Saturday, January 30, 2010

Traction Alopecia

Abstract: 15 yo girl with one year history of alopecia
HPI: This 15 yo African-American girl has noted progressive alopecia for the past year or so. Earlier in her life her hair was in corn-rows for one to two years. She has used "relaxers" for many years but stopped ~ a year ago. Her hair was pulled back for many years. Her mother has been applying "fish oil" to the area which they think may be helping.
O/E: There is marked thinning of the hair at the temporal and occipital areas. Much less involvement on frontal and parietal areas. No inflammation, scaling or scarring is appreciated.

This is most likely " Marginal Traction Alopecia"
Questions: What would you offer this young woman as for treatment. I told her to leave her hair natural, avoid relaxers or any tension on hair.
1. has a good chapter on Traction Alopecia: Here is an excerpt: "Traction alopecia is a common cause of hair loss due to pulling forces exerted on the scalp hair. This excessive tension leads to breakage in the outermost hairs. This condition is seen in children and adults, but it most commonly affects African American women. The 2 types of traction alopecia are marginal and nonmarginal. Unlike trichotillomania, a psychiatric disorder of compulsive hair pulling that leads to patchy hair loss, traction alopecia is unintentionally induced by various hairstyling practices (eg, use of braids, hair rollers, weaves, twists, locks, or "cornrows"). In the initial stages, this hair loss is reversible. With prolonged traction, alopecia can be permanent. Physicians, especially dermatologists, must recognize this condition early to prevent irreversible hair loss."

2. I would recommend renting Chris Rock's documentary "Good Hair" when it is available.

Wednesday, January 27, 2010

Cheilitis in a Young Woman

Abstract: 1.5 year history of cheilitis in a 26 yo woman
HPI: This is a a 23 yo esthetician who first developed cheilitis on her honeymoon in Mexico. She was using many lip balms at the time. These were discontinued and she found toothpaste without cinnamates. The process continued to flare. While initially on upper and lower lips, it is now just on the lower lip. She has read a lot on the subject and has many concerns. The patient has had a problem with anxiety since her father's death when she was 14 and sees a therapist. Cool compresses and fluocinalone 0.025% ointment control the problem fairly well; but it flares when she stops this. At one point, a KOH prep was positive for Candida (but that was when she'd been using a optical corticosteroid and this resolved quickly with ketoconazole cream).
O/E: Recently, the process is located on the lower lip. Here there is erythema, some induaation and scaling.
Clinical Photos: 1/10/1010

This photo was taken on Feb. 8, 2010 after a month off usual lip products and use of Vaseline and/or fluocinalone ointment.

Pathology: A 3 mm punch biopsy was taken from the lower lip.
This shows "confluent scale crust containing neutrophils, acanthosis with spongiosis and a dense lichenoid infiltrate. No granulomatous changes. The pathologist felt that these changes were non-diagnostic but "consistent with cheilitis glandularis."
Diagnosis: Cheilitis. In the ddx is contact, cheilitis glandularis and factitial cheilitis.
Discussion: I am not comfortable with a disgnosis of cheilitis glandularis here. Contact and factitial etiologies could still play a role. Patch testing will be done, but if negative and the problem persists consideration to having more in-depth patch testing may be given. We are also working with patient to stop licking and chewing lips.
Questions: What are your thoughts re: 00etiology here?
Addendum: A few months after this case was presented, the patient recalled that she had received a new dental retainer shortly befor the cheilitis began. Her old retainer was plastic and the new one was metal. She stopped using this new retainer and her cheilitis disappeared. Thus, a metal sensitivity (most likely nickel) was the culprit.
1. Nico MM, Nakano de Melo J, Lourenço SV. Cheilitis glandularis: A clinicopathological study in 22 patients. J Am Acad Dermatol.. [Epub ahead of print]
Department of Dermatology, Medical School, São Paulo, Brazil.
BACKGROUND: Cheilitis glandularis (CG) is a condition in which thick saliva is secreted by minor labial salivary glands and adheres to a swollen lip causing discomfort to the patient. Most publications refer to single case reports or small case series. OBJECTIVE: We sought to report and to analyze clinical, pathological, and therapeutic data on 22 patients with CG seen at the department of dermatology at our university. METHOD: Retrospective data about 22 patients with CG are reviewed and presented. RESULTS: Seventeen patients were male and 5 were female. All were fair skinned, including 6 albino individuals. Several of them presented significant signs of photodamage on the lips. Surgical treatment was performed in 10 severely affected patients and consisted of a vermilionectomy followed by minor salivary gland removal. Histopathological study revealed various degrees of chronic sialadenitis and vermilion epithelial changes. Superficially invasive and in situ squamous cell carcinoma of the vermilion was detected in 3 cases. LIMITATIONS: Biopsy and surgery were not performed in all patients. CONCLUSIONS: CG is strongly related to sun sensitivity and may be more severe in albino patients. The swollen, sun-exposed lip may become more susceptible to the occurrence of squamous cell carcinoma.

