Biotin: overview of the treatment of diseases of cutaneous appendages and of hyperseborrhea

One of the most common micronutrient deficiencies with cutaneous findings is the vitamin B, also known as biotin, deficiency. Biotin deficiency may be due to congenital lack of biotinidase, or acquired following some conditions that interfere with its absorption, such as inflammatory bowel disorders, a diet too rich in avidin, magnesium deficiency, smoking habit and treatment with broad-spectrum antibiotics, anticonvulsants and sulfonamides. This review highlights the role of biotin in the most common skin disorders such associated with biotin deficiency and an approach to their treatment. Biotin administration may improve the treatment of hair loss when deficiency is detected on the basis of a careful patient history, clinical examination and the determination of serum biotin levels. The use of biotin is rationale in seborrheic dermatitis as the vitamin intercepts the main metabolic pathways underlying the pathogenesis of the disease. Treatment with biotin could also be useful in comedonal acne characterized by a high