS VSUJDBSJBM CVMMPVT PS QVSQVSJD ɨFZ PGUFO EFWFMPQ B UBSHFUPJE BQQFBSBODF BOE BSF GSFRVFOUMZ MPDBUFE PO UIF FYUFOTPS TVSGBDFT PG UIF FYUSFNJUJFT " MFTJPOBM CJPQTZ XIJDI DBO BJE JO FTUBCMJTIJOH UIF EJBHOPTJT EFNPOTUSBUFT B TVQFSmDJBM QFSJWBTDVMBS NPOPOVDMFBS JOmMUSBUF FQJEFSNBM JOUSBDFMMVMBS FEFNB BOE TQPOHJPTJT BOE OFDSPUJD LFSBUJOPDZUFT 1–8

3BEJBUJPO QPSU FSZUIFNB NVMUJGPSNF JO PODPMPHZ QBUJFOUT IBT CFFO EFTDSJCFE JO DMJOJDBM TFUUJOHT 5BCMF * 1 3 5–7 10 11 ɨF mSTU TDFOBSJP JOWPMWFT QBUJFOUT SFDFJWJOH QIFOZUPJO BOE DSBOJBM SBEJPUIFSBQZ ɨF TFDPOE PDDVST JO QBUJFOUT SFDFJWJOH SBEJBUJPO UIFSBQZ BOE DPODPNJUBOUMZ PS TFRVFOUJBMMZ CFJOH USFBUFE XJUI DIFNPUIFSBQZ ɨF UIJSE TDFOBSJP JEJPQBUIJD SBEJBUJPO QPSU FSZUIFNB NVMUJGPSNF IBT CFFO PCTFSWFE JO QBUJFOUT XIP IBWF POMZ CFFO USFBUFE XJUI SBEJBUJPO UIFSBQZ &SZUIFNB NVMUJGPSNF XJUIPVU BOZ PUIFS QSFEJTQPTJOH GBDUPS JT QSJNBSJMZ MJNJUFE UP UIF SBEJBUJPO mFME JO JOEJWJEVBMT XIP IBWF OPU SFDFJWFE BOZ BEEJUJPOBM BOUJOFPQMBTUJD USFBUNFOU 0VS QBUJFOU EFWFMPQFE CJPQTZ DPOmSNFE JEJPQBUIJD FSZUIFNB NVMUJGPSNF SFTUSJDUFE UP UIF SBEJBUJPO QPSU )F OFJUIFS SFDFJWFE BOZ DIFNPUIFSBQZ OPS TUBSUFE BOZ OFX NFEJDBUJPOT )F BMTP IBE OP BTTPDJBUFE FUJPMPHJD GBDUPST GPS FSZUIFNB NVMUJGPSNF

ɨF QBUIPHFOFTJT PG FSZUIFNB NVMUJGPSNF JT VOLOPXO IPXFWFS JU JT DPOTJEFSFE UP CF B IZQFSTFOTJUJWJUZ SFBDUJPO 2 8 *U JT NPTU DPNNPOMZ BTTPDJBUFE XJUI FJUIFS IFSQFT TJNQMFY WJSVT PS NZDPQMBTNB QOFVNPOJB *O BEEJUJPO TFWFSBM NFEJDBUJPOT IBWF CFFO FTUBCMJTIFE BT FUJPMPHJD GBDUPST 2 3 8 "MCFJU MFTT GSFRVFOUMZ FSZUIFNB NVMUJGPSNF IBT BMTP CFFO BTTPDJBUFE XJUI PS QSFDFEFE 8F IBWF BMTP JEFOUJmFE BOPUIFS QBUJFOU XIP EFWFMPQFE JEJPQBUIJD SBEJBUJPO QPSU FSZUIFNB NVMUJGPSNF B ZFBS PME NBO CZ SBEJBUJPO UIFSBQZ 1 9

From The Medical School, The University of Texas-Houston Medical School;1 The University of Houston Health Center, University of Houston;2 the Department of Dermatology, The University of Texas M.D Anderson Cancer Center;3 and the Department of Dermatology, University of Texas-Houston Medical School,4 Houston, TX "EESFTT GPS $PSSFTQPOEFODF 1IJMJQ 3 $PIFO .% 5XJOMFBG $PVSU 4BO %JFHP $" t & NBJM NJUFIFBE!HNBJM DPN

SKINmed. 2012;10:390–392

390

ª 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$

$"4& 456%:

November/December 2012

Table I. Radiation Port Erythema Multiforme in Oncology Patients $IFNPUIFSBQZ BTTPDJBUFE SBEJBUJPO QPSU FSZUIFNB NVMUJGPSNF" &SZUIFNB NVMUJGPSNF BTTPDJBUFE XJUI QIFOZUPJO BOE DSBOJBM SBEJBUJPO UIFSBQZ &.1"$5 TZOESPNF# *EJPQBUIJD SBEJBUJPO QPSU FSZUIFNB NVMUJGPSNF$ " ɨJT JT B QBSUJDVMBSMZ SBSF DBVTF PG SBEJBUJPO QPSU FSZUIFNB NVMUJGPSNF " ZFBS PME XPNBO XJUI DPMPO DBODFS XBT USFBUFE XJUI SBEJBUJPO GPMMPXFE CZ DIFNPUIFSBQZ FSZUIFNB NVMUJGPSNF JOJUJBMMZ BQQFBSFE JO UIF BOUFSJPS BOE QPTUFSJPS SBEJBUJPO QPSUT XJUIJO UIF mSTU EBZ CFGPSF TQSFBEJOH PVUXBSE 1 "OPUIFS QBUJFOU BMTP EFWFMPQFE MFTJPOT DPOTJTUFOU XJUI EJĊVTF FSZUIFNB NVMUJGPSNF JOWPMWJOH UIF SBEJBUJPO QPSU BOE FYUFOEJOH PVUXBSET BGUFS SFDFJWJOH DPODVSSFOU DIFNPSBEJBUJPO USFBUNFOU GPS FTPQIBHFBM DBODFS QFSTPOBM PCTFSWBUJPO 13$

Figure 1. Distant view of right mid back showing individual and confluent erythematous papules and plaques confined to the area of radiation.

#

ɨJT TZOESPNF PDDVST JO PODPMPHZ QBUJFOUT XJUI CSBJO NFUBTUBTFT SFDFJWJOH DSBOJBM SBEJPUIFSBQZ BOE DPODPNJUBOU QSPQIZMBDUJD QIFOZUPJO UP QSFWFOU TFJ[VSFT &SZUIFNB NVMUJGPSNF VTVBMMZ EFWFMPQT XJUIJO UIF mSTU NPOUI PG UIFSBQZ ɨF MFTJPOT BSF JOJUJBMMZ MJNJUFE UP UIF SBEJBUJPO mFME BOE PGUFO TVCTFRVFOUMZ CFDPNF HFOFSBMJ[FE IPXFWFS FSZUIFNB NVMUJGPSNF RVJDLMZ JNQSPWFT BGUFS TUPQQJOH UIF QIFOZUPJO BOE SBEJBUJPO USFBUNFOU o $ ɨJT GPSN PG SBEJBUJPO QPSU FSZUIFNB NVMUJGPSNF IBT OPU GSFRVFOUMZ CFFO EFTDSJCFE ɨF NBKPSJUZ PG UIF QBUJFOUT XFSF PCTFSWFE CFUXFFO BOE UIF QBVDJUZ PG SFDFOU SFQPSUT NBZ CF UIF SFTVMU PG UFDIOJDBM BEWBODFT TVDI BT JNQSPWFE FRVJQNFOU BOE NFUIPEPMPHZ PG SBEJBUJPO BENJOJTUSBUJPO UIBU IBWF EFDSFBTFE TLJO SFMBUFE EBNBHF MFBEJOH UP GFXFS QBUJFOUT XJUI JEJPQBUIJD SBEJBUJPO QPSU FSZUIFNB NVMUJGPSNF DVSSFOU SFQPSU

Table II. Immunologic Dermatology Disorders Arising in Sites of Ionizing Radiation #VMMPVT QFNQIJHPJE &SZUIFNB NVMUJGPSNF o o DVSSFOU SFQPSU

Figure 2. Closer view of radiation port location on the patient’s right mid back shows that some of the erythematous plaques have dusky-appearing central areas. The centrally located black keratotic plaque is an inflamed seborrheic keratosis.

