Nov. / Dec., 2012 by jo-ann kalaka-Adams

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

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

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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

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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

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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 XIJÄ&#x152;F 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;63:67â&#x20AC;&#x201C;70. 3 Twain M. A Connecticut Yankee in King Arthurâ&#x20AC;&#x2122;s Court. 1889. UJNFT UIF BEWFOU PG IBJS USBOTQMBOUT BOE UIF VTF PG UPQJDBM NJONewÂ York, NY. http://www.twainquotes.com/Redheads.html Accessed PYJEBM BOE PSBM mOBTUFSJEF IBWF BEESFTTFE UIF DPODFSOT PG SFDFESeptemberÂ 23, 2012. JOH IBJSMJOFT 4 Olson K. Dress and the Roman Women: Self-Presentation and Society. London, England: Routledge; 2008:71.

Iâ&#x20AC;&#x2122;m not really bald, Iâ&#x20AC;&#x2122;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 InďŹ&#x201A;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

Olson K. Dress and the Roman Women: Self-Presentation and Society. London, England: Routledge; 2008:74.

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

Corson R. Fashions in Hair: The First Five Thousand Years. 8th ed. London, England: Peter Owen Limited; 2001:21.

Latham R, Matthews WG. The Diary of Samuel Pepys: Volume X - Companion. London, England: Harper Collins; 2010:10â&#x20AC;&#x201C;100.

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.

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Volume 10 • Issue 6

COMMENTARY

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

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

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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.

Schweiger E, Boychenko O, Bernstein R. Update on the pathogenesis, genetics and medical treatment of patterned hair loss. J Drugs Dermatol. 2010;9:1412.

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.

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

REFERENCES

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.

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.

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.

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

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.

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.

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7PMVNF t *TTVF

November/December 2012

COMMENTARY

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

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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

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

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diagnostic value of striae. J Am Acad Dermatol. 201;64: 290â&#x20AC;&#x201C;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 ĂĽCSPCMBTUT FNCFEEFE JO DPMMBHFO MBUtices. Arch Dermatol Res. 2005;297:10â&#x20AC;&#x201C;17.

Agache P. Mechanical factors in striae distensae. In: Morettig ( 3FCPSB " FET Stria Distensae. Milan, Italy: Brocades; 1976: 87â&#x20AC;&#x201C;96.

8BUTPO 3& 1BSSZ &+ )VNQISJFT +% FU BM 'JCSJMMJO NJDSPĂĽCSJMT BSF SFEVDFE JO TLJO FYIJCJUJOH TUSJBF EJTUFOTBF Bri Dermatol J. 1998;138:931â&#x20AC;&#x201C;937.

.JMFXJD[ %. 6SCĂ&#x2C6;O ; #PZE $ (FOFUJD EJTPSEFST PG UIF FMBTUJD ĂĽCFS TZTUFN Matrix Biol. 2000;19:471â&#x20AC;&#x201C;480.

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

3PCFSUTPO * +FOTFO 4 )BOEGPSE 1 5# EPNBJO QSPUFJOT FWPMVUJPOBSZ JOTJHIUT JOUP UIF NVMUJGBDFUFE SPMFT PG ĂĽCSJMMJOT BOE -5#1T Biochem J. 2010;433:263â&#x20AC;&#x201C;276.

3BHIVOBUI . 6OTĂ&#x161;ME $ ,VCJUTDIFDL 6 5IF DVUBOFPVT NJDSPĂĽCSJMMBS BQQBSBUVT DPOUBJOT MBUFOU USBOTGPSNJOH HSPXUI GBDUPS CFUB CJOEJOH QSPUFJO -5#1 BOE JT B SFQPTJUPSZ GPS MBUFOU 5(' CFUB J Invest Dermatol. 1998;111:559â&#x20AC;&#x201C;564.

0MJWJFSJ + 4NBMEPOF 4 3BNJSF[ ' 'JCSJMMJO BTTFNCMJFT FYUSBDFMMVMBS EFUFSNJOBOUT PG UJTTVF GPSNBUJPO BOE ĂĽCSPTJT Fibrogenesis Tissue Repair. 2010;3:24â&#x20AC;&#x201C;31.

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;13:150â&#x20AC;&#x201C;156.

