Validation of medical service insurance claims as a surrogate for ascertaining vitiligo cases

The epidemiology of vitiligo, especially its disease burden on the healthcare system, can be assessed indirectly by analyzing health insurance claims data. Validating this approach is integral to ensuring accurate case identification and cohort characterization. The primary aim of this study was to develop and validate an indirect measure of vitiligo ascertainment using health insurance claims data. These data were used secondarily to identify demographic characteristics, body site involvement, vitiligo subtypes, disease associations, and treatments. This study assessed the validity of identifying vitiligo from billing claims within a Canadian provincial universal health insurance program, versus vitiligo cases accrued from direct medical chart reviews. Claims-based algorithms combining ICD-9-CM diagnostic code 709 with treatment-specific data were derived and tested to identify vitiligo patients. This was compared against cases arising from the manual review of medical records of 606 patient with a diagnostic code for "dyschromia" (ICD-9-CM diagnostic code 709) from January 1 to December 31, 2016. Based on the chart reviews, 204 (33.7%) patients were confirmed to have vitiligo. 42 separate claims-based algorithms combining ICD-9-CM diagnostic code 709 with treatment data specific to vitiligo were modeled and individually tested to evaluate their accuracy for vitiligo ascertainment. One algorithm achieved a sensitivity, specificity, PPV and NPV of 86.8% (95% CI 82.1-91.4), 92.5% (95% CI 90.0-95.1), 85.5% (95% CI 80.7-90.3), and 93.2% (95% CI 90.8-95.7), respectively. There was a 2.2 female-to-male ratio. The most common medical treatments were tacrolimus (74.5%) and topical corticosteroids (54.3%). Hypertension (24.2%) and hypothyroidism (19.6%) were the predominant co-morbidities associated with vitiligo. Health insurance claims data can be used to indirectly ascertain vitiligo for epidemiologic purposes with relatively high diagnostic performance between 85.5 and 93.2%.

The WHO ICD-11 Classification of Dermatological Disorders: a new comprehensive online skin disease taxonomy designed by and for dermatologists

In May 2019, the World Health Assembly officially adopted the Eleventh Revision of the International Classification of Diseases (ICD-11)¹ . When the current 10th Revision (ICD-10) was released some three decades ago, the world was at the beginning of the modern information technology era. The World Health Organization (WHO) had long recognised that the "one size fits all" nature of ICD-10 and its inability to adapt to change seriously hampered its usefulness in healthcare research and management. The initial designs for ICD-11 were formulated by the WHO in 2007. Since then, many individuals from around the globe have participated in its development.

Regulation of systemic tissue injury by coagulation inhibitors in B6.MRL/lpr autoimmune mice

Impaired fibrinolysis and complement activation in Systemic Lupus Erythematosus contributes to disease amplification including increased risk of thrombosis and tissue Ischemia/Reperfusion (IR) injury. Previous work has demonstrated complement is a key regulator of tissue injury. In these studies inhibitors had varying efficacies in attenuating injury at primary versus systemic sites, such as lung. In this study the role of coagulation factors in tissue injury and complement function was evaluated. Tissue Factor Pathway Inhibitor (TFPI), an extrinsic pathway inhibitor, and Anti-Thrombin III, the downstream common pathway inhibitor, were utilized in this study. TFPI was more effective in attenuated primary intestinal tissue injury. However both attenuated systemic lung injury. However, ATIII treatment resulting in enhanced degradation of C3 split products in lung tissue compared to TFPI. This work delineates the influence of specific early and late coagulation pathway components during initial tissue injury versus later distal systemic tissue injury mechanism.

A feature fusion system for basal cell carcinoma detection through data-driven feature learning and patient profile

BACKGROUND

Basal cell carcinoma (BCC) is the most common skin cancer, which is highly damaging in its advanced stages. Computer-aided techniques provide a feasible option for early detection of BCC. However, automated BCC detection techniques immensely rely on handcrafting high-level precise features. Such features are not only computationally complex to design but can also represent a very limited aspect of the lesion characteristics. This paper proposes an automated BCC detection technique that directly learns the features from image data, eliminating the need for handcrafted feature design.

METHODS

The proposed method is composed of 2 parts. First, an unsupervised feature learning framework is proposed which attempts to learn hidden characteristics of the data including vascular patterns directly from the images. This is done through the design of a sparse autoencoder (SAE). After the unsupervised learning, we treat each of the learned kernel weights of the SAE as a filter. Convolving each filter with the lesion image yields a feature map. Feature maps are condensed to reduce the dimensionality and are further integrated with patient profile information. The overall features are then fed into a softmax classifier for BCC classification.

RESULTS

On a set of 1199 BCC images, the proposed framework achieved an area under the curve of 91.1%, while the visualization of learned features confirmed meaningful clinical interpretation of the features.

CONCLUSION

The proposed framework provides a non-invasive fast BCC detection tool that incorporates both dermoscopic lesional features and clinical patient information, without the need for complex handcrafted feature extraction.

A randomized phase II study of weekly paclitaxel with or without pelareorep in patients with metastatic breast cancer: final analysis of Canadian Cancer Trials Group IND.213

BACKGROUND

Pelareorep, a serotype 3 reovirus, has demonstrated preclinical and early clinical activity in breast cancer and synergistic cytotoxic activity with microtubule targeting agents. This multicentre, randomized, phase II trial was undertaken to evaluate the efficacy and safety of adding pelareorep to paclitaxel for patients with metastatic breast cancer (mBC).