(SBGU WFSTVT IPTU EJTFBTF -JDIFO QMBOVT -JDIFO TDMFSPTVT FU BUSPQIJDVT19

XJUI MVOH DBODFS XIP XBT SFDFJWJOH SBEJBUJPO USFBUNFOU UP CPUI -VQVT FSZUIFNBUPTVT IJT DIFTU BOE CBDL 4JNJMBS UP PVS QBUJFOU IF EFWFMPQFE UBSHFUPJE 1FNQIJHVT WVMHBSJT QMBRVFT BOE NBDVMFT PG FSZUIFNB NVMUJGPSNF BOE UIF MFTJPOT 7JUJMJHP23 XFSF NPSF QSPOPVODFE JO IJT SBEJBUJPO QPSU ɨF MFTJPOT JO IJT SBEJBUJPO QPSU IPXFWFS XFSF QSFDFEFE CZ FSZUIFNB NVMUJGPSNF JNNVOPDPNQSPNJTFE EJTUSJDU JT B SFDFOUMZ JOUSPEVDFE VOJGZJOH CFHJOOJOH PO UIF EPSTBM BTQFDU PG CPUI IBOET 11 DPODFQU GPS UIF PDDVSSFODF PG PQQPSUVOJTUJD JOGFDUJPOT UVNPST "O FUJPMPHJD GBDUPS GPS UIF QBUIPHFOFTJT PG SBEJBUJPO QPSU FSZ- BOE JNNVOF EJTPSEFST BU TJUFT PG QSJPS DMJOJDBM FWFOUT JODMVEJOH UIFNB NVMUJGPSNF NBZ CF UIF EFWFMPQNFOU PG B DVUBOFPVT DISPOJD MZNQIFEFNB IFSQFUJD JOGFDUJPOT WBDDJOBUJPOT BOE IFUiJNNVOPDPNQSPNJTFE EJTUSJDUw CZ UIF JPOJ[JOH SBEJBUJPO ɨF FSPHFOFPVT QIZTJDBM JOKVSJFT TVDI BT JPOJ[JOH BOE 67 SBEJBUJPO 20

SKINmed. 2012;10:390–392

391

3BEJBUJPO 1PSU &SZUIFNB .VMUJGPSNF

$"4& 456%:

November/December 2012 UIFSNBM CVSOT BOE USBVNB XIJDI TFMFDUJWFMZ EBNBHF BOE PS JNNVOPMPHJDBMMZ BMUFS UIF DVUBOFPVT TJUF 12 *O BEEJUJPO UP FSZUIFNB NVMUJGPSNF TFWFSBM PUIFS JNNVOF EJTPSEFST IBWF CFFO PCTFSWFE UP PDDVS JO TJUFT QSFWJPVTMZ USFBUFE XJUI JPOJ[JOH SBEJBUJPO 5BCMF ** 1 3 5โ 7 9โ 11 13โ 23

6

.JDBMJ ( -JOUIJDVN , )BO / 8FTU %1 *ODSFBTFE SJTL PG FSZUIFNB NVMtiforme major with combination anticonvulsant and radiation therapies.

Pharmacotherapy. 1999;19:223โ 227.

7

#PSH .' 1SPCFSU +$ ;XJ -+ *T QIFOZUPJO DPOUSBJOEJDBUFE JO QBUJFOUT receiving cranial irradiation? Australas Radiol. 1995;39:42โ 46.

8

)VGG +$ 8FTUPO 8- 5POOFTFO .( &SZUIFNB NVMUJGPSNF B DSJUJDBM SFview of characteristics, diagnostic criteria, and causes. J Am Acad Dermatol. 1983;8:763โ 775.

CONCLUSIONS

9

.BYรฅFME 84 $PMFNBO 81 $VUBOFPVT SFBDUJPOT BGUFS SBEJBUJPO UIFSapy. Report of 7 cases. Am J Roentgenol Radium Ther Nucl Med. 1969;105:636โ 643.

&SZUIFNB NVMUJGPSNF DBO CF BTTPDJBUFE XJUI SBEJBUJPO UIFSBQZ 3BEJBUJPO QPSU FSZUIFNB NVMUJGPSNF PDDVST XIFO TLJO MFTJPOT BSF JTPMBUFE UP PS CFHJO JO UIF SBEJPUIFSBQZ mFME 0VS QBUJFOU EFWFMPQFE JEJPQBUIJD FSZUIFNB NVMUJGPSNF SFTUSJDUFE UP IJT SBEJBUJPO QPSU 0UIFS DMJOJDBM TJUVBUJPOT PG SBEJBUJPO QPSU FSZUIFNB NVMUJGPSNF JODMVEF FSZUIFNB NVMUJGPSNF BTTPDJBUFE XJUI QIFOZUPJO BOE DSBOJBM SBEJBUJPO UIFSBQZ BOE DIFNPUIFSBQZ BTTPDJBUFE SBEJBUJPO QPSU FSZUIFNB NVMUJGPSNF 8F QPTUVMBUF UIBU UIF QBUIPHFOFTJT PG SBEJBUJPO QPSU FSZUIFNB NVMUJGPSNF JT TFDPOEBSZ UP UIF Fฤ FDUT PG JPOJ[JOH SBEJBUJPO TFMFDUJWFMZ EBNBHJOH BOE PS JNNVOPMPHJDBMMZ BMUFSJOH UIF TJUF PG USFBUNFOU BOE UIFSFCZ DSFBUJOH B DVUBOFPVT JNNVOPDPNQSPNJTFE EJTUSJDU UIBU FOBCMFT UIF TVCTFRVFOU EFWFMPQNFOU PG FSZUIFNB NVMUJGPSNF MPDBMJ[FE UP UIF SBEJBUJPO QPSU REFERENCES 1

'MFJTDIFS "# 3PTFOUIBM %* #FSOBSE 4" 0 ,FFGF &+ 4LJO SFBDUJPOT UP radiotherapyโ a spectrum resembling erythema multiforme: case report and review of the literature. Cutis. 1992;49:35โ 39.

2

5POOFTFO .( 4PUFS /" &SZUIFNB NVMUJGPSNF J Am Acad Dermatol.

1979;1:357โ 364.

3

"INFE * 3FJDIFOCFSH + -VDBT " 4IFIBO +. &SZUIFNB NVMUJGPSNF associated with phenytoin and cranial radiation therapy: a report of three patients and review of the literature. Int J Dermatol. 2004;43:67โ 73.

4

"VRVJFS %VOBOU " .PDLFOIBVQU . /BMEJ - FU BM $PSSFMBUJPOT CFUXFFO clinical patterns and causes of erythema multiforme majus, Stevens+PIOTPO TZOESPNF BOE UPYJD FQJEFSNBM OFDSPMZTJT SFTVMUT PG BO JOUFSOBtional prospective study. Arch Dermatol. 2002;138:1019โ 1024.

5

#BSCPTB -" 5FJYFJSB $3 &SZUIFNB NVMUJGPSNF BTTPDJBUFE XJUI QSPQIZlactic use of phenytoin during cranial radiation therapy. Am J Health Syst Pharm. 2008;65:1048โ 1050.

10 8PISM 4 -PFXF 3 1JDLM 8' 4UJOHM ( 8BHOFS 4/ &.1"$5 TZOESPNF J Dtsch Dermatol Ges. 2005;3:39โ 43.

11 Pandya AG, Kettler AH, Bruce S. Radiation-induced erythema multiforme.

An unusual presentation with elastic tissue phagocytosis. Int J Dermatol.

1989;28:600โ 602.

12 3VPDDP 7 #SVOFUUJ ( 1VDB 37 3VPDDP & 5IF JNNVOPDPNQSPNJTFE EJTtrict: a unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites. J Eur Acad Dermatol Venereol. 2009;23:1364โ 1373.

13 .VM 7& WBO (FFTU "+ 1JKMT +PIBOOFTNB .$ FU BM 3BEJBUJPO JOEVDFE CVMlous pemphigoid: a systematic review of an unusual radiation side effect.

Radiother Oncol. 2007;82:5โ 9.

14 'PMMJFSP ( ;VSMP " "NBOUJ $ 5PNCPMJOJ 7 %J 1BPMB . #VMMPVT QFNQIJgoid induced by radiation therapy. Clin Oncol. 1995;7:266โ 267.

15 Okamoto S, Takahashi S, Inoue T, et al. Cutaneous chronic graft-versushost disease localized to the field of total lymphoid irradiation. Bone Marrow Transplant. 1996;17:111โ 113.

16 4PDJF ( (MVDLNBO & $PTTFU +. FU BM 6OVTVBM MPDBMJ[BUJPO PG DVUBOFPVT chronic graft-versus-host disease in the radiation fields in four cases.

Bone Marrow Transplant. 1989;4:133โ 135.

17 4IVSNBO % 3FJDI )- +BNFT 8% -JDIFO QMBOVT DPOรฅOFE UP B SBEJBtion field: the โ isoradiotopicโ response. J Am Acad Dermatol. 2004;50: 482โ 483.

18 ,JN +) ,SJWEB 4+ -JDIFO QMBOVT DPOรฅOFE UP B SBEJBUJPO UIFSBQZ TJUF J Am Acad Dermatol. 2002;46:604โ 605.

