European expert consensus statement on the systemic treatment of alopecia areata

Alopecia areata is an autoimmune form of non-scarring hair loss. It is usually characterized by limited areas of hair loss. However, the disease may progress to complete scalp and body hair loss (alopecia totalis, alopecia universalis). In patients with alopecia areata hair loss significantly impacts the quality of life. Children and adolescents with alopecia areata often experience bullying, including physical aggression. The disease severity evaluation tools used in clinical practice are: the Severity of Alopecia Tool (SALT) score and the Alopecia Areata Scale (AAS). A SALT score equal to or greater than 20 constitutes a commonly accepted indication for systemic therapy in alopecia areata. When using the AAS, moderate to severe alopecia areata should be considered a medical indication for systemic treatment. Currently, the only two EMA-approved medications for alopecia areata are baricitinib (JAK 1/2 inhibitor) for adults and ritlecitinib (JAK 3/TEC inhibitor) for individuals aged 12 and older. Both are EMA-approved for patients with severe alopecia areata. Other systemic medications used off-label in alopecia areata include glucocorticosteroids, cyclosporine, methotrexate and azathioprine. Oral minoxidil is considered an adjuvant therapy with limited data confirming its possible efficacy. This consensus statement is to outline a systemic treatment algorithm for alopecia areata, indications for systemic treatment, available therapeutic options, their efficacy and safety, as well as the duration of the therapy.

Current controversies in trichology: a European expert consensus statement

INTRODUCTION

Hair disorders are one of the most common conditions within dermatology practice but, although new diagnostic tools and therapeutic options have arisen, the management of these patients still represents a major clinical challenge.

OBJECTIVE

This study aimed at gathering information and achieving consensus on relevant recommendations on the latest advances in alopecia, trichoscopy and hair dermocosmetics.

METHODS

Experts of the steering committee consulted the available evidence on trichology-related areas from the past 5 years and formulated recommendations based on the evidence and their experience. A modified two-round Delphi procedure was performed among 45 European dermatologists experts in trichology to consult their degree of agreement on twenty recommendations, using a 4-point Likert scale. Consensus was defined as >80% of participants scoring either 1 (totally agree) or 2 (agree).

RESULTS

In the first round of the Delphi questionnaire, 75% of the recommendations reached consensus. Those that were not agreed upon were reformulated by the steering committee and voted again after an online meeting, where consensus was achieved in all recommendations.

CONCLUSIONS

All recommendations reached consensus after the two-round Delphi questionnaire and may be useful in clinical practice for dermatologists. The participants agreed that besides this consensus, further clinical studies are needed to assess the benefits of the emerging tools and treatments and to clarify the controversies that still exist in the field, aiming at improving patients' quality of life.

Guidelines for clinical trials of frontal fibrosing alopecia: consensus recommendations from the International FFA Cooperative Group (IFFACG)

BACKGROUND

Frontal fibrosing alopecia (FFA) has become one of the most common causes of cicatricial alopecia worldwide. However, there is a lack of clear aetiology and robust clinical trial evidence for the efficacy and safety of agents currently used for treatment.

OBJECTIVES

To enable data to be collected worldwide on FFA using common criteria and assessment methods.

METHODS

A multicentre, international group of experts in hair loss was convened by email to create consensus recommendations for clinical trials. Consensus was defined at > 90% agreement on each recommended part of these guidelines.

RESULTS

Standardized diagnostic criteria, severity rating, staging, and investigator and patient assessment of scalp hair loss and other clinical features of FFA were created.

CONCLUSIONS

These guidelines should allow the collection of reliable aggregate data on FFA and advance efforts in both clinical and basic research to close knowledge gaps in this condition.

Skin manifestations of COVID-19 in children: Part 2

The current COVID-19 pandemic is caused by the SARS-CoV-2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS-CoV-2 infection in children differ from those in adults, as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID-19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discussed one of the first and most widespread cutaneous manifestations of COVID-19, chilblain-like lesions. In this part of the review, we describe other manifestations, including erythema multiforme, urticaria and Kawasaki disease-like inflammatory multisystemic syndrome. In Part 3, we discuss the histological findings of COVID-19 manifestations, and the testing and management of infected children for both COVID-19 and any other pre-existing conditions.

Skin manifestations of COVID-19 in children: Part 3

The current COVID‐19 pandemic is caused by the SARS‐CoV‐2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS‐CoV‐2 infection in children differ from those in adults as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID‐19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discuss one of the first and most widespread cutaneous manifestations of COVID‐19, chilblain‐like lesions, and in Part 2 we expanded to other manifestations, including erythema multiforme, urticaria and Kawasaki disease‐like inflammatory multisystemic syndrome. In this part of the review, we discuss the histological findings of COVID‐19 manifestations, and the testing and management of infected children for both COVID‐19 and any other pre‐existing conditions.