METHODS

Following a safety run-in of 7 patients, 74 women with previously treated mBC were randomized either to paclitaxel 80 mg/m² intravenously on days 1, 8, and 15 every 4 weeks plus pelareorep 3 × 10¹⁰ TCID₅₀ intravenously on days 1, 2, 8, 9, 15, and 16 every 4 weeks (Arm A) or to paclitaxel alone (Arm B). Primary endpoint was progression-free survival (PFS). Secondary endpoints were objective response rate, overall survival (OS), circulating tumour cell counts, safety, and exploratory correlative analyses. All comparisons used a two-sided test at an alpha level of 20%. Survival analyses were adjusted for prior paclitaxel.

RESULTS

Final analysis was performed after a median follow-up of 29.5 months. Pelareorep was well tolerated. Patients in Arm A had more favourable baseline prognostic variables. Median adjusted PFS (Arm A vs B) was 3.78 mo vs 3.38 mo (HR 1.04, 80% CI 0.76-1.43, P = 0.87). There was no difference in response rate between arms (P = 0.87). Median OS (Arm A vs B) was 17.4 mo vs 10.4 mo (HR 0.65, 80% CI 0.46-0.91, P = 0.1).

CONCLUSIONS

This first, phase II, randomized study of pelareorep and paclitaxel in previously treated mBC did not show a difference in PFS (the primary endpoint) or RR. However, there was a significantly longer OS for the combination. Further exploration of this regimen in mBC may be of interest.

Gene expression profiling in psoriatic scalp hair follicles: clobetasol propionate shampoo 0.05% normalizes psoriasis disease markers

BACKGROUND

Clobetasol propionate shampoo is effective and safe in treatment of scalp psoriasis (SP). Gene expression profiling of psoriatic skin biopsies led to the identification of numerous disease-related genes. However, it remained unknown whether the gene expression profile of hair follicles of SP patients was also affected.

OBJECTIVES

To determine whether psoriasis-related genes are differentially regulated in the hair follicles of SP patients and whether the modulation of these genes can be correlated with clinical severity scores.

METHODS

A single arm, open study was conducted in three centres. SP patients received daily treatment with clobetasol propionate shampoo. At Baseline, Weeks 2 and 4, investigators assessed clinical severity parameters and collected scalp hair follicles in anagen phase. Total RNA extracted from hair follicles was used to determine the expression level of 44 genes, which were reported previously to be upregulated in the skin of psoriasis patients.

RESULTS

RNA of good quality and sufficient quantity was obtained from hair follicles of psoriasis patients and healthy volunteers (HV). The expression level of 10 inflammation-related genes was significantly increased in psoriatic hair follicles. The patient's exploratory transcriptomic score, defined as the mean fold modulation of these 10 genes compared with HV, correlated with clinical severity scores. Clobetasol propionate shampoo was effective in decreasing both the exploratory transcriptomics and the clinical severity scores.

CONCLUSION

Hair follicles of SP patients are affected by the inflammatory process. The change in the expression level of inflammation-related genes correlates with the severity of the disease.

Methyl aminolevulinate-PDT for actinic keratoses and superficial nonmelanoma skin cancers

Methyl aminolevulinate-hydrochloride cream (Metvix [in Canada] and Metvixia [in the US], Galderma) in combination with photodynamic therapy (PDT) provides an effective treatment option for actinic keratoses (AKs), superficial basal cell carcinoma (sBCC), and Bowen's disease (BD). Good clinical outcomes have been reported in the literature. Complete responses (CRs) in AK range from 69% to 93% at 3 months. In sBCC, reported CR rates were from 85% to 93% at 3 months and almost on par with cryosurgery at 60 months (75% vs. 74%). In BD, CR rates were 93% at 3 months and 68% at 2 years. Current evidence has shown that this noninvasive treatment is superior in terms of cosmetic outcome to other management strategies such as surgery. It also offers the advantages of relative simplicity, low risk of side-effects and decreased complications due to scar formation.

Treatments for unwanted facial hair

Twenty-two percent of women in North America have unwanted facial hair, which can cause embarrassment and result in a significant emotional burden. Treatment options include plucking, waxing (including the sugar forms), depilatories, bleaching, shaving, electrolysis, laser, intense pulsed light (IPL), and eflornithine 13.9% cream (Vaniqa, Barrier Therapeutics in Canada and Shire Pharmaceuticals elsewhere). Eflornithine 13.9% cream is a topical treatment that does not remove the hairs, but acts to reduce the rate of growth and appears to be effective for unwanted facial hair on the mustache and chin area. Eflornithine 13.9% cream can be used in combination with other treatments such as lasers and IPL to give the patient the best chance for successful hair removal.

Efficacy of once-daily treatment regimens with calcipotriol/betamethasone dipropionate ointment and calcipotriol ointment in psoriasis vulgaris

BACKGROUND

A two-compound ointment containing calcipotriol 50 micro g g-1 and betamethasone dipropionate 0.5 mg g-1 has recently been shown to be an effective treatment for psoriasis.