19 :BUFT 7. ,JOH $. %BWF 7, -JDIFO TDMFSPTVT FU BUSPQIJDVT GPMMPXJOH radiation therapy. Arch Dermatol. 1985;121:1044โ 1047.

20 $BSSPUUF -FGFCWSF * %FMBQPSUF & .JSBCFM 9 1JFUUF ' 3BEJBUJPO JOEVDFE TLJO reactions (except malignant tumors). Bull Cancer. 2003;90:319โ 325.

21 3PCCJOT "$ -B[BSPWB ; +BOTPO .. 'BJSMFZ +" 1FNQIJHVT WVMHBSJT QSFsenting in a radiation portal. J Am Acad Dermatol. 2007;56:S82โ S85.

22 %FMBQPSUF & 1JFUUF ' #FSHPFOE ) 1FNQIJHVT WVMHBSJT JOEVDFE CZ SBEJPtherapy. Ann Dermatol Venereol. 1991;118:447โ 451.

23 Polat M, Yalรงin B, Alli N. Vitiligo at the site of radiotherapy for nasopharyngeal carcinoma. Am J Clin Dermatol. 2007;8:247โ 249.

VINTAGE LABEL

$PVSUFTZ PG #VZ&OMBSHF 1IJMBEFMQIJB 1" SKINmed. 2012;10:390โ 392

392

3BEJBUJPO 1PSU &SZUIFNB .VMUJGPSNF

November/December 2012

Volume 10 • Issue 6

CASE STUDY Vesna Petronic-Rosic, MD, MSc, Section Editor

Cladosporium Scalp Infection Erwin Eduardo Argueta Sosa, MD;1 Philip R. Cohen, MD;2,3,4 Jaime A. Tschen, MD4,5,6

An 11-year-old healthy red-haired girl presented with a 3-year history of hair loss and mild pruritus of her scalp. She had previously been diagnosed with trichotillomania. Cutaneous examination showed scant hair loss with neither crusting nor scaly lesions. The scalp hair was diffusely thin, dry, and brittle on the frontal, mid-parietal, and anterior occipital scalp (Figure 1A). A pull test was negative, and a significant number of hair shafts were not detached on repeated traction. Closer examination using a dermatoscope showed follicles with broken hair shafts. The dermatoscopic evaluation also showed frequent pinpoint black dots scattered among the terminal hair shafts at their bases.

No scale, scar, or inflammatory changes were seen in the involved areas (Figure 1B). A 20% potassium hydroxide (KOH) preparation of material obtained after gentle scrapping of the black dots on the scalp provided fragments of hair fibers containing aggregates of pigmented yeast forms (Figure 2A) and brown septate hyphae (Figure 2B). Two samples were sent for fungal culture and both showed dark brown colonies on the surface and black coloration when viewed from the reverse side (Figure 3A). Lactophenol cotton blue preparation of the fungal colonies revealed long and septate hyphae with laterally branching conidiophores ending in round-shaped conidia (Figure 3B).

The microorganism was identified by the reference laboratory as Cladosporium species. The conidia were usually noted to be single-celled with a distinct dark hilum. They also exhibited prominent attachment scars that caused the cells to appear “shield-shaped.” These features were considered to be diagnostic for Cladosporium; however, the reference laboratory could not identify the organism to the species level.

The girl’s Cladosporium scalp infection was treated with itraconazole at an oral daily dose of 200 mg for 2 months. Upon re-evaluation, she showed significant improvement with not only discontinuation of her alopecia and new hair growth (Figure 4A), but also an absence of broken hair shafts and the dark pigmentation found initially at their base when her scalp was examined using a dermatoscope (Figure 4B).

In addition, a new KOH preparation did not reveal the presence of conidia.

DISCUSSION Cladosporium is classified as a dematiaceous fungus. This refers to fungi whose cell walls produce melanin and therefore are naturally pigmented black or brown. The melanin also results in the dark pigment that is clearly visible when colonies of dematiaceous organisms grow in fungal culture media. Cladosporium is considered to be a saprophyte that can be found in soil, a site common to keratinophilic fungi.1,2 In addition to plants and decaying matter, Cladosporium has also been documented in hospital air equipment.1 Direct inoculation of the fungal microorganism into the involved human tissue is considered necessary for Cladosporium infections to occur. Cladosporium isolates have been cultured from superficial infections of skin (Cladosporium carrionii), mucosa (Cladosporium cladosporioides), and nails (Cladosporium

species): chromoblastomycosis, keratomycosis, and onychomycosis, respectively.3–6 In addition, Cladosporium infection of superficial skin (Cladosporium cladosporioides) may extend into the subcutaneous tissue2; occasionally, more severe central nervous system involvement (secondary to Caldosporium bantianum— which has recently been named Cladophialophora bantiana—or Cladosporium macrocarpum) has also been described.7–9 The diagnosis of Cladosporium infection may be suspected by finding the characteristic morphological features of the fungus when examining a 20% KOH preparation taken from a cutaneous lesion for which the possibility of a fungal skin infection is being entertained. Subsequently, the diagnosis can be confirmed by isolating the organism on Sabouraud glucose agar culture media. Superficial Cladosporium infections have been effectively treated with daily oral itraconazole for extended periods.

From the Universidad Francisco Marroquin, Guatemala, Guatemala;1 the University of Houston Health Center, University of Houston, Houston, TX;2 the Department of Dermatology, University of Texas M.D. Anderson Cancer Center, Houston, TX;3 the Department of Dermatology, University of Texas-Houston Medical School, Houston, TX;4 St. Joseph Dermpath, Houston, TX;5 and the Department of Dermatology, Baylor College of Medicine, Houston, TX6 Address for Correspondence: Philip R. Cohen, MD, 10991 Twinleaf Court, San Diego, CA 92131. • E-mail: mitehead@gmail.com

SKINmed. 2012;10:393–394

393

© 2012 Pulse Marketing & Communications, LLC

November/December 2012

A

CASE STUDY

B

A

Figure 1. Initial scalp evaluation demonstrates hair loss (A).

A view of the scalp using a dermatoscope shows evidence of broken hair shafts and dark spots at the hair base (B).

Figure 4. Clinical examination of patient’s scalp at re-evaluation performed after 2 months of oral itraconazole daily treatment demonstrates hair growth (A). In contrast to her evaluation prior to oral antifungal therapy, there is an absence of broken hair shafts and the dark spots at the base of the hair shafts when the scalp is examined using a dermatoscope (B).

B

A

scope examination of her scalp and microscopic examination of the 20% KOH preparation from scalp scrapings prompted us to suspect a fungal scalp infection. The fungal culture established the identification of the causative organism. Two months of daily oral treatment with 200 mg of itraconazole were sufficient to resolve our patient’s symptoms and to eliminate the offending organism of her Cladosporium scalp infection. Albeit rare, a fungal infection secondary to Cladosporium should be considered when evaluating young patients with hair loss.

Figure 2. A 20% potassium hydroxide preparation of the patient’s scalp scrapings show clusters of brown, round to ellipsoid-shaped spores (original magnification ×400) (A).

Brown septate hyphae are also observed (original magnification ×400) (B).

A

REFERENCES

B

Figure 3. The fungal colonies show the characteristic black coloration of Cladosporium when viewed from the reverse side (A). Lactophenol cotton blue preparation shows the characteristic morphology of Cladosporium: a long, septate hyphae with laterally branching conidiophores that end in round to ellipsoid-shaped conidia (original magnification ×220) (B).

CONCLUSIONS Cladosporium is a not a classic dermatophyte. The opportunity to discover Cladosporium spores from our patient’s scalp scrapings is extraordinary. Indeed, to the best of our knowledge, this is the first individual in whom Cladosporium scalp infection has been reported. Our patient’s hair loss had previously been incorrectly diagnosed as trichotillomania; however, dermato-

SKINmed. 2012;10:393–394

B

394

1

Hedayati MT, Mohseni-Bandpi A, Moradi S. A survey on the pathogenic fungi in soil samples of potted plants from Sari hospitals, Iran. J Hosp Infect. 2004;58:59–62.

2

Sang H, Zheng XE, Zhou WQ, et al. A case of subcutaneous phaeohyphomycosis caused by Cladosporium cladosporioides and its treatment.

Mycoses. 2012;55:195–197.

3

Namratha N, Nadgir S, Kale M, Rathod R. Chromoblastomycosis due to Cladosporium carrionii. J Lab Physicians. 2010;2:47–48.

4

Hafidh RR, Abdulamir AS. Cladosporium spp. as a causative agent of white superficial onychomycosis. East Mediterr Health. J 2008;14: 231–233.

5

Chew FLM, Subrayan V, Chong PP, Goh MC, Ng KP. Cladosporium cladosporioides keratomycosis: a case report. Jpn J Ophthalmol. 2009; 53:657–659.