2. Aydin E, Gokoglu O, Ozcurumez G, Aydin H. Factitious cheilitis: a case report. J Med Case Reports. 2008 Jan 29;2:29.
Baskent University Department of Otolaryngology, Ankara, Turkey.
INTRODUCTION: Factitious cheilitis is a chronic condition characterized by crusting and ulceration that is probably secondary to chewing and sucking of the lips. Atopy, actinic damage, exfoliative cheilitis, cheilitis granulomatosa or glandularis, contact dermatitis, photosensitivity reactions and neoplasia should be considered in the differential diagnosis of crusted and ulcerated lesions of the lip. CASE PRESENTATION: We present a 56 year-old female with an ulcerated and crusted lesion on her lower lip. The biopsy showed granulation tissue and associated inflammation but no malignancy. Based on the tissue examination and through clinical evaluation the diagnosis of factitious cheilitis was rendered. CONCLUSION: Thorough clinical history, utilization of basic laboratory tests and histopathologic evaluation are required to exclude other diseases and a thoruough psychiatric evaluation and treatment is vital for successful management of these patients.

3. Torgerson RR, Davis MD, Bruce AJ, Farmer SA, Rogers RS 3rd. Contact allergy in oral disease. J Am Acad Dermatol. 2007 Aug;57(2):315-21. Epub 2007 May 25.
Department of Dermatology, Mayo Clinic, Rochester, MN 55905, USA.
BACKGROUND: The role of contact allergy in oral cavity disease processes is unknown. OBJECTIVE: We sought to determine the prevalence of contact allergy to flavorings, preservatives, dental acrylates, medications, and metals in patients with oral disease. METHODS: Patients were tested with an 85-item oral antigen screening series. Data were analyzed retrospectively. RESULTS: We evaluated 331 patients with burning mouth syndrome, lichenoid tissue reaction, cheilitis, stomatitis, gingivitis, orofacial granulomatosis, perioral dermatitis, and recurrent aphthous stomatitis. Positive patch test results were identified in 148 of the 331 patients; 90 patients had two or more positive reactions. Allergens with the highest positive reaction rates were potassium dicyanoaurate, nickel sulfate, and gold sodium thiosulfate. Of the 341 positive patch test reactions, 221 were clinically relevant. LIMITATIONS: No follow-up data were available in this retrospective analysis. CONCLUSION: The positive and relevant allergic reactions to metals, fragrances, and preservatives indicated that contact allergy may affect oral disease.

Tuesday, January 05, 2010

Pityrosporon Folliculitis

Abstract: 32 yo woman with 4 day history of folliculitis chest and back
HPI: This 32 year-0ld woman has had a folliculitis for 3 - 4 days. She has a history of ulcerative colitis and had been on prednisone for a few weeks and the dosage was recently increased. She is also on Apriso and Cipro.
O/E: This is a healthy-appearing woman with scores of erythematous papules admixed with a few pustules on upper chest and back. No other findings.
Clinical Photos:

Steroid acne vs. Pityrosporon folliculitis.

Biopsy: There are dilated follicles with basophilic debris and numerous PAS positive spores (no hyphae). This is P. folliculitis.

Discussion: She was treated with ketoconazole 200 mg daily for a month. Will put a f/u after she is seen back. Although it seems obvious that the prednisone played a role, there is scant support for this in the literature. We will have to see how the patient does with treatment and whether she suffers recurrences.

Lévy A, Feuilhade de Chauvin M, Dubertret L, Morel P, Flageul B. [Malassezia folliculitis: characteristics and therapeutic response in 26 patients] Ann Dermatol Venereol. 2007 Nov;134(11):823-8.

[Article in French]

Service de Dermatologie I, Hôpital Saint-Louis, Paris.

BACKGROUND: Malassezia folliculitis is most often described in patients living in hot and humid countries or in immunocompromised patients. Its frequency in France is unknown. We report 26 cases diagnosed at Saint-Louis Hospital between May 2002 and April 2004. The clinical features, the contributing factors, the results of direct mycological examination and/or histology and the efficacy of antifungal treatments were compared to the literature. PATIENTS AND METHODS: The inclusion criteria were the presence of folliculitis on the trunk confirmed by direct microscopy and/or histopathology showing abundant yeast cells in the follicles. RESULTS: Patients comprised 22 men and 4 women (M/F sex ratio: 5: 5) with a mean age of 46 years. Five patients (19%) were immunocompromised. In normal patients, the duration of folliculitis was long with a mean of 61 months. The eruption was typical, with follicular papules and superficial pustules distributed predominantly on the trunk. Itching was frequent (70%). Direct microscopy was more often positive than histology (89% vs 33%). Some sixty-five percent of the patients had been previously treated by topical or systemic antibiotics or anti-acne drugs, which was ineffective in all cases. Cure with topical ketoconazole, oral ketoconazole alone or in combination with topical ketoconazole occurred respectively in 12%, 75% and 75% of patients, but with consistent recurrence within 3 to 4 months after cessation of treatment. DISCUSSION: Malassezia folliculitis is probably misdiagnosed, as suggested by the long time between onset and diagnosis and the high frequency of non-antifungal treatments prescribed. In our study, direct mycological examination provided more effective diagnosis than histology. Treatment is difficult especially because of the high frequency of relapses. CONCLUSION: A diagnosis of Malassezia folliculitis should be considered in young adults or immunocompromised patients with an itching follicular eruption. Further therapeutic trials are needed due to the frequency of relapse.