OBJECTIVES

This study was designed to investigate efficacy and safety of different treatment regimens with the two-compound product (Daivobet/Dovobet; LEO Pharma, Ballerup, Denmark) and calcipotriol 50 micro g g-1 ointment (Daivonex/Dovonex; LEO Pharma).

METHODS

In total, 972 patients with psoriasis vulgaris were randomized to one of three treatment regimens: group 1, the two-compound product once daily for 8 weeks followed by calcipotriol ointment once daily for 4 weeks; group 2, the two-compound product once daily for 4 weeks followed by 8 weeks of treatment with calcipotriol ointment once daily on weekdays and the two-compound product once daily at weekends; and group 3, calcipotriol ointment twice daily for 12 weeks. The efficacy was evaluated by Psoriasis Area and Severity Index (PASI) and investigators' global assessments of disease severity. The primary response criteria were percentage reduction in PASI and proportion of patients with absent/very mild disease according to the investigators' global assessments after 8 weeks of treatment.

RESULTS

The mean reduction in PASI from baseline to the end of 8 weeks of treatment was 73.3% for group 1, 68.2% for group 2 and 64.1% for group 3. The proportion of patients with absent/very mild disease at the end of 8 weeks of treatment was 55.3% for group 1, 47.7% for group 2 and 40.7% for group 3. For both primary response criteria, group 1 was statistically superior to group 3 (P < 0.001), whereas group 2 did not differ significantly from group 3. The difference between group 1 and group 2 was statistically significant with regard to PASI but not regarding the proportion of patients with absent/very mild disease. Patients receiving initial therapy with the two-compound product achieved the fastest treatment response, and the maximum treatment effect for these patients was seen after 5 weeks. This effect was maintained with continued treatment with the two-compound product for up to 8 weeks. After 12 weeks of treatment, no significant differences were seen between the three groups with regard to reduction in PASI, whereas the proportion of patients with absent/very mild disease in group 2 was superior to that in group 3. Patients receiving therapy with the two-compound product experienced fewer lesional/perilesional adverse drug reactions than the calcipotriol-treated patients (P < 0.001): 10.9% in group 1, 11.5% in group 2 and 22.3% in group 3.

CONCLUSIONS

Two different short-term treatment regimens employing a recently developed two-compound product (calcipotriol/betamethasone dipropionate) provided rapid and marked clinical efficacy and were shown to be safe therapies for psoriasis vulgaris.

Restoration of hair growth in mice with an alopecia areata-like disease using topical anthralin

Anthralin is a widely used topical anti-psoriatic drug that may have an immunomodulating effect on alopecia areata (AA) as it does in psoriasis. The aims of the present study were to investigate the effects of anthralin on hair growth in balding C3H/HeJ mice affected by an AA-like disease and to study the underlying mechanisms. Affected C3H/HeJ mice were treated daily for 10 weeks on half of the dorsal skin with 0.2% anthralin and the contra-lateral side was treated with the vehicle ointment. The percentage of surface hair coverage and hair density was graded weekly for both sides and hair growth indices were calculated using these two variables. Hair regrowth was observed in 9/14 mice on the treated sides. Four mice displayed near complete replacement of normal density and length hairs. All the vehicle-treated sides showed either no change or continued hair loss. An RNase protection assay (RPA) showed that expression of tumor necrosis factor-alpha (TNF-alpha) and -beta were inhibited by anthralin upon successful treatment. It appears that anthralin may be an effective therapy for C3H/HeJ mice with AA and certain cytokines may be involved in the therapeutic effects of anthralin on restoring hair regrowth in AA-affected C3H/HeJ mice.

Computerized morphometry and three-dimensional image reconstruction in the evaluation of scalp biopsy from patients with non-cicatricial alopecias

BACKGROUND

A major challenge in the histopathological examination of scalp biopsies is to perform an adequate evaluation of all the hair follicles present in the tissue. Transverse sectioning is currently the preferred technique to demonstrate every follicular structure in a punch biopsy specimen, although diagnostic accuracy is dependent on subjective evaluation of follicular morphology and hair size.

OBJECTIVES

To determine if computer-based morphometry and three-dimensional (3D) image reconstruction software can be used to evaluate scalp biopsies from patients with non-cicatricial alopecias.

METHODS

Nine 4-mm scalp punches were taken from nine patients with noncicatricial alopecias and step-sectioned transversely at 0.1-mm intervals from the epidermal surface to the subcutaneous fat. Each tissue section was then digitized and analysed using morphometric and 3D image reconstruction software. Morphometric data and 3D images were collated with clinical and conventional light microscopic diagnoses, as well as follow-up information.

RESULTS

In four of the nine patients, results of morphometric analysis concurred with conventional clinicopathological diagnoses. In the remaining five patients, morphometry revealed a lower telogen count in one patient and higher telogen count in four patients. One of the four patients with a higher telogen count also had a low mean hair diameter and miniaturized anagen follicles in the 3D image that were suggestive of early androgenetic alopecia (AGA). 3D virtual microscopic imagery allowed the direct visualization of colour-coded, scaled hair follicles which demonstrated characteristic changes in alopecia areata, AGA and telogen effluvium.

CONCLUSIONS

Our study demonstrated the feasibility of using morphometric and 3D reconstruction software to evaluate scalp biopsies. With further validation, this technique may prove to be more sensitive to detect subtle quantitative and qualitative follicular changes in non-cicatricial alopecias.