6

Surjushe A, Kamath R, Oberai C, et al. A clinical and mycological study of onychomycosis. Indian J Dermatol Venereol Leprol. 2007;73: 397–401.

7

Singh S, Singh P, Sarkar C, et al. Fungal granuloma of the brain caused

by Cladosporium bantianum—a case report and review of the literature.

J Neurol Sci. 2005:228:109–112.

8

George IA, Mathews MS, Karthik R, et al. Fatal cerebral abscess caused

by Cladophialophora bantiana. J Assoc Physicians India. 2008;56: 470–472.

9

Lalueza A, Lopez-Medrano F, del Palacio A, et al. Cladosporium macrocarpum brain abscess after endoscopic ultrasound-guided celiac plexus block. Endoscopy. 2011;43 suppl 2 UCTN:E9–E10.

Cladosporium Scalp Infection

7PMVNF t *TTVF

November/December 2012

CASE STUDY Vesna Petronic-Rosic, MD, MSc, Section Editor

Metastatic Melanoma From an Unknown Primary Site Presenting as Skin-Colored Nodules and Multiple Visceral Involvement Sudip Kumar Ghosh, MD, DNB;1 Debabrata Bandyopadhyay, MD;1 Kuntal Deb Barma, MBBS;1 Swapnendu Basu, MD;2 Amit Roy, MS3

" ZFBS PME NBO QSFTFOUFE XJUI NVMUJQMF HSBEVBMMZ QSPHSFTTJOH BTZNQUPNBUJD TXFMMJOHT PO IJT CPEZ GPS UIF QSFDFEJOH NPOUIT )F IBE OP QFSTPOBM PS GBNJMZ IJTUPSZ PG BOZ TLJO EJTFBTF ɨFSF XBT OP TZTUFNJD TZNQUPN BQBSU GSPN PDDBTJPOBM DPOTUJQBUJPO &YBNJOBUJPO SFWFBMFE NVMUJQMF EJTDSFUF ëSN OPOUFOEFS TLJO DPMPSFE OPEVMFT PG WBSZJOH TJ[FT ëYFE UP UIF TLJO CVU GSFF GSPN UIF VOEFSMZJOH TUSVDUVSFT PO IJT DIFTU BCEPNFO BOE CBDL ɨF PWFSMZJOH TLJO PG UIF OPEVMFT XBT FSZUIFNBUPVT BU QMBDFT 'JHVSF A TPMJUBSZ EFQJHNFOUFE OPOBOFTUIFUJD QBUDI NFBTVSJOH DN ¨ DN XBT OPUFE BSPVOE B DFOUSBM HSBZ NBDVMF NN ¨ NN PO IJT MFGU TIJO 'JHVSF ɨF TVSGBDF PG UIJT MFTJPO XBT PUIFSXJTF OPSNBM 8PPE T MBNQ FYBNJOBUJPO PG UIJT BSFB TIPXFE BUUFOVBUJPO PG QJHNFOUBUJPO JO UIF DFOUSBM BSFB BOE UPUBM EFQJHNFOUBUJPO TVSSPVOEJOH JU /P EZTQJHNFOUFE BSFB XBT OPUFE PO 8PPE T MBNQ FYBNJOBUJPO PG UIF PUIFS BSFBT ɨFSF XBT OP BCOPSNBMJUZ PG UIF PSPHFOJUBM NVDPTBF (FOFSBM FYBNJOBUJPO SFWFBMFE NJME QBMMPS BOE NVMUJQMF EJTDSFUF OPOUFOEFS ëSN MZNQI OPEFT NFBTVSJOH DN ¨ DN BUUBDIFE UP UIF TLJO JO UIF MFGU JOHVJOBM SFHJPO ɨF PWFSMZJOH TLJO XBT OPSNBM 0DVMBS FYBNJOBUJPO JODMVEJOH EJSFDU BOE JOEJSFDU PQIUIBMNPTDPQZ BOE PUPMBSZOHPMPHJD FWBMVBUJPO XFSF OPSNBM 1SPDUPTDPQJD FYBNJOBUJPO SFWFBMFE B SFEEJTI CMBDL JOEVSBUFE NBTT BU UIF SJHIU MBUFSBM XBMM PG UIF MPXFS UIJSE PG UIF SFDUVN &YBNJOBUJPO PG UIF PUIFS TZTUFN XBT OPODPOUSJCVUPSZ $PNQMFUF IFNPHSBN TIPXFE NJME BOFNJB IFNPHMPCJO HN BOE SBJTFE &43 NN JO UIF ëSTU IPVS 8FTUFSHSFO T NFUIPE #JPDIFNJTUSZ QBOFM XBT OPSNBM BQBSU GSPN SBJTFE MFWFMT PG BTQFSUBUF USBOTBNJOBTF 6 - BMBOJOF USBOTBNJOBTF 6 - BMLBMJOF QIPTQIBUBTF 6 - BOE MBDUBUF EFIZESPHFOBTF 6 - $IFTU Y SBZ TIPXFE B SPVOEFE PQBDJUZ JO UIF MFGU BQJDBM BSFB TVHHFTUJWF PG DBOOPO CBMM NFUBTUBTJT 'JHVSF 6MUSBTPOPHSBQIZ BOE DPNQVUFE UPNPHSBQIZ PG UIF BCEPNFO SFWFBMFE NVMUJQMF MJWFS OPEVMFT TVHHFTUJWF PG IFQBUJD NFUBTUBTJT 'JOEJOHT GSPN PNQVUFE UPNPHSBQIZ PG UIF CSBJO BOE VQQFS HBTUSPJOUFTUJOBM FOEPTDPQZ XFSF OPSNBM $PMPOPTDPQJD FYBNJOBUJPO EJE OPU SFWFBM BOZ DPMPOJD MFTJPO 'JOF OFFEMF BTQJSBUJPO DZUPMPHZ PG UIF FOMBSHFE JOHVJOBM MZNQI OPEF XBT TVHHFTUJWF PG NBMJHOBOU NFMBOPNB .. )JTUPQBUIPMPHJD FYBNJOBUJPO PG UIF FYDJTJPO CJPQTZ TQFDJNFO PG B TLJO OPEVMF TIPXFE B UVNPS NBTT JO UIF EFSNJT DPNQPTFE PG OFTUT PG PWBM UP QPMZHPOBM DFMMT XJUI WFTJDVMBS OVDMFJ BOE MBSHF QSPNJOFOU OVDMFPMJ 'JHVSF &YUFOTJWF BSFBT PG OFDSPTJT XFSF BMTP TFFO ɨ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ΉEBZT JOUFOEFE UP CF HJWFO FWFSZ XFFLT GPS QBMMJBUJPO ɨF QBUJFOU EJFE XFFLT BGUFS UIF ëSTU USFBUNFOU XJUI DIFNPUIFSBQZ

DISCUSSION &TUBCMJTINFOU PG UIF EJBHOPTJT PG .. EFQFOET PO D MJOJDBM FYBNJOBUJPO IJTUPQBUIPMPHJD PCTFSWBUJPO PG UIF NFMBOPJE OBUVSF PG UIF MFTJPOT BOE JNNVOPIJTUPDIFNJTUSZ "MUIPVHI .. JT DMBTTJDBMMZ QJHNFOUFE BNFMBOPUJD MFTJPOT NBZ BMTP

PDDVS 2 ɨF UVNPS JT QSPOF UP NFUBTUBTJ[F FBSMZ JO UIF DPVSTF PG UIF EJTFBTF .. BSJTJOH GSPN BO VOLOPXO QSJNBSZ TJUF .61

JT SBSF ɨF NPTU DPNNPO TJUF PG NFUBTUBTJT JO DBTF PG .61 JT SFHJPOBM MZNQI OPEFT IPXFWFS UIF QBUJFOU NBZ BMTP QSFTFOU XJUI BEWBODFE EJTFBTF BMCFJU SBSFMZ 2

From the Departments of Dermatology, Venereology, & Leprosy,1 the Department of Radiotherapy,2 and the Department of Surgery,3 R.G. Kar Medical College, 1, Khudiram Bose Sarani, Kolkata-700004, India.

Address for Correspondence: Sudip Kumar Ghosh, MD, DNB, Department of Dermatology, Venereology, & Leprosy, R.G. Kar Medical $PMMFHF ,IVEJSBN #PTF 4BSBOJ ,PMLBUB *OEJB t & NBJM ES@TLHIPTI!ZBIPP DP JO

SKINmed. o

ª 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$

$"4& 456%:

November/December 2012

Figure 1. Multiple, discrete, skin-colored nodules of varying sizes on chest wall and abdomen. The skin overlying some of the nodules is erythematous.

Figure 2. Depigmented patch (measuring 3 cm Ã&#x2014; 3 cm) around a central pigmented macule (4 mm Ã&#x2014; 4 mm).