10 #BSOFUU $1 $IJUBZBU % #SBEMFZ 5+ 8BOH : )JOFL " %FYBNFUIBTPOF OPSNBMJ[FT BCFSSBOU FMBTUJD ĂĽCFS QSPEVDUJPO BOE DPMMBHFO TFDSFUJPO CZ -PFZT %JFU[ TZOESPNF ĂĽCSPCMBTUT B QPTTJCMF treatment? Eur J Hum Genet. 2011;19:624â&#x20AC;&#x201C;633. 11 8BUTPO 3& $SBWFO /. ,BOH 4 FU BM " TIPSU UFSN TDSFFOJOH QSPUPDPM VTJOH ĂĽCSJMMJO BT B SFQPSUFS NPMFDVMF GPS QIPUPBHJOH repair agents. J Invest Dermatol. 2001;116:672â&#x20AC;&#x201C;678. 12 ,JTTJO &: -FNBJSF 3 ,PSO +) -BGZBUJT 3 5SBOTGPSNJOH HSPXUI factor Î˛ JOEVDFT ĂĽCSPCMBTU ĂĽCSJMJO NBUSJY GPSNBUJPO Arthritis Rheum. 2002;46:3000-3009. 13 )JSBJ . )PSJHVDIJ . 0ICBZBTIJ 5 FU BM -BUFOU 5(' Î˛ CJEJOH QSPUFJO CJOET UP %"/$& ĂĽCVMJO BOE SFHVMBUFT FMBTUJD ĂĽCFS BTTFNCMZ EMBO J. 2007;26:3283â&#x20AC;&#x201C;3295. 14 /BLBNVSB 5 -P[BOP 13 *LFEB : FU BM 'JCVMJO %"/$& JT essential for elastogenesis in vivo. Nature. 2002;417:171â&#x20AC;&#x201C;175. 15 :BOBHJTBXB ) %BWJT &$ 4UBSDIFS #$ FU BM 'JCVMJO JT BO FMBTUJO CJEJOH QSPUFJO FTTFOUJBM GPS FMBTUJD ĂĽCSF EFWFMPQNFOU JO WJWP Nature. 2002;415:168â&#x20AC;&#x201C;171.

VINTAGE LABEL

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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

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

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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

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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? ÂŁ5 min_______ 6â&#x20AC;&#x201C;10 min________ 11â&#x20AC;&#x201C;20 min________ 21â&#x20AC;&#x201C;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________

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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

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November/December 2012

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

AFRICAN CAUCASIAN AMERICAN

Actual Wash Hair Times Per Week

n=59

P VALUE

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HAIR ATTRIBUTES

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0 0.0

1.0

2.0

3.0 4.0 Predicted Value

5.0

6.0

7.0

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

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6 Actual Wash Hair Times Per Week

n=37

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1.0

2.0

3.0 4.0 Predicted Value

5.0

6.0

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

$IFNJDBM 1SPDFTT 3FMBYFS

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$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

Actual Wash Hair Times Per Week

"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

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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;25:183â&#x20AC;&#x201C;188.

)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;70:327â&#x20AC;&#x201C;332.

(SJNBMU 3 " QSBDUJDBM HVJEF UP TDBMQ EJTPSEFST J Investig Dermatol Symp Proc. 2007;12:10â&#x20AC;&#x201C;14.

McMichael AJ. Hair and scalp disorders in ethnic populations. Dermatol Clin. 2003;2:629â&#x20AC;&#x201C;644.

7 8

2VJOO $3 2VJOO 5. ,FMMZ "1 )BJS DBSF QSBDUJDFT JO "GSJDBO "NFSJDBO women. Cutis. 2003;72:280â&#x20AC;&#x201C;282, 285â&#x20AC;&#x201C;289. %F MB .FUUSJF 3 4BJOU -Ă?HFS % -PVTTPVBSO ( FU BM 4IBQF WBSJBCJMJUZ BOE classification of human hair: a worldwide approach. Hum Biol. 2007;79:265â&#x20AC;&#x201C;281. -PVTTPVBSO ( (BSDFM "- -P[BOP * FU BM 8PSMEXJEF EJWFSTJUZ PG IBJS DVSMJ ness: a new method of assessment. Int J Dermatol. 2007;46 suppl 1:2â&#x20AC;&#x201C;6. ,BKJVSB : 8BUBOBCF 4 *UPV 5 FU BM 4USVDUVSBM BOBMZTJT PG IVNBO hair single fibres by scanning microbeam SAXS. J Struct Biol. 2006; 155:438â&#x20AC;&#x201C;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;64:253â&#x20AC;&#x201C;262.

VINTAGE LABEL

Courtesy of BuyEnlarge, Philadelphia, PA SKINmed. o

)BJS $BSF 1SBDUJDFT JO %JWFSTF 1PQVMBUJPOT

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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

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

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Table II. General Population Characterization

ACETYLCYSTEINE

PLACEBO

PATIENTS, NO.

PERCENTAGES

PATIENTS, NO.