Click here for the corresponding questions to this CME article.

Skin manifestations of COVID-19 in children: Part 1

The current COVID‐19 pandemic is caused by the SARS‐CoV‐2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS‐CoV‐2 infection in children differ from those in adults as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID‐19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discuss one of the first and most widespread cutaneous manifestation of COVID‐19, chilblain‐like lesions. In Part 2, we review other manifestations, including erythema multiforme, urticaria and Kawasaki disease‐like inflammatory multisystemic syndrome, while in Part 3, we discuss the histological findings of COVID‐19 manifestations, and the testing and management of infected children, for both COVID‐19 and any other pre‐existing conditions.

Click here for the corresponding questions to this CME article.

Beard alopecia areata: a multicentre review of 55 patients

BACKGROUND

Alopecia areata on the beard area (BAA) is a common clinical manifestation, but there are no studies about its characteristics.

OBJECTIVE

To describe the epidemiology, comorbidities, clinical presentation, evolution, diagnostic findings and therapeutic choices in a series of patients with BAA.

METHODS

This retrospective multicentre review included patients diagnosed with BAA as the first and unique clinical manifestation with at least 12 months of follow-up. Diagnosis was performed based on the typical clinical features. Extra-beard involvement was monitored in all cases.

RESULTS

Overall, 55 male patients with a mean age of 39.1 years (range 20-74) were included. Twenty-five patients (45.5%) developed alopecia of the scalp during follow-up and more than 80% of cases appeared in the first 12.4 months. Clinical presentation of AA on the scalp was patchy AA (less than 5 patches) (52%), multifocal AA (28%), AA totalis (12%) and AA universalis (8%). Multivariate analysis revealed a trend of association between scalp involvement and family history of AA without statistical significance.

CONCLUSIONS

According to this study, BAA may progress to scalp AA in a significant number of patients (45.5% of the patients with a follow-up interval of at least 12 months). In the group of patients who developed scalp AA, 80% of them did it within the first 12 months, so follow-up of patients with BAA is highly encouraged.

Rapidly-growing squamous cell carcinoma shortly after treatment with ingenol mebutate for actinic keratoses: report of two cases

Actinic keratoses (AKs) are defined as cutaneous areas of atypical squamous transformation that are regarded as an early step in the continuum of alterations leading from normal skin to invasive and metastatic squamous cell carcinoma (SCC). AKs are classified as precancerous lesions by some authors and in situ SCC by others. The rate of evolution of a given AK to an invasive SCC has been estimated as 0·075-0·096% per lesion per year. These rates are similar to those estimated for gynaecological intraepithelial neoplasia. We describe two cases of SCC with rapid onset that developed after the application of ingenol mebutate gel for the treatment of AKs.

Folliculitis decalvans: a multicentre review of 82 patients

BACKGROUND

Folliculitis decalvans (FD) is a rare neutrophilic scarring alopecia that represents a therapeutic challenge for dermatologists.

OBJECTIVE

To describe the epidemiology, comorbidities, clinical presentation, diagnostic findings and therapeutic options in a large series of patients with FD.

METHODS

This retrospective multicentre review includes patients diagnosed with FD based on clinical and histopathologic findings. The clinical severity was determined by the maximum diameter of the largest alopecic patch (slight: <2 cm, moderate: 2-4.99 cm, severe: 5 cm or more). Response to therapy was assessed as improvement, worsening or stabilization depending on the clinical symptoms (pruritus and trichodynia), inflammatory signs (erythema, pustules and crusts) and the extension of the alopecic patch.

RESULTS

Overall, 82 patients (52 males and 30 females) with a mean age of 35 years were included. No significant comorbidities were present. A family history was present in three males. Severe FD was observed in 17 patients (21%). The independent factors associated with severe FD after multivariate analysis were: onset of FD before 25 years of age and presence of pustules. Oral antibiotics (tetracyclines and the combination of clindamycin and rifampicin) improved 90% and 100% of the patients, with a mean duration of response of 4.6 and 7.2 months respectively.

CONCLUSIONS

The onset of FD before 25 years of age and the presence of pustules within the alopecic patch were associated with severe FD. Tetracyclines and the combination of clindamycin and rifampicin were the most useful treatments.