" IJTUPSZ PG DIBOHF JO UIF DPMPS TIBQF PS TJ[F PG B QSFWJPVTMZ FYJTUJOH QJHNFOUFE MFTJPO PS EF OPWP BQQFBSBODF PG B QJHNFOUFE MFTJPO DBVTFT TVTQJDJPO PG NFMBOPNB *O BCTFODF PG BOZ QJHNFOUFE MFTJPO JU JT EJïDVMU UP NBLF B EJBHOPTJT PG NFMBOPNB 1BUJFOUT XJUI NFUBTUBUJD NBMJHOBOU NFMBOPNB CVU OP PCWJPVT QSJNBSZ UVNPS GSFRVFOUMZ QPTF EJïDVMU EJBHOPTUJD BOE UIFSBQFVUJD QSPCMFNT ɨFTF VOLOPXO QSJNBSZ NFMBOPNBT IBWF B SFQPSUFE JODJEFODF PG UP 3o5 5ZQJDBMMZ UIFSF JT OP IJTUPSZ TVHHFTUJWF PG B QSJNBSZ NFMBOPNB BOE UIF EJBHOPTJT JT NBEF BGUFS CJPQTZ PG BO FOMBSHFE MZNQI OPEF PS SFTFDUJPO PG B WJTDFSBM NFUBTUBTJT .FUBTUBTFT GSPN NFMBOPNB NPTU PGUFO EFWFMPQ BT DVUBOFPVT PS TVCDVUBOFPVT OPEVMFT PS BT MZNQI OPEF NFUBTUBTFT " WBSZJOH QFSDFOUBHF PG DBTFT IBWF TJNVMUBOFPVT WJTDFSBM NFUBTUBTFT BU UIF UJNF PG EJBHOPTJT BT JO PVS DBTF SKINmed. o

Figure 3. Skiagram of the chest (posteroanterior view) showing a rounded opacity in the right apical area.

*O NPTU QBUJFOUT XJUI .61 UIFSF JT FWJEFODF PG B DPNQMFUFMZ SFHSFTTFE QSJNBSZ NFMBOPNB QSFTFOUJOH UZQJDBMMZ BT BO BSFB PG EFQJHNFOUBUJPO PS B IJTUPSZ PG B TVHHFTUJWF MFTJPO XIJDI TQPOUBOFPVTMZ DMFBST 2 ɨF EFQJHNFOUFE QBUDI PO UIF MFGU TIJO JO PVS DBTF NJHIU IBWF CFFO TVDI BO BSFB PG SFTPMWFE NFMBOPNB ɨF PUIFS QPTTJCJMJUZ JO PVS DBTF XBT UIBU UIF BOPSFDUBM MFTJPO DPVME IBWF CFFO UIF QSJNBSZ TJUF PG PSJHJO PG NFUBTUBUJD MFTJPOT IPXFWFS

.FUBTUBUJD .FMBOPNB 'SPN BO 6OLOPXO 1SJNBSZ 4JUF

$"4& 456%:

November/December 2012

Figure 4. Oval to polygonal tumor cells containing melanin pigments (original magnification, hematoxylin-eosin stain, original magnification Ã&#x2014;400).

XF DPVME OPU FMJDJU UIF UFNQPSBM SFMBUJPOTIJQ CFUXFFO UIF DVUBOFPVT MFTJPOT BOE UIF SFDUBM NBTT UP JODSJNJOBUF UIF SFDUBM MFTJPO BT UIF QSJNBSZ POF .61 JT UXJDF BT DPNNPO JO NFO UIBO JO XPNFO XIJDI JT JO DPOTPOBODF XJUI UIF PCTFSWBUJPO UIBU UVNPS SFHSFTTJPO JT NPSF DPNNPOMZ PCTFSWFE JO NFO UIBO JO XPNFO

Figure 5. &YDJTJPO CJPQTZ PG EFQJHNFOUFE NBDVMF PO MFH showed mild hyperkeratosis, proliferation of capillary-sized blood vessels in the dermis (hematoxylin-eosin stain, original magnification Ã&#x2014;100).

*O B TFSJFT DBTFT PG .61 XFSF JEFOUJëFE JO B DPMMFD- IFBE BOE OFDL GFNBMF HFOJUBM USBDU FTPQIBHVT BOPSFDUVN BOE UJWF PG QBUJFOUT XJUI NFMBOPNB 5 /P QSJNBSZ UVNPST XFSF VSJOBSZ USBDU GPVOE CZ QIZTJDBM FYBNJOBUJPO XIJDI JODMVEFE PQIUIBMNPTDPQJD FYBNJOBUJPO ɨF QSPHOPTUJD TJHOJëDBODF PG .. PG VOLOPXO QSJNBSZ PSJHJO ɨF PDDVSSFODF PG .. XJUI OP JEFOUJëBCMF QSJNBSZ MFTJPO NBZ IBT CFFO JOUFSQSFUFE EJêFSFOUMZ CZ WBSJPVT BVUIPST " ZFBS TVS5 CF DBVTFE CZ B WBSJFUZ PG DBVTFT *U XBT QPTUVMBUFE UIBU NFMBOPNB WJWBM SBUF PG XBT OPUFE JO POF TFSJFT *O BOPUIFS TFSJFT POF NBZ BSJTF EF OPWP JO MZNQI OPEFT 5 /FWVT DFMMT IBWF CFFO JEFOUJ- UIJSE PG QBUJFOUT IBE WJTDFSBM NFUBTUBTFT BOE B NFEJBO TVSWJWBM PG ëFE JO MZNQI OPEFT PG QBUJFOUT VOEFSHPJOH TVSHFSZ GPS EJTFBTFT NPOUIT "QQSPYJNBUFMZ UXP UIJSET IBE MZNQI OPEF NFUBTUBTFT

PUIFS UIBO NFMBOPNB *U JT DPODFJWBCMF UIBU NFMBOPNB DPVME BOE B ZFBS TVSWJWBM SBUF PG *O B TFSJFT PG QBUJFOUT BSJTF GSPN UIFTF OFWVT DFMMT SFTVMUJOH JO BQQBSFOU MZNQI OPEF UXP UIJSET PG UIFTF QBUJFOUT IBE WJTDFSBM NFUBTUBTFT BOE UIFJS NFUBTUBTFT XJUI OP PCWJPVT QSJNBSZ .FMBOPNB EFWFMPQJOH JO NFEJBO TVSWJWBM XBT BMTP NPOUIT 1BUJFOUT XJUI MZNQI OPEF NFUBTUBTFT TIPXFE BO VOFYQFDUFEMZ IJHI TVSWJWBM SBUF ZFBS WJTDFSBM PSHBOT PDDVST JOGSFRVFOUMZ 5 SBUF PG 10 "OZ QBUJFOU XJUI EJTUBOU NFUBTUBTFT JT DPOTJE.. JOWPMWJOH UIF HBTUSPJOUFTUJOBM USBDU JT NBJOMZ SFMBUFE UP FSFE TUBHF *7 %JTUBOU NFUBTUBTFT NBZ JODMVEF TLJO PS TPGU UJTTVF NFUBTUBUJD EJTFBTF UIF QSJNBSZ DVUBOFPVT NFMBOPNB NBZ OPU NFUBTUBTFT EJTUBOU GSPN B LOPXO QSJNBSZ TJUF PS WJTDFSBM CPOF CF DMJOJDBMMZ EFUFDUFE 6TVBMMZ BTZNQUPNBUJD TVDI NFUBTUBTFT PS CSBJO NFUBTUBTFT "MM BSF BTTPDJBUFE XJUI B WFSZ QPPS QSPHOPTJT BSF EJBHOPTFE QSFNPSUFN JO UP PG QBUJFOUT *ODJ- XJUI NFEJBO TVSWJWBMT PG UP NPOUIT 11o13 ɨF QSPHOPTJT JT EFODF PG HBTUSPJOUFTUJOBM NFMBOPUJD NFUBTUBTFT GSPN VOLOPXO CFUUFS GPS TLJO BOE TVCDVUBOFPVT UJTTVF NFUBTUBTFT XIJDI BSF QSJNBSZ PSJHJO SBOHFT GSPN UP 9 ɨFTF DBTFT NJHIU DPOTJEFSFE . B UIBO GPS MVOH NFUBTUBTFT . C PS PUIFS EJT SFQSFTFOU NFMBOPNBT QSJNBSJMZ EFSJWFE GSPN UIF BMJNFOUBSZ UBOU NFUBTUBTFT . D

USBDU BT JO PVS QBUJFOU XJUI B EPDVNFOUFE BOPSFDUBM MFTJPO QSFTFOUJOH BMPOH XJUI NFUBTUBUJD TLJO OPEVMFT BOE WJTDFSBM NFUBTUB- ɨFSBQZ GPS NFUBTUBUJD TUBHF *7 NFMBOPNB JT MJNJUFE 3FTFDTFT 1SJNBSZ NVDPTBM NFMBOPNBT BSF SBSF NBJOMZ BSJTJOH JO UIF UJPO PG NFUBTUBUJD MZNQI OPEFT NBZ CFOFëU TPNF QBUJFOUT XIJMF