Once daily application of a combination of calcipotriol and betamethasone dipropionate (Dovobet, Daivobet) for the treatment of psoriasis

This new compound product containing 50 micrograms/gram calcipotriol and 0.5 milligrams/gram betamethasone dipropionate was recently introduced in Canada for the treatment of psoriasis. Clinical trials demonstrated that this compound was more active than either agent used alone. Recent changes in the product monograph involving the reduction in dose to once daily use has raised questions about the relevance of some previous comparisons of twice daily Dovobet. Pooling the available data from 5,500 patients in clinical trials for Dovobet will allow an inter-trial comparison of the various treatment arms, demonstrating that Dovobet, when applied once daily is significantly more effective than with twice daily applications of either its individual components used alone.

Rapid near-infrared Raman spectroscopy system for real-time in vivo skin measurements

A rapid dispersive-type near-infrared (NIR) Raman spectroscopy system and a Raman probe were developed to facilitate real-time, noninvasive, in vivo human skin measurements. Spectrograph image aberration was corrected by a parabolic-line fiber array, permitting complete CCD vertical binning, thereby yielding a 3.3-16-fold improvement in signal-to-noise ratio. Good quality in vivo cutaneous NIR Raman spectra free of interference from fiber fluorescence and silica Raman scattering can be acquired in less than 1 s, which greatly facilitates practical noninvasive tissue characterization and clinical diagnosis.

The treatment of moderate to severe psoriasis with a new anti-CD11a monoclonal antibody

BACKGROUND

Anti-CD11a (hu1124) is a humanized monoclonal antibody directed against the CD11a subunit of LFA-1. This study investigated whether treatment with anti-CD11a antibody provides clinical benefit to patients with moderate to severe plaque psoriasis.

METHODS

This was a double-blind, placebo-controlled, phase II, multicenter study. In total, 145 patients with minimum Psoriasis Area and Severity Index scores of 12 and affected body surface area of 10% or more were sequentially enrolled into low-dose (0.1 mg/kg, n = 22) or high-dose (0.3 mg/kg, n = 75) groups. Within groups, patients were randomized to treatment or placebo (n = 48) in a 2:1 ratio. Drug was administered intravenously at weekly intervals for 8 weeks.

RESULTS

The percentage of subjects achieving more than 50% improvement in physician's global assessment at day 56 (1 week after final dose) was 15% and 48% for placebo and 0.3 mg/kg of drug, respectively (P =.002). A physician's global assessment of excellent (>75% improvement) was greater in the 0.3 mg/kg group versus placebo (25% vs 2%, P =.0003). Average Psoriasis Area and Severity Index scores at day 56 were 13.9 +/- 7.5 (placebo) and 10.9 +/- 8.4 (0.3 mg/kg) (P <.0001). Epidermal thickness was reduced in the 0.3 mg/kg group compared with the placebo group (37% vs 19%, P =.004). Treatment was well tolerated; mild to moderate flu-like complaints were the most common adverse events. White blood cell counts and lymphocyte counts transiently increased. Depletion of circulating lymphocytes did not occur.

CONCLUSIONS

Anti-CD11a antibody administered intravenously in 8 weekly doses of 0.3 mg/kg was well tolerated and induced clinical and histologic improvements in psoriasis.

Oral aminolevulinic acid induces protoporphyrin IX fluorescence in psoriatic plaques and peripheral blood cells

Photodynamic therapy (PDT) with topical aminolevulinic acid (ALA) has been shown in previous studies to improve psoriasis. However, topical ALA-PDT may not be practical for the treatment of extensive disease. In order to overcome this limitation we have explored the potential use of oral ALA administration in psoriatic patients. Twelve patients with plaque psoriasis received a single oral ALA dose of 10, 20 or 30 mg/kg followed by measurement of protoporphyrin IX (PpIX) fluorescence in the skin and circulating blood cells. Skin PpIX levels were determined over time after ALA administration by the quantification of the 635 nm PpIX emission peak with in vivo fluorescence spectroscopy under 442 nm laser excitation. Administration of ALA at 20 and 30 mg/kg induced preferential accumulation of PpIX in psoriatic as opposed to adjacent normal skin. Peak fluorescence intensity in psoriatic and normal skin occurred between 3 and 5 h after the administration of 20 and 30 mg/kg, respectively. Ratios of up to 10 for PpIX fluorescence between psoriatic versus normal skin were obtained at the 30 mg/kg dose of ALA. Visible PpIX fluorescence was also observed on normal facial skin, and nonspecific skin photosensitivity occurred only in patients who received the 20 or 30 mg/kg doses. PpIX fluorescence intensity was measured in circulating blood cells by flow cytometry. PpIX fluorescence was higher in monocytes and neutrophils as compared to CD4+ and CD8+ T lymphocytes. PpIX levels in these cells were higher in patients who received higher ALA doses and peaked between 4 and 8 h after administration of ALA. There was only a modest increase in PpIX levels in circulating CD4+ and CD8+ T lymphocytes. In conclusion oral administration of ALA induced preferential accumulation of PpIX in psoriatic plaques as compared to adjacent normal skin suggesting that PDT with oral ALA should be further explored for the treatment of psoriasis.