Hair loss in infancy

Hair diseases represent a significant portion of cases seen by pediatric dermatologists although hair has always been a secondary aspect in pediatricians and dermatologists training, on the erroneous basis that there is not much information extractable from it. Dermatologists are in the enviable situation of being able to study many disorders with simple diagnostic techniques. The hair is easily accessible to examination but, paradoxically, this approach is often disregarded by non-dermatologist. This paper has been written on the purpose of trying to serve in the diagnostic process of daily practice, and trying to help, for example, to distinguish between certain acquired and some genetically determined hair diseases. We will focus on all the data that can be obtained from our patients' hair and try to help on using the messages given by hair for each patient. Quite often it is extremely hard to distinguish between abnormality and normality in neonatal hair aspects. We will specially focus in the most common physiological changes that may mislead to an incorrect diagnosis. Specific treatment for those hair diseases that do have one, and basic general approach to improve the cosmetic appearance of hair, will be also be discussed for those hair disturbances that do not have a specific treatment.

[Results of video-assisted thoracoscopic sympathectomy for facial blushing]

BACKGROUND

Involuntary craniofacial erythema, or blushing, due to autonomic dysfunction can be a cause of psychological distress. Although anecdotal reports have suggested that pharmacologic treatments or cognitive behavioral therapy can be used to treat the condition, no rigorous analyses of their efficacy have been reported.

OBJECTIVES

To assess the efficacy of video-assisted thoracoscopic sympathectomy and to study phobic anxiety and other personality traits in a series of patients with involuntary facial blushing.

MATERIALS AND METHODS

We carried out a retrospective observational study of patients treated with bilateral video-assisted thoracoscopic sympathectomy for blushing over a 7-year period (2001-2008). All the patients were treated by a dermatologist, a psychologist, and a thoracic surgeon and were informed of the predicted outcomes.

RESULTS

A total of 204 patients with a mean age of 34 years (range, 15-67 years) were included; the numbers of males and females were similar. Only 10% had unpredicted outcomes; in such cases, either the procedure was insufficiently effective or postoperative reflex sweating developed (and was considered serious in 2%). There were no deaths and only 1 case of transient Horner syndrome. Video-assisted thoracotomy was required for pleural symphysis in 1 patient; 5 patients developed pneumothorax, but only 1 of them required pleural drainage.

CONCLUSIONS

Video-assisted sympathectomy is a safe, effective and definitive treatment for disabling blushing. Anxiety that is detected before surgery is a reaction to blushing rather than a cause of it.

[Trichothiodystrophy: PIBIDS syndrome]

Trichothiodystrophy comprises a heterogeneous group of autosomal recessive entities. This fact gives rise to different interrelated neuroectodermal disorders. From a structural point of view these features are the result of the low tissue sulfur content. We report a case of trichothiodystrophy initially classified as Tay syndrome that based on clinical features, complementary exams as well as on the disease evolution was labelled as PIBIDS syndrome.

Dermatological image search engines on the Internet: do they work?

BACKGROUND

Atlases on CD-ROM first substituted the use of paediatric dermatology atlases printed on paper. This permitted a faster search and a practical comparison of differential diagnoses. The third step in the evolution of clinical atlases was the onset of the online atlas. Many doctors now use the Internet image search engines to obtain clinical images directly.

OBJECTIVES

The aim of this study was to test the reliability of the image search engines compared to the online atlases.

METHODS

We tested seven Internet image search engines with three paediatric dermatology diseases.

RESULTS

In general, the service offered by the search engines is good, and continues to be free of charge. The coincidence between what we searched for and what we found was generally excellent, and contained no advertisements. Most Internet search engines provided similar results but some were more user friendly than others. It is not necessary to repeat the same research with Picsearch, Lycos and MSN, as the response would be the same; there is a possibility that they might share software.

CONCLUSIONS

Image search engines are a useful, free and precise method to obtain paediatric dermatology images for teaching purposes. There is still the matter of copyright to be resolved. What are the legal uses of these 'free' images? How do we define 'teaching purposes'? New watermark methods and encrypted electronic signatures might solve these problems and answer these questions.

Treatment of patients with atopic dermatitis using wet-wrap dressings with diluted steroids and/or emollients. An expert panel's opinion and review of the literature

BACKGROUND

The use of dampened bandages to reduce inflamed eczema (synonyme dermatitis) is an old remedy. In order to evaluate the current indications for so-called wet-wrap treatment (WWT) for atopic dermatitis (AD), and to compare the different currently recognized methods, a group of experts critically reviewed their own expertise on WWT in respect to the existing literature on the subject.