SKINmed. o

.FUBTUBUJD .FMBOPNB 'SPN BO 6OLOPXO 1SJNBSZ 4JUF

$"4& 456%:

November/December 2012 JO PUIFST JU JT EPOF GPS QBMMJBUJWF SFBTPOT UP BMMFWJBUF QSFTTVSF TZNQUPNT ɨF UIFSBQJFT BQQSPWFE CZ UIF 64 'PPE BOE %SVH "ENJOJTUSBUJPO GPS .. BSF TJOHMF BHFOU EBDBSCB[JOF BOE IJHI EPTF JOUFSMFVLJO #PUI PG UIFTF UIFSBQJFT MFBWF NVDI UP CF EFTJSFE 4JOHMF BHFOU EBDBSCB[JOF QSPEVDFT BO PWFSBMM SFTQPOTF SBUF PG UP BU CFTU XJUI WFSZ GFX DPNQMFUF SFTQPOEFST 0CKFDUJWF SFNJTTJPOT NPSF UIBO SFEVDUJPO JO UVNPS NBTT

BSF BDIJFWFE JO UP PG QBUJFOUT $IFNPUIFSBQZ DBO MFBE UP SFHSFTTJPO PG UVNPST BOE B SFEVDUJPO JO UVNPS SFMBUFE TZNQUPNT )JHI EPTF JOUFSMFVLJO JT BTTPDJBUFE XJUI B TJNJMBS PWFSBMM SFTQPOTF SBUF CVU JO UIF BQQSPYJNBUFMZ PG QBUJFOUT XIP BDIJFWF B DPNQMFUF SFTQPOTF JU TFFNT UP CF EVSBCMF 15 ɨF DPNCJOBUJPO PG NVMUJQMF DIFNPUIFSBQFVUJD BHFOUT QPMZDIFNPUIFSBQZ PS PG NVMUJQMF DIFNPUIFSBQFVUJD BHFOUT BOE DZUPLJOFT QPMZDIFNPJNNVOPUIFSBQZ NBZ BDIJFWF IJHIFS SFNJTTJPO SBUFT UIBO NPOPUIFSBQZ o CVU JU EJE OPU JNQSPWF PWFSBMM TVSWJWBM o ɨF DMJOJDBM DPVSTF PG QBUJFOUT XJUI .61 JT DPNQBSBCMF UP UIBU PG QBUJFOUT XJUI QSJNBSZ DVUBOFPVT NFMBOPNB PG UIF TBNF DMJOJDBM TUBHFT PG UIF EJTFBTF 19

5

Das Gupta T, Bowden L, Berg JW. Malignant melanoma of unknown primary origin. Surg Gynecol Obstet. 1963;117:341â&#x20AC;&#x201C;345.

6

+PIOTPO 85 )FMXJH &# #FOJHO OFWVT DFMMT JO UIF DBQTVMF PG MZNQI nodes. Cancer. 1969;23:747.

7

,BEJWBS 5' 7BOFL 78 ,SJTIOBO &6 1SJNBSZ NBMJHOBOU NFMBOPNB PG UIF small bowel: a case study. Am Surg. 1992;58:418â&#x20AC;&#x201C;422.

8

"WJUBM 4 3PNBHVFSB 3- 4BOET - .BSDIFUUJ ' )FMMJOHFS .% 1SJNBSZ malignant melanoma of the right colon. Am Surg. 2004;70:649â&#x20AC;&#x201C;651.

9

.BOPVSBT " (FOFU[BLJT . -BHPVEJBOBLJT & FU BM .BMJHOBOU gastrointestinal melanomas of unknown origin: should it be considered primary? World J Gastroenterol. 2007;13:4027â&#x20AC;&#x201C;4029.

CONCLUSIONS

15 "ULJOT .# -PU[F .5 %VUDIFS +1 FU BM )JHI EPTF SFDPNCJOBOU JOUFSleukin 2 therapy for patients with metastatic melanoma: analysis of 270 patients treated between 1985 and 1993. J Clin Oncol. 1999;17: 2105â&#x20AC;&#x201C;2116.

0VS DBTF JMMVTUSBUFT UIF JNQPSUBODF PG JODMVTJPO PG .. JO UIF EJêFSFOUJBM EJBHOPTFT PG TLJO DPMPSFE OPEVMFT BOE PG B EFUBJMFE DMJOJDBM MBCPSBUPSZ JNNVOPIJTUPMPHJD BOE SBEJPMPHJD XPSLVQ GPS BDDVSBUF EJBHOPTJT PG TVDI DBTFT REFERENCES 1

.FMBOPNB PG UIF 4LJO *O &EHF 4# #ZSE %3 $PNQUPO $$ FU BM eds. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer; 2010:325.

2

Bishop JAN. Lentigos, melanocytic naevi and melanoma. In: Burns T, Breathnach S, Cox N, Griffiths C, eds. Rookâ&#x20AC;&#x2122;s Textbook of Dermatology.

8th ed. Oxford: Wiley-Blackwell; 2010:54.1â&#x20AC;&#x201C;54.57

3

(JVMJBOP "& .PTFMFZ )4 .PSUPO %- $MJOJDBM BTQFDUT PG VOLOPXO primary melanoma. Ann Surg. 1980;191:98â&#x20AC;&#x201C;104.

4

#BBC () .D#SJEF $. .BMJHOBOU NFMBOPNB UIF QBUJFOU XJUI BO unknown site of primary origin. Arch Surg. 1975;110:896â&#x20AC;&#x201C;900.

10 $IBOH 1 ,OBQQFS 8) .FUBTUBUJD NFMBOPNB PG VOLOPXO QSJNBSZ Cancer. 1982;49:1106â&#x20AC;&#x201C;1111.

11 Balch CM, Buzaid AC, Soong SJ, et al. Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma. J Clin Oncol. 2001;19:3635â&#x20AC;&#x201C;3648.

12 #BMDI $. 4PPOH 4+ (FSTIFOXBME +& FU BM 1SPHOPTUJD GBDUPST analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system. J Clin Oncol.

2001;19:3622.

13 .BOPMB + "ULJOT . *CSBIJN + ,JSLXPPE + 1SPHOPTUJD GBDUPST JO NFUBTUBUJD NFMBOPNB B QPPMFE BOBMZTJT PG &BTUFSO $PPQFSBUJWF 0ODPMPHZ Group trials. J Clin Oncol. 2000;18:3782.

14 &HHFSNPOU ". ,JSLXPPE +. 3F FWBMVBUJOH UIF SPMF PG EBDBSCB[JOF JO metastatic melanoma: what have we learned in 30 years? Eur J Cancer.

2004;40:1825â&#x20AC;&#x201C;1836.

16 /BTIBO % .Ã MMFS .- (SBCCF 4 8VTUMJDI 4 &OL " 4ZTUFNJD UIFSBQZ of disseminated malignant melanoma: an evidence-based overview of the state-of-the-art in daily routine. J Eur Acad Dermatol Venereol.

2007;21:1305â&#x20AC;&#x201C;1318.

17 #BKFUUB & %J -FP " ;BNQJOP .( FU BM .VMUJDFOUFS SBOEPNJ[FE USJBM PG dacarbazine alone or in combination with two different doses and schedules of interferon alfa-2a in the treatment of advanced melanoma. J Clin Oncol. 1994;12:806â&#x20AC;&#x201C;811.

18 'BMLTPO $* *CSBIJN + ,JSLXPPE +. FU BM 1IBTF *** USJBM PG EBDBSCB[JOF versus dacarbazine with interferon alpha-2b versus dacarbazine with tamoxifen versus dacarbazine with interferon alpha-2b and tamoxifen in QBUJFOUT XJUI NFUBTUBUJD NBMJHOBOU NFMBOPNB BO &BTUFSO $PPQFSBUJWF Oncology Group study. J Clin Oncol. 1998;16:1743â&#x20AC;&#x201C;1751.

19 4DIMBHFOIBVGG # 4USPFCFM 8 &MMXBOHFS 6 FU BM .FUBTUBUJD NFMBOPNB PG unknown primary origin shows prognostic similarities to regional metastatic melanoma: recommendations for initial staging examinations.

Cancer. 1997;80:60â&#x20AC;&#x201C;65.

FORMULARY OF DR. GEORGE C. ANDREWS TOOTH POWDER 1SFDJQ $BMD $BSC

3 i

1PXEFSFE $BTUJMMF TPBQ

3 i

Sod. perb.

3 ii

Ol. of Gaultheria

mx xxv

Submitted by Douglas D. Altchek, MD, New York, NY

SKINmed. o

399

.FUBTUBUJD .FMBOPNB 'SPN BO 6OLOPXO 1SJNBSZ 4JUF

Wailea Marriott, Maui | January 16-18, 2013

Register Now for the 2nd Annual Conference!

