Thursday, June 16, 2016

Hypopigmentation in an African

The patient is a 39 yo man from Ghana.  His wife noticed these spots on his back recently.  My first diagnosis was tinea versicolor; but KOH prep showed only spores.  Is this just quiescent T.v.?  It's symmetrically distributed over upper back (no where else).  In differential diagnosis was vitiligo -- but this is incomplete hypopigmentyation (which can occur with vitiligo, but less commonly).  I suggested ketoconazole cream and a follow-up in 3 months.  If still present, may do a biopsy.
What are your thoughts?

1. The utility of dermoscopy in the diagnosis of evolving lesions of vitiligo.
Thatte SS1, Khopkar US.  Indian J Dermatol Venereol Leprol. 2014 Nov-Dec;80(6):505-8.
BACKGROURD: Early lesions of vitiligo can be confused with various other causes of hypopigmentation and depigmentation. Few workers have utilized dermoscopy for the diagnosis of evolving lesions of vitiligo.
CONCLUSION: Pigmentary network changes, and perifollicular and perilesional hyperpigmentation on polarized light examination, and a diffuse white glow on ultraviolet light examination were noted in evolving vitiligo lesions. Histopathological examination was comparatively less reliable. Dermoscopy appears to be better than routine histopathology in the diagnosis of evolving lesions of vitiligo and can obviate the need for a skin biopsy. Free Full Text.

2. Dermoscopy as an ancillary tool for the diagnosis of pityriasis versicolor.
Zhou H, Tang XH, Chen MK. J Am Acad Dermatol. 2015 Dec;73(6):e205-6. (this is only reference in PubMed on T.v. and dermsocopy and it is not particularly helpful)

3. Dermatoscope--the dermatologist's stethoscope.
Lallas A, Argenziano G.  Indian J Dermatol Venereol Leprol. 2014 Nov-Dec;80(6):493-4. Full Free Text 
This is an interesting somewhat philosophical article.  The references are extensive and helpful.

Wednesday, June 08, 2016

Alopecia Universalis in a Teenage Girl

Presented by Henry Foong, Ipoh, Malaysia

Here is a patient I saw recently.  She is a 17-year-old girl who has a history of severe alopecia since the age of 12 years.  It was abrupt and sudden with marked loss of scalp hair followed by eye brows and other body hair.  Within a month, she had developed alopecia universalis.  She was initially treated with intralesional triamcinolone and topical minoxidil but did not help.  Subsequently she had NB-UVB 3 times weekly in the local hospital but that also did not do much good.  She was advised to go to tertiary centres in KL but was disappointed with only one visit.  She could not go to NSC in Singapore because of financial constraints.  As a Malay, she always wears a tudong to cover her scalp.  There was no other systemic complaints.  She is the 4th in the family of 5 siblings.  No family history of alopecia. 

She saw me yesterday.  Am trying out DPCP diphencyprone sensitisation for her.  She had a previous sensitisation done but quit after one treatment.  She had total alopecia affecting the scalp, eyebrow, eyelash, axillary and suprapubic area. Used 0.1% DPCP concentration, left on the scalp for 24 hours and reviewed the next day.  She does have good reaction with small vesicles and plan to do it weekly till her hair grows.  The eyebrow hair loss was treated with intralesional triamcinolone acetonide injection of 10 mg/ml strength.  According to literature, topical minoxidil 5% solution, topical clobetasol ointment and weekly methotrexate 25mg/wk do help too.  Other novel therapy would include JAK inhibitors.
Comment:  Who has had real success treating patients with AU? Are there any lab tests of real value?

After DPCP sensitization

1. Clinical Efficacy of Diphenylcyclopropenone in Alopecia Areata: Retrospective Data Analysis of 50 Patients.  Chiang KS, Mesinkovska NA, Piliang MP, Bergfeld WF. J Investig Dermatol Symp Proc. 2015 Nov;17(2):50-5.
Abstract: Diphenylcyclopropenone (DPCP) is widely considered the most effective topical immunotherapy for refractory or extensive alopecia areata (AA), but questions regarding how long to try DPCP therapy before terminating and what factors are prognostic of therapeutic success still remain unanswered. In this retrospective study of 50 AA patients, we evaluated DPCP efficacy and identified patient factors predictive of therapeutic success/failure. The median duration of DPCP treatment was 3 years, with 47% patients experiencing their first regrowth in the first 6 months of DPCP therapy, 20% between 6 months-1 year, and 8% between 1-2 years. In our study, treatment success, defined as 50% terminal hair regrowth, was reached in 71% of alopecia totalis patients and in 56% of alopecia universalis patients. Three factors were statistically significant predictors of poor treatment outcome-extent of hair loss before DPCP treatment, history of thyroid disease, and extent of body hair involvement. Relapse was observed in 44% of patients and significantly associated with history of thyroid disease. Common side effects were itching, rash, and local lymphadenopathy. The results of this study support our belief that DPCP therapy is a viable treatment option, can be successfully accomplished at home, and should not be terminated before 2 years.

2.  Pulse corticosteroid therapy for alopecia areata: study of 139 patients.
Nakajima T1, Inui S, Itami S. Dermatology. 2007;215(4):320-4.
Author information
Abstract: Of the patients, 72.7% had hair loss on > 50% of their scalp area. Among the recent-onset group (duration of AA < or = 6 months), 59.4% were good responders (> 75% regrowth of alopecia lesions), while 15.8% with > 6 months duration showed a good response. Recent-onset AA patients with less severe disease (< or = 50% hair loss) responded at a rate of 88.0%, but only 21.4% of recent-onset patients with 100% hair loss responded. No serious adverse effects were observed.

3. Association between vitamin D levels and alopecia areata.
Mahamid M, Abu-Elhija O, Samamra M, Mahamid A, Nseir W. Isr Med Assoc J. 2014 Jun;16(6):367-70.
RESULTS: Mean CRP values were significantly higher in the AA group than the control group (1.1 +/- 0.7 mg/dl vs. 0.4 +/- 0.8 mg/ dl, P < 0.05). Vitamin D levels were significantly decreased in the AA group (11.32 +/- 10.18 ng/ml vs. 21.55 +/- 13.62 ng/ml in the control group, P < 0.05). Multivariate analysis showed that CRP (odds ratio 3.1, 95% confidence interval 2.6-4.2, P = 0.04) and serum vitamin D levels < 30 ng/ml (OR 2.3, 95% CI 2.2-3.1, P = 0.02) were associated with AA.
CONCLUSIONS: We found a significant correlation between AA and vitamin D deficiency. Vitamin D deficiency can be a significant risk factor for AA occurrence.

4. Pulse corticosteroid therapy with oral dexamethasone for the treatment of adult alopecia totalis and universalis JAAD, May 2016  Link.