RESULTS

WWT is well tolerated in eczema due to the cooling effect on the skin and the rapid improvement in skin inflammation. It has been shown to be an extremely effective treatment for acute erythrodermic dermatitis, therapy-resistant AD and intolerable pruritus. Advantages of WWT include rapid response to therapy, reduction in itch and sleep disturbance, and potential for reduction in usage of topical corticosteroids (TCS). However, disadvantages include high cost, the necessity for special training in usage, potential for increased TCS absorption, increased cutaneous infections and folliculitis, and poor tolerability. Precautions to reduce the risks of long-term treatment should include education, monitoring of weight and height and, if necessary, serum cortisol levels. In adolescents the risk of striae from TCS absorption around puberty is high, and WWT with TCS in this age group should be used as a short-term therapy only and with extreme caution. To reduce risks, dilutions of steroids may be used ranging from 5 to 10%. In the maintenance phase this treatment can be rotated with the use of emollients only. Low potency TCS should be used on the face (with a mask).

CONCLUSION

WWT using diluted steroids is a relatively safe addition to the therapeutic treatment options for children and adults with severe and/or refractory AD. Explanation and education is extremely important in the treatment of AD and WWT should only be employed by practitioners trained in its use. Specialized nursing care is essential, especially when using WWT for prolonged periods.

Radiotherapy for in situ extramammary Paget disease of the vulva

BACKGROUND

Radiotherapy as a first-choice treatment for in situ extramammary Paget disease has been successfully used.

OBJECTIVES

To review the most relevant aspects of radiotherapy as first-choice treatment in selected cases of in situ extramammary Paget disease of the vulva.

PATIENTS AND METHODS

Two Caucasian females aged 76 and 92 years with in situ extramammary Paget disease localized in the genital region were treated by means of ortovoltage X-rays: 100 kV, 8 mA, 1.7 mm Al filter, field size of 12-cm cone, and source skin distance of 30 cm. Both patients received 40 Gy, 200 cGy per fraction, five fractions per week.

RESULTS

Complete regression of in situ extramammary Paget disease was observed in both patients after radical radiation therapy and neither local recurrences nor internal malignancies were detected.

CONCLUSIONS

Radiotherapy is a curative treatment in selected cases of in situ extramammary Paget disease affecting the vulva.

The true and the false: pixel-byte syndrome

The possible use of retouched images for fraudulent purposes in scientific articles, posters, and conferences is not a future but a present possibility (probably already used) that poses serious questions as to the need for additional control mechanisms other than scientific peer quality review in evaluating and accepting articles. We propose the term "pixel-byte syndrome" to illustrate how easy it might be to electronically create a new syndrome for fraudulent purposes. The aim of this article is to stimulate discussion among professionals, add some examples of easy-to-realize frauds and sow the seeds of doubt in the minds of some of the referees of journal articles and the scientific secretariat of congresses in reviewing digitally retouched images.

Radiotherapy for genital extramammary Paget's disease in situ

BACKGROUND

Radiotherapy as a first-choice treatment for extramammary Paget's (EMP) disease in situ has been seldom used.

OBJECTIVE

To review the most relevant aspects of radiotherapy as first-choice treatment in selected cases of anogenital EMP disease in situ.

METHODS

Two men with an age range of 71-79 years (mean age 75 +/- 5.6 years) with EMP disease in situ localized in the genital region were treated by means of X-rays of 100 kV, 440 cGy/day, 3 days a week over 3 weeks until a total dose of 3960 cGy was completed.

RESULTS

Complete regression of EMP disease in situ was observed in both patients after radical radiation therapy and neither local recurrences nor internal malignancies have been documented.

CONCLUSION

Radiotherapy is a curative treatment in selected cases of EMP disease in situ affecting large areas of the anogenital region.

Acquired partial curly hair

We report 6 adolescent females apparently affected by diffuse partial woolly hair. The patients complained of thinning and curling of some hair of the scalp. Examination revealed two distinct hair populations. The first hair population was straight, normally pigmented and of normal length, thus considered "normal" hair. The second hair population was wavy, curly, thinner and apparently slightly shorter, thus considered abnormal. Direct examination of the abnormal hair population under a light microscope revealed a curled pattern of the hair shaft, and single torsions. With light microscopy the clinically normal hair had no abnormalities. Under scanning electron microscopy (SEM) the abnormal hair had curly and flattened hair shafts of 30-60 mum in diameter, oval shaped sections, canalicular formations, single torsions and cuticular weathering. With SEM, clinically "normal" hair had a diameter between 60-80 mum, with no major relevant abnormalities except for weathering. These results are suggestive of a new variant of acquired kinking (curling) of hair simulating diffuse partial woolly hair. The absence of clinical alterations in the proximal area of the affected hair and the spontaneous improvement with time, suggests that this variant may result from environmental exposure (weathering, cosmetic procedures) in predisposed individuals.