Exclusively for Dermatologic Nurse Practitioners + Physician Assistants Refresh & Renew : January 16-18, 2013 at the Wailea Marriott, Maui Join us for the 2nd annual ACMD:NP+PA course which is offered exclusively for nurse practitioners and physician assistants who already provide dermatologic healthcare. Join our world class faculty who combine basic science and clinical medicine to keep you informed of the latest developments in wide variety of clinical topics relevant to your daily practice. Our sessions are highly interactive and case based. You will learn some alternate ways to handle common problems and emerging methods to tackle those tough cases.

Presentations are geared toward providing pearls you can put to use your ďŹ rst day back at work!

Faculty COURSE DIRECTOR

FACULTY

George Martin, MD

L. Aldredge, MSN, RN, ANP-BC Neal Bhatia, MD Andrew Blauvelt, MD Joel Cohen, MD Gordon Day, R. Ph., PA-C Sheila Fallon-Friedlander, MD Keri Holyoak, PA-C, MPH Arthur Kavanaugh, MD

Suzanne Kilmer, MD Ashfaq Marghoob, MD Ted Rosen, MD Bruce Stober, MD, PhD James Treat, MD Hensin Tsao, MD, PhD Melodie Young, MSN, ANP-c John Zone, MD

Content #UTANEOUS /NCOLOGY 0EDIATRIC $ERMATOLOGY s !CNE 2OSACEA 0SORIASIS s %CZEMA s !GING 3KIN #OSMECEUTICALS s )NFECTIOUS $ISEASES s 3KIN 3URGERY s .EW $RUGS AND 4HERAPIES s (OT 4OPICS IN $ERMATOLOGY s 7ORKSHOPS AND PRODUCT THEATERS s #LINICAL REVIEWS AND UPDATES ON LASERS TOXINS DERMAL l LLERS AND THE MANAGEMENT OF VARICOSE VEINS

Information + Registration For more details, visit our website at:

acmd-derm-hawaii.com

Scan the QR tag for a direct link to the AMCD: NP+PA website.

7PMVNF t *TTVF

November/December 2012

BOOK REVIEW Jennifer L. Parish, MD, Section Editor

ACS(I) Textbook on Cutaneous and Aesthetic Surgery Venkataram M. Textbook on Cutaneous and Aesthetic Surgery. New Delhi, Jaypee Brothers Medical Publishers (P) Ltd; 2012: 952p. $150 1SPDFEVSBM BOE DPTNFUJD EFSNBUPMPHZ IBT CFDPNF B GVOEBNFOUBM BTQFDU PG DVUBOFPVT NFEJDJOF 1 ɨF TQFDJBMUZ IBT SBQJEMZ BEWBODFE TJODF UIF mSTU IBJS USBOTQMBOU JO CZ /PSNBO 0SFOUSFJDI .% 2 BOE UIF EFWFMPQNFOU PG UIF mSTU .PIT GFMMPXTIJQ JO CZ 1FSSZ 3PCJOT .% 3 CPUI PG /FX :PSL The Textbook on Cutaneous and Aesthetic Surgery DPNQJMFE CZ UIF "TTPDJBUJPO PG $VUBOFPVT 4VSHFPOT PG *OEJB JT SFNBSLBCMF JO JUT FYUFOTJWF BOE DPNQSFIFOTJWF SFWJFX PG UIJT WBTU BOE QSPHSFTTJWF mFME ɨF FEJUPS PG UIF CPPL UIF QSFTJEFOU PG UIF "$4 * BOE QBTU FEJUPS PG Journal of Cutaneous and Aesthetic Surgery JOWJUFE BVUIPST XIP BSF NFNCFST PG UIF 4PDJFUZ UP QBSUJDJQBUF ɨF DBSFGVM BUUFOUJPO UIBU UIF FEJUPS UPPL JO EFTJHOJOH UIF CPPL BOE CSJOHJOH UIF CPPL UP GSVJUJPO NBLFT JU B XPOEFSGVM BEEJUJPO UP UIF TQFDJBMJTU T MJCSBSZ ɨF DIBQUFST FODPNQBTT CPUI TVSHJDBM BOE DPTNFUJD EFSNBUPMPHZ ɨF UPQJDT BSF CSPBE BOE SBOHF GSPN UIF TVSHJDBM NBOBHFNFOU PG BDOF TDBST BOE QFSJPSCJUBM SFKVWFOBUJPO UP UJQT GPS CFHJOOFST BOE TVQQMJFST EFUBJMT ɨF PSHBOJ[BUJPO PG FBDI DIBQUFS JT VOJGPSN XJUI LFZ NFTTBHFT BOE QSBDUJDBM UJQT IJHIMJHIUFE XJUI UIF SFGFSFODFT CFJOH DVSSFOU BOE JODMVTJWF ɨF DPMPS JMMVTUSBUJPOT BSF TQFDUBDVMBS BT EFNPOTUSBUFE JO UIF DIBQUFST PO Local Anesthesia, Cosmetic Uses of Botulinum Toxin BOE Wound Management and Dressings ɨF mHVSFT EFNPOTUSBUJOH BQQSPQSJBUF CBOEBHJOH PG EJÄ&#x160;FSFOU XPVOE TJUFT FYFNQMJmFT UIF

BUUFOUJPO UP EFUBJM ɨF DMBSJUZ BOE EFUBJM PG UIF JNBHFT BOE mHVSFT NBLF UIF CPPL JOWBMVBCMF 0OF PG UIF IJHIMJHIUT PG UIF CPPL JT UIF TQFDJBM GPDVT PO iCSPXO TLJO w XIJDI JT MBDLJOH JO UIF MJUFSBUVSF ɨJT NBLFT JU QBSUJDVMBSMZ VTFGVM UP UIF TQFDJBMJTU XIP USFBUT QBUJFOUT PG DPMPS ɨF DPOUSJCVUPST IBWF QSPWJEFE QFSUJOFOU UJQT GPS BWPJEJOH QJUGBMMT JO UIF USFBUNFOU PG CSPXO TLJO BT FYFNQMJmFE JO UIF SFWJFX PG WJUJMJHP ɨFSF BSF DIBQUFST PO UIJT TVCKFDU SBOHJOH GSPN Overview of Vitiligo Surgery UP Complications of Vitiligo Surgery ɨF UFYUCPPL FNQIBTJ[FT UIBU UIF QIZTJDJBO NVTU SFDPHOJ[F UIF EJÄ&#x160;FSFODFT CFUXFFO TLJO UZQFT UP FÄ&#x160;FDUJWFMZ USFBU QBUJFOUT QBSUJDVMBSMZ UIPTF GSPN UIF *OEJBO TVCDPOUJOFOU ɨF DIBQUFST PO Circumcision BOE Leprosy Surgery EFNPOTUSBUF UIF CSPBE TDPQF PG UIJT UFYUCPPL "MUIPVHI NPTU EFSNBUPMPHJTUT XJMM OPU QFSGPSN UIFTF QSPDFEVSFT JU QSPWJEFT UIF QIZTJDJBO XJUI BO FYDFQUJPOBM PWFSWJFX PG UIFTF TVSHFSJFT ɨF TFDUJPO PO SFDPOTUSVDUJWF TVSHFSZ GPS EFGPSNJUJFT TVDI BT MBHPQIUIBMPNPT EFQSFTTFE OPTF BOE GPPU ESPQ DBVTFE CZ MFQSPTZ JT PG QBSUJDVMBS JOUFSFTU ɨF EJTDVTTJPO BOE JNBHFT JO UIFTF DIBQUFST FYFNQMJGZ UIF CSPBE TDPQF PG UIJT CPPL BOE UIF BUUFOUJPO UP EFUBJM ɨJT UFYUCPPL NFFUT UIF OFFE PG B HMPCBM BVEJFODF *U JT BO FYFNQMBSZ SFGFSFODF CPPL GPS CPUI UIF CFHJOOJOH BOE TFBTPOFE EFSNBUPMPHJTU *U BMSFBEZ PDDVQJFT BO JNQPSUBOU QMBDF PO NZ MJCSBSZ TIFMG REFERENCES 1

Coleman WP 3rd, Hanke CW, Orentreich N, et al. A history of dermatologic surgery in the United States. Dermatol Surg. 2000;26:5â&#x20AC;&#x201C;11.

2

Hanke CW. Key moments in the history of dermatologic surgery (19522000). Semin Cutan Med Surg. 2012;31:52â&#x20AC;&#x201C;59.

3

Robins P. 44 years in dermatologic surgery: a retrospective. J Drugs Dermatol. 2009;8:519â&#x20AC;&#x201C;525.