PERCENTAGES

<13–18

19–21

"HF Z

.FBO

4FY .FO

8PNFO

8IJUF

#MBDL

0UIFS

3BDF

%VSBUJPO PG BDOF Z /PU TUBUFE

.FBO

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

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

MEN

WOMEN

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

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

É¨F 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

É¨F QSFDJTF NFDIBOJTN PG BDUJPO PG UPQJDBM BDFUZMDZTUFJOF JO BDOF SFNBJOT UP CF JOWFTUJHBUFE É¨F 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 É¨F 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 É¨JT 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 É¨F DMPTFE DPNFEP JT FOUJSFMZ DPW FSFE CZ BO BMNPTU JOUBDU FQJUIFMJBM MBZFS BOE IBT B NJDSPTDPQJD REFERENCES QPSF É¨F PQFO DPNFEP EJTQMBZT B EJTDPOUJOVPVT FQJUIFMJBM MBZFS 1 Acetylcysteine. In: Osol A, Pratt R, eds. The United States Dis JOUFSSVQUFE CZ B EJMBUFE PQFOJOH É¨F 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 É¨FTF 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 É¨JT 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.

"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.

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

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

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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

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REVIEW

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

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Table. Chemical Formulae of Green Tea Compounds

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VINTAGE LABEL

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

355

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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

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"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

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CONTRAINDICATIONS/WARNINGS

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OINTMENTS

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3&7*&8

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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

" 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.

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.

.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.

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.

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

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

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.

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.

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 Î¼g/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

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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

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

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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

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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

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'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

.FMBOPNB SFNPWBM

&ZFMJE TVSHFSZ

#BTBM DFMM DBSDJOPNB SFNPWBM

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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

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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

/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

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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.

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REFERENCES 1

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

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

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

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November/December 2012

CORE CURRICULUM Virendra N. Sehgal, MD, Section Editor

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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

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

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November/December 2012

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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.

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DRUG-DEPENDENT PEMPHIGUS

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1BUIPQIZTJPMPHZ PG "EWFSTF $VUBOFPVT %SVH 3FBDUJPOT

$03& $633*$6-6.

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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

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$03& $633*$6-6.

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ACNEIFORM ERUPTION

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

SKINmed. 2012;10:373–383

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379

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

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

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

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

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.

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

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.

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.

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.

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, BeÂ´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

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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.

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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.

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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)

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

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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.

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

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.

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

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”

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.

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

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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

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

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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

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

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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

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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

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

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.JDBMJ ( -JOUIJDVN , )BO / 8FTU %1 *ODSFBTFE SJTL PG FSZUIFNB NVMtiforme major with combination anticonvulsant and radiation therapies. Pharmacotherapy. 1999;19:223โ 227.

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

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

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.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.

5POOFTFO .( 4PUFS /" &SZUIFNB NVMUJGPSNF J Am Acad Dermatol. 1979;1:357โ 364.

"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.

"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.

#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

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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

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CASE STUDY

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).

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

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-

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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.

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.

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

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

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

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

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.

George IA, Mathews MS, Karthik R, et al. Fatal cerebral abscess caused by Cladophialophora bantiana. J Assoc Physicians India. 2008;56: 470–472.

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

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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

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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).

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

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

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

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

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

.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 EJÃªFSFOUJBM 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.

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

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

#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.

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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.

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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 É¨F 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 É¨F 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 É¨F 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 É¨F DIBQUFST FODPNQBTT CPUI TVSHJDBM BOE DPTNFUJD EFSNBUPMPHZ É¨F UPQJDT BSF CSPBE BOE SBOHF GSPN UIF TVSHJDBM NBOBHFNFOU PG BDOF TDBST BOE QFSJPSCJUBM SFKVWFOBUJPO UP UJQT GPS CFHJOOFST BOE TVQQMJFST EFUBJMT É¨F PSHBOJ[BUJPO PG FBDI DIBQUFS JT VOJGPSN XJUI LFZ NFTTBHFT BOE QSBDUJDBM UJQT IJHIMJHIUFE XJUI UIF SFGFSFODFT CFJOH DVSSFOU BOE JODMVTJWF É¨F DPMPS JMMVTUSBUJPOT BSF TQFDUBDVMBS BT EFNPOTUSBUFE JO UIF DIBQUFST PO Local Anesthesia, Cosmetic Uses of Botulinum Toxin BOE Wound Management and Dressings É¨F mHVSFT EFNPOTUSBUJOH BQQSPQSJBUF CBOEBHJOH PG EJÄ&#x160;FSFOU XPVOE TJUFT FYFNQMJmFT UIF

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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.

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

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

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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.

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

DRUG INTERACTIONS

No drug interaction studies were conducted with SORILUX Foam.

OVERDOSAGE

PATIENT COUNSELING INFORMATION

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.

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