Predictive model for immunotherapy of alopecia areata with diphencyprone

BACKGROUND

Immunotherapy with diphencyprone (diphenylcyclopropenone) is used in the treatment of alopecia areata (AA). Response rates have varied in the literature.

OBJECTIVES

To determine the efficacy of diphencyprone therapy for AA in the largest reported cohort of patients; to identify patient and treatment factors predictive of therapeutic success; and to develop a practical model for predicting patient response.

METHODS

The medical records of 148 consecutive patients treated with diphencyprone were reviewed. A clinically significant response to diphencyprone therapy was defined as a cosmetically acceptable response or greater than 75% terminal hair regrowth. Survival analyses using the Kaplan-Meier method and the Cox proportional hazards model were performed to determine significant factors predictive of regrowth and relapse.

RESULTS

Using a survival analysis model, the cumulative patient response at 32 months was 77.9% (95% confidence interval, 56.8%-98.9%). Variables independently associated with clinically significant regrowth were age at onset of disease and baseline extent of AA. Older age at onset of AA portended a better prognosis. A cosmetically acceptable end point was obtained in 17.4% of patients with alopecia totalis/universalis, 60.3% with 75% to 99% AA, 88.1% with 50% to 74% AA, and 100% with 25% to 49% AA. A lag of 3 months was present between initiation of therapy and development of significant hair regrowth in the first responders. Relapse after achieving significant regrowth developed in 62.6% of patients.

CONCLUSIONS

Response to diphencyprone treatment in AA is affected by baseline extent of AA and age at disease onset. A prolonged treatment course might be necessary. A predictive model has been developed to assist with patient prognostication and counseling.

Systemic photodynamic therapy with aminolaevulinic acid delays the appearance of ultraviolet-induced skin tumours in mice

BACKGROUND

Photodynamic therapy (PDT) with topical aminolaevulinic acid (ALA) has recently been approved by the US Food and Drug Administration for the treatment of actinic keratoses.

OBJECTIVES

To determine whether weekly systemic suberythemogenic ALA-PDT could prevent the appearance of ultraviolet (UV) -induced skin tumours in hairless mice.

METHODS

One group of 20 mice received daily UV radiation from FS 20 tubes, and weekly intraperitoneal injections of ALA 40 mg kg(-1), each followed 3 h later by 12 J cm(-2) of white light (ALA-PDT). Control groups consisted of mice exposed only to UV, to UV and ALA without white light, or UV and white light without ALA, as well as untreated mice.

RESULTS

The tumour-free survival was significantly longer for mice exposed to daily UV and weekly ALA-PDT as compared with the control groups. Neither the mortality nor the incidence of large skin tumours was higher in the UV/ALA-PDT group than in mice exposed only to UV. In vivo fluorescence spectroscopy showed that the 635-nm fluorescence emission within tumours was lower than in normal skin 3 h after ALA administration. This was also confirmed by quantitative fluorescence microscopy.

CONCLUSIONS

Systemic ALA-PDT can delay the appearance of UV-induced skin tumours in mice without increasing mortality or the incidence of large tumours.

Vaniqa--eflornithine 13.9% cream

Eflornithine HCl 13.9% cream is the first topical prescription treatment to be approved by the US FDA for the reduction of unwanted facial hair in women. It irreversibly inhibits ornithine decarboxylase (ODC), an enzyme that catalyzes the rate-limiting step for follicular polyamine synthesis, which is necessary for hair growth. In clinical trials eflornithine cream slowed the growth of unwanted facial hair in up to 60% of women. Improvement occurs gradually over a period of 4-8 weeks or longer. Most reported adverse reactions consisted of minor skin irritation.

Topical photodynamic therapy with 5-aminolaevulinic acid does not induce hair regrowth in patients with extensive alopecia areata

BACKGROUND

Photodynamic therapy (PDT) is a new modality involving the administration of a photosensitizer, or photosensitizer precursor, followed by its activation with light to generate a therapeutic effect. 5-Aminolaevulinic acid (ALA) is a photosensitizer precursor that is transformed by cells into protoporphyrin IX (PpIX), which can in turn be activated by red light.

OBJECTIVES

To investigate the effect of PDT in alopecia areata (AA).

METHODS

In six patients with extensive AA, topical ALA lotion at 5%, 10% and 20% as well as the vehicle lotion alone were applied separately to different scalp areas, followed 3 h later by exposure to red light at each treatment session.

RESULTS

No significant hair growth was observed after 20 twice-weekly treatment sessions. A significant increase in erythema and pigmentation was observed for the three concentrations of ALA lotion vs. the vehicle, implying that a phototoxic PDT effect was achieved in the skin. In vivo fluorescence spectroscopy in one patient showed an increase in red PpIX fluorescence 3 h after ALA application followed by a decrease after light exposure. On fluorescence microscopy, bright red fluorescence was present in the epidermis and sebaceous glands, but not in the inflammatory infiltrate surrounding the hair follicle following ALA application.

CONCLUSIONS

PDT was ineffective in the treatment of AA.

Practical management of hair loss

OBJECTIVE

To describe an organized diagnostic approach for both nonscarring and scarring alopecias to help family physicians establish an accurate in-office diagnosis. To explain when ancillary laboratory workup is necessary to confirm the diagnosis.

QUALITY OF EVIDENCE

Current diagnostic and therapeutic interventions for hair loss are based on randomized controlled studies, uncontrolled studies, and case series. MEDLINE was searched from January 1966 to December 1998 with the MeSH words alopecia, hair, and alopecia areata. Articles were selected on the basis of experimental design, with priority given to the most current large multicentre controlled studies. Overall global evidence for therapeutic intervention for hair loss is quite strong.

MAIN MESSAGE

The most common forms of nonscarring alopecias are androgenic alopecia, telogen effluvium, and alopecia areata. Other disorders include trichotillomania, traction alopecia, tinea capitis, and hair shaft abnormalities. Scarring alopecia is caused by trauma, infections, discoid lupus erythematosus, or lichen planus. Key to establishing an accurate diagnosis is a detailed history, including medication use, systemic illnesses, endocrine dysfunction, hair-care practices, and family history. All hair-bearing sites should be examined. A 4-mm punch biopsy of the scalp is useful, particularly to diagnose scarring alopecias. Once a diagnosis has been established, specific therapy can be initiated.

CONCLUSIONS

Diagnosis and management of hair loss is an interesting challenge for family physicians. An organized approach to recognizing characteristic differential features of hair loss disorders is key to diagnosis and management.

The Arabidopsis Cdc2a-interacting protein ICK2 is structurally related to ICK1 and is a potent inhibitor of cyclin-dependent kinase activity in vitro

Cyclin-dependent kinases (CDKs) are important regulators of the eukaryotic cell division cycle. To study protein-protein interactions involving plant CDKs, the Arabidopsis thaliana Cdc2aAt was used as bait in the yeast two-hybrid system. Here we report on the isolation of ICK2, and show that it interacts with Cdc2aAt, but not with a second CDK from Arabidopsis, Cdc2bAt. ICK2 contains a carboxy-terminal domain related to that of ICK1, a previously described CDK inhibitor from Arabidopsis, and to the CDK-binding domain of the mammalian inhibitor p27Kip1. Outside of this domain, ICK2 is distinct from ICK1, p27Kip1, and other proteins. At nanogram levels (8 nM), purified recombinant ICK2 inhibits p13Suc1-associated histone H1 kinase activity from Arabidopsis tissue extracts, demonstrating that it is a potent inhibitor of plant CDK activity in vitro. ICK2 mRNA was present in all tissues analysed by Northern hybridization, and its distribution was distinct from that of ICK1. These results demonstrate that plants possess a family of differentially regulated CDK inhibitors that contain a conserved carboxy terminal but with distinct amino terminal regions.

Alopecia areata-like hair loss in C3H/HeJ mice and DEBR rats can be reversed using topical diphencyprone

This study demonstrates the ability to treat successfully alopecia areata-like hair loss in both mouse and rat models using topical immunotherapy with diphencyprone.

Excess tissue friability during CO2 laser vaporization of nodular amyloidosis

BACKGROUND

Nodular amyloidosis is a rare cutaneous disorder for which many treatments have been described, including carbon dioxide (CO2) laser vaporization.

OBJECTIVE

We describe the intraoperative tissue effects encountered during successful treatment of nodular amyloidosis with CO2 laser surgery.

METHODS

Two nodules of cutaneous amyloid on the nose of a patient were vaporized with a defocused, continuous-wave CO2 laser.

RESULTS

The tissue was found to be highly friable and hemostasis was difficult to achieve during the surgery. These clinical observations were correlated with amyloid infiltration of the dermis and blood vessels on preoperative histologic examination.

CONCLUSION

CO2 laser vaporization of nodular amyloidosis may be associated with prominent tissue friability and poor hemostasis.

Treatment of refractory solar urticaria with plasma exchange

BACKGROUND

Solar urticaria is a photodermatosis that can be very disabling for patients who are highly sensitive to light and can also be very resistant to therapy.

OBJECTIVE

To correlate the results of serial phototesting in a patient with severe and refractory solar urticaria before and after treatment with plasma exchange.

METHODS

Plasma exchange was performed five times over a period of 10 days. Phototesting to ultraviolet A (UVA) irradiation and visible light was performed with fluorescent ultraviolet tubes and an incandescent lamp.

RESULTS

The urticaria that developed after very low light doses during baseline phototesting could not be provoked following plasma exchange. The patient is now almost symptom-free, with only occasional and transient hives more than 21 months after her last plasma exchange.

CONCLUSIONS

Plasma exchange is a therapeutic modality to consider in highly light-sensitive patients when other treatments have failed.

Plaque-type multinucleate cell angiohistiocytoma

BACKGROUND

Multinucleate cell angiohistiocytoma (MCAH) is a rare cutaneous disorder that usually presents as papules or nodules.

OBJECTIVE

This article reports a case of MCAH that appeared clinically as a large cutaneous plaque.

METHODS AND RESULTS

A 74-year-old woman presented with a large painless, dusky red, indurated plaque measuring 12 x 6 cm on the trunk that was found on histopathologic examination to be a MCAH. Based on a literature review, this is the first reported case of MCAH presenting as a plaque rather than a papule or nodule.

CONCLUSION

Multinucleate cell angiohistiocytoma may manifest clinically as a solitary cutaneous plaque.

Psoriatic plaques exhibit red autofluorescence that is due to protoporphyrin IX

In evaluating the autofluorescence properties of normal and diseased skin we discovered that psoriatic plaques can emit a distinct red fluorescence when illuminated with UVA or blue light. Using a macrospectrofluorometer equipped with a 442 nm excitation laser, a sharp in vivo fluorescence emission peak around 635 nm could be demonstrated within the plaques of 34 of 75 (45%) patients with psoriasis. This peak was absent from normal appearing skin of psoriatic patients and also from the skin of 66 patients with other dermatologic diseases. A microspectrofluorometer coupled with the same excitation laser was used to obtain emission spectra of separated epidermal sheets and dermis from plaques demonstrating macroscopic red autofluorescence. An emission peak around 635 nm was observed in all three patients thus studied, but only on spectra obtained from the epidermis. Additional spectra of vertical microscopic sections of intact psoriatic skin from five other patients revealed that the peak originated from the stratum corneum. Emission spectra from other microlocations including the mid-epidermis and dermis of psoriatic and normal skin, as well as the stratum corneum of normal skin, failed to demonstrate a 635 nm peak. The excitation and emission fluorescence spectra of acid extracts of psoriatic scale from five patients were all similar to those of protoporphyrin IX in acid solution. High performance liquid chromatography identified the presence of protoporphyrin IX in the acid extracts from psoriatic scale of the same patients. We conclude that native psoriatic plaques can exhibit red autofluorescence that is due to elevated levels of protoporphyrin IX within scales.

The dynamics of laser-induced changes in human skin autofluorescence--experimental measurements and theoretical modeling

To study the temporal dynamics of human skin autofluorescence photobleaching, we measured the autofluorescence spectral changes of skin in vivo during continuous exposure to 442 nm (He-Cd) laser light. Integral intensities were calculated for various spectral wavelength bands and plotted as a function of time. Mathematical analysis of the time function revealed a double-exponential photobleaching process: I(t) = a exp (-t/tau 1) + b exp(-t/tau 2) + c, in which tau 1 and tau 2 differed by an order of magnitude. A hypothesis for the mechanism of the double-exponential photobleaching dynamics was proposed and evaluated using Monte Carlo modeling of light propagation in the skin and autofluorescence escape from skin. By combining the fluorophore microdistributions, Monte Carlo simulation results and the variation in fluorescence decrease parameters (a, b, c, tau 1, tau 2) with increasing exposure intensities a biophysical explanation for the double-exponential photobleaching function was elucidated. The fast decrease term corresponds to laser-induced photobleaching in the stratum corneum, while the slow decrease term represents fluorophore changes in the dermis. The measured autofluorescence photobleaching dynamics can be used to determine the fractional contributions of different skin layers to the total autofluorescence signal measured in vivo.

Advances in dermatologic lasers

Lasers continue to fundamentally redefine the nature of dermatologic practice. Recent advances in dermatologic lasers have focused on refining the process of selective photothermolysis, as well as evaluating new devices and treatment indications. Despite the current multiplicity of available lasers and associated marketing claims, what is perhaps most lacking are data comparing the efficacy of different lasers that can be used to treat the same condition, and data on the long term benefits of laser treatment.

Effects of sulfanilamide and methotrexate on 13C fluxes through the glycine decarboxylase/serine hydroxymethyltransferase enzyme system in arabidopsis

In C3 plants large amounts of photorespiratory glycine (Gly) are converted to serine by the tetrahydrofolate (THF)-dependent activities of the Gly decarboxylase complex (GDC) and serine hydroxymethyltransferase (SHMT). Using 13C nuclear magnetic resonance, we monitored the flux of carbon through the GDC/SHMT enzyme system in Arabidopsis thaliana (L.) Heynh. Columbia exposed to inhibitors of THF-synthesizing enzymes. Plants exposed for 96 h to sulfanilamide, a dihydropteroate synthase inhibitor, showed little reduction in flux through GDC/SHMT. Two other sulfonamide analogs were tested with similar results, although all three analogs competitively inhibited the partially purified enzyme. However, methotrexate or aminopterin, which are confirmed inhibitors of Arabidopsis dihydrofolate reductase, decreased the flux through the GDC/SHMT system by 60% after 48 h and by 100% in 96 h. The uptake of [alpha-13C]Gly was not inhibited by either drug class. The specificity of methotrexate action was shown by the ability of 5-formyl-THF to restore flux through the GDC/SHMT pathway in methotrexate-inhibited plants. The experiments with sulfonamides strongly suggest that the mitochondrial THF pool has a long half-life. The studies with methotrexate support the additional, critical role of dihydrofolate reductase in recycling THF oxidized in thymidylate synthesis.

A comparative study of calcipotriol and anthralin for chronic plaque psoriasis in a day care treatment center

Eighteen patients with symmetric plaque-type psoriasis were recruited for an open, controlled, bilateral half-body comparison study to evaluate the efficacy of calcipotriol/tar/UVB vs. anthralin/tar/UVB in a day care treatment setting. No patient had been on systemic antipsoriatic agents for at least 3 months prior to enrolment. One half-body was arbitrarily assigned to treatment with gradually increasing concentrations of anthralin as tolerated. The other half-body received calcipotriol ointment twice daily. Both sides received UVB and additional coal tar distillate in accordance with our standard day care regimen. Patients who were admitted to the day care program attended the clinic for UVB, anthralin, and calcipotriol on weekdays for two consecutive weeks. Anthralin was applied to psoriatic plaques on one side in the following fashion: anthralin 0.1% with salicylic acid 3% in zinc oxide paste on days 1 and 2; anthralin 0.2% with salicylic acid 3% in zinc oxide paste on days 3-5; anthralin 1% with salicylic acid 3% in hydrophilic petrolatum for 60 min on days 8-10 to thicker lesions; and anthralin 2% with salicylic acid 3% in hydrophilic petrolatum for 60 min on day 11 to thicker lesions. On the contralateral side, calcipotriol ointment 0.05 microgram/mL (Leo Pharmaceuticals, Ajax, Ontario) was applied to lesions twice daily. No anthralin or calcipotriol was applied on weekends. All patients applied coal tar oil 50% (Doak Oil Forte, Trans CanaDerm, St-Laurent, Québec, equivalent to 5% coal tar distillate) with salicylic acid 5% in hydrophilic petrolatum to their lesions at home in the evenings and on weekends. UVB (FSX72T12 lamps, National Biologic Corporation, Twinsburg, Ohio) was administered twice daily on weekdays in increasing doses as tolerated (to erythema) prior to the application of the topical medications. No trial medications were applied to the face, scalp, or genital regions. For clinical evaluation, the standard Psoriasis Activity and Severity Index (PASI) score was modified by splitting the score for area under 10%; the modified score (mPASI) for an area of coverage of 1%-4% was 0.5 and for an area of 5%-9% was 1. The head and neck area was excluded from the analysis since neither anthralin nor calcipotriol was used at these sites. Each half-body was considered to represent 100% in the area score determination. The maximum modified score for each side was 64.8 (vs. 72 in the standard PASI scoring system). Clinical evaluations were completed at days 0 (baseline), 3, 7, 10, and 42. The primary end-point was day 10. On day 10, patients were asked to compare the calcipotriol ointment to the anthralin on a five-point scale in terms of efficacy and irritancy and to state their future preferred treatment modality. Following discharge from day care, patients were continued on outpatient UVB and tar treatments three times weekly and asked to return for a repeat clinical assessment after 4 weeks (day 42). Blood samples taken prior to treatment and at day 10 were analyzed for serum calcium. Comparisons of treatment efficacy were based on changes in the mPASI scores from onset of treatment to day 10, as well as on the corresponding percentage changes. Analyses were carried out using the Wilcoxon test. Subjective patient comparisons of effectiveness and irritancy, as well as patient preference, were tested for equiprobability using the chi-square goodness-of-fit test with an examination of the adjusted residuals.

Current status of photodynamic therapy in dermatology

The accessibility of skin to light treatment, as well as the expertise developed by dermatologists in laser surgery and phototherapy, creates an exciting opportunity for dermatologic PDT to become part of our standard therapeutic armamentarium. PDT appears to be viable alternative to conventional therapy for superficial BCC and Bowen's disease, although definitive controlled studies are lacking. The introduction of ongoing research developments, new photosensitizers, and better light sources into clinical PDT trials in the coming years will undoubtedly expand the range of indications for this novel form of therapy, particularly for nononcologic conditions.

Arabidopsis dihydropteroate synthase: general properties and inhibition by reaction product and sulfonamides

Dihydropteroate synthase (DHPS) (EC 2.5.1.15) was extracted from leaves of Arabidopsis thaliana and purified 21-fold by ion-exchange chromatography. This enzyme preparation was then characterized for several of its properties. Michaelis-Menten constants for the substrates, p-aminobenzoic acid and dihydropteridine diphosphate were estimated to be 2.5 and 91 microM, respectively. In an optimized assay, the reaction product, dihydropteroic acid, competitively inhibited the enzyme activity with a Ki of 81 microM. However, neither dihydropteroic acid nor tetrahydrofolate, products further downstream in the biosynthetic pathway inhibited enzymatic activity. This appears to be the first report of product inhibition of DHPS from a higher plant. The relative inhibitory properties of several sulfonamides, analogues of p-aminobenzoic acid, were also examined. The substitutions on the amide nitrogen of the sulfonamides influenced the degree of inhibition; thus I50 values for the inhibition of the DHPS activity by sulfanilamide, sulfacetamide and sulfadiazine were estimated to be 18.6, 9.6 and 4.2 microM, respectively. The competitive pattern of inhibition was shown in experiments with sulfadiazine.

Nitric oxide synthase distribution in the enteric nervous system of children with cardiac achalasia

OBJECTIVE

To study the distribution of nitric oxide synthase (NOS) in the enteric nervous system of children with cardiac achalasia.

METHODS

Biopsy specimens of the lower esophagus, cardia, gastric fundus and pylorus from 13 patients with cardiac achalasia and 6 controls were obtained and studied histochemically with nicotinamide adenine dinucleotide phosphate diaphorase (NADPH-d) and immunohistochemically with a specific polyclonal antiserum.

RESULTS

NOS was abundant in the myenteric plexus and the nerve fibers of musculatures in the esophagus, cardia and gastric fundus in control group, while it was nearly absent in the patient group. The distribution of NOS in the pylorus was similar in the two groups.

CONCLUSION

These findings suggest that a lack of NOS in the lower esophagus, cardia and gastric fundus is involved in the pathophysiology of cardiac achalasia in children.