Reviewed by Jennifer L. Parish, MD Assistant Clinical Professor of Dermatology and Cutaneous Biology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, and Assistant Professor of Dermatology, Tulane University School of Medicine, New Orleans, LA t & NBJM KFOEFSN!ZBIPP DPN

SKINmed. 2012;10:401

401

ÂŞ 1VMTF .BSLFUJOH $PNNVOJDBUJPOT --$

Edward L. Keyes Resident Contest for Outstanding Case Reports To be awarded for the best Case Report submitted by a physician in training (resident, fellow, or registrar) for presentation at the 9th World Congress of the International Academy of Cosmetic Dermatology in Athens, Greece, June 27–30, 2013.

We invite you to submit original Case Reports that reflect the presentation of new ideas and original observations to the Academy membership and other attendees of the Congress. The author whose abstract receives the highest score during the review process will be awarded a scholarship by the IACD to present the full paper at the 9th World Congress of the International Academy of Cosmetic Dermatology in Athens, Greece, June 27–30, 2013.

Abstracts should be submitted before noon, CDT, February 15, 2013 via e-mail and should be no longer than 2,500 characters including spacing. Previously published material should not be submitted; however, it is acceptable if the case report has been submitted for publication but not actually published as of February 15, 2013. Applicants should not submit abstracts that include material that has been previously presented. Applications will be graded based upon the educational value of the abstract and the extent to which it presents new and significant work. The Review Committee strongly recommends that abstracts have an organized, coherent, well-thought-out, and complete presentation.

All applicants will receive e-mail notice of the Resident Case Report Review Committee’s decision by April 1, 2013.

Vesna Petronic-Rosic, MD, MSc Chair, Resident Contest Committee Associate Professor Ambulatory Practice Medical Director University of Chicago Pritzker School of Medicine, Section of Dermatology Tel: +1.773.702.6559 vrosic@medicine.bsd.uchicago.edu

SORILUX

™

BRIEF SUMMARY The enlarged fontanelles are most likely due to calcipotriene’s (calcipotriene) Foam, 0.005% ribs. effect upon calcium metabolism. The maternal and fetal no-effect

The following is a brief summary only; see full prescribing information for complete product information.

exposures in the rat (43.2 mcg/m2/d) and rabbit (17.6 mcg/m2/d) studies are approximately equal to the expected human systemic exposure level (18.5 mcg/m2/d) from dermal application.

INDICATIONS AND USAGE

Nursing Mothers

SORILUX Foam is indicated for the topical treatment of plaque psoriasis in patients aged 18 years and older.

It is not known whether calcipotriene is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when SORILUX Foam is administered to a nursing woman.

CONTRAINDICATIONS

Pediatric Use

SORILUX Foam should not be used by patients with known hypercalcemia.

Safety and effectiveness of SORILUX Foam in pediatric patients less than 18 years of age have not been established.

WARNINGS AND PRECAUTIONS

Geriatric Use

Flammability The propellant in SORILUX is flammable. Instruct the patient to avoid fire, flame, and/or smoking during and immediately following application.

Effects on Calcium Metabolism Transient, rapidly reversible elevation of serum calcium has occurred with use of calcipotriene. If elevation in serum calcium outside the normal range should occur, discontinue treatment until normal calcium levels are restored.

Ultraviolet Light Exposure Instruct the patient to avoid excessive exposure of the treated areas to either natural or artificial sunlight, including tanning booths and sun lamps. Physicians may wish to limit or avoid use of phototherapy in patients who use SORILUX Foam. [See Nonclinical Toxicology (13.1).]

Unevaluated Uses SORILUX Foam has not been evaluated in patients with erythrodermic, exfoliative, or pustular psoriasis.

ADVERSE REACTIONS Clinical Trials Experience Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in clinical practice.

SORILUX Foam was studied in 3-vehicle controlled trials. Seven hundred and thirty-one subjects with plaque psoriasis, including 473 exposed to SORILUX Foam were treated twice daily for 8 weeks.

Adverse events reported in greater than 1% of subjects and in a higher rate in subjects treated with SORILUX Foam compared to vehicle were limited to erythema.

DRUG INTERACTIONS

No drug interaction studies were conducted with SORILUX Foam.

USE IN SPECIFIC POPULATIONS Pregnancy Teratogenic Effects, Pregnancy Category C: There are no adequate and well-controlled studies in pregnant women.

Therefore, SORILUX Foam should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Studies of teratogenicity were done by the oral route where bioavailability is expected to be approximately 40–60% of the administered dose. Increased rabbit maternal and fetal toxicity was noted at 12 mcg/kg/d (132 mcg/m2/d). Rabbits administered 36 mcg/kg/d (396 mcg/m2/d) resulted in fetuses with a significant increase in the incidences of incomplete ossification of pubic bones and forelimb phalanges. In a rat study, doses of 54 mcg/kg/d (318 mcg/m2/d) resulted in a significantly higher incidence of skeletal abnormalities consisting primarily of enlarged fontanelles and extra

Clinical studies of SORILUX Foam did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients.

OVERDOSAGE

Topically applied calcipotriene can be absorbed in sufficient amounts to produce systemic effects. Elevated serum calcium has been observed with use of topical calcipotriene. [See Warnings and Precautions (5.2).]

NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Calcipotriene topically administered to mice for up to 24 months at dose levels of 3, 10, or 30 mcg /kg/d (corresponding to 9, 30, or 90 mcg /m2/d) showed no significant changes in tumor incidence when compared to controls. In a study in which albino hairless mice were exposed to both UVR and topically applied calcipotriene, a reduction in the time required for UVR to induce the formation of skin tumors was observed (statistically significant in males only), suggesting that calcipotriene may enhance the effect of UVR to induce skin tumors.

[See Warnings and Precautions (5.3).]

The genotoxic potential of calcipotriene was evaluated in an Ames assay, a mouse lymphoma TK locus assay, a human lymphocyte chromosome aberration assay, and a mouse micronucleus assay. All assay results were negative.

Studies in rats at doses up to 54 mcg /kg/d (318 mcg /m2/d) of calcipotriene indicated no impairment of fertility or general reproductive performance.

PATIENT COUNSELING INFORMATION

[See FDA-approved Patient Labeling in full Prescribing Information].

The patient should be instructed as follows: t %o not place SORILUX Foam in the refrigerator or freezer. t "WPJd excessive exposure of the treated areas to either natural or artificial sunlight, including tanning beds and sun lamps. t *f SORILUX Foam gets in or near their eyes, to rinse thoroughly with water. t Talk to their doctor if their skin does not improve after treatmen with SORILUX Foam for 8 weeks. t Wash their hands after applying SORILUX Foam unless their hands are the affected site t "WPJd fire, flame, or smoking during and immediately following application since SORILUX Foam is flammable.

SOR:4BRS

SORILUX is a trademark of Stiefel Laboratories, Inc. ©2011 Stiefel Laboratories, Inc. April 2011

Indicated for the topical treatment of plaque psoriasis in patients aged 18 years or older

My doctor has prescribed SORILUX Foam for my plaque psoriasis...

My Life. My Treatment.

The only vitamin D3 analog treatment in a topical foam formulation VersaFoam®-AEF: Aqueous-based Emulsion Formulation Free of ethanol, preservatives, parabens, and fragrance SORILUX Foam, with VersaFoam technology, penetrates the skin barrier to deliver the molecule into the epidermis and dermis1 The contribution to efficacy of individual components of the vehicle has not been established.

Important Safety Information for SORILUX Foam SORILUX Foam should not be used by patients with known hypercalcemia The propellant in SORILUX Foam is flammable. Instruct the patient to avoid fire, flame, and/or smoking during and immediately following application Transient, rapidly reversible elevation of serum calcium has occurred with use of calcipotriene. If elevation in serum calcium outside the normal range should occur, discontinue treatment until normal calcium levels are restored Instruct the patient to avoid excessive exposure of the treated areas to either natural or artificial sunlight, including tanning booths and sun lamps. Physicians may wish to limit or avoid use of phototherapy in patients who use SORILUX Foam SORILUX Foam has not been evaluated in patients with erythrodermic, exfoliative, or pustular psoriasis

Adverse events reported in greater than 1% of subjects and in a higher rate in subjects treated with SORILUX Foam compared with vehicle were limited to erythema SORILUX Foam should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus It is not known whether calcipotriene is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when SORILUX Foam is administered to a nursing woman Safety and effectiveness of SORILUX Foam in pediatric patients less than 18 years of age have not been established SORILUX Foam is not for oral, ophthalmic, or intravaginal use

Please see Brief Summary of Prescribing Information on the previous page.

Reference: 1. Data on file, Stiefel Laboratories, Inc. SORILUX is a trademark and VersaFoam is a registered trademark of Stiefel Laboratories, Inc. ©2012 Stiefel Laboratories, Inc. All rights reserved. Printed in USA. SLX001R0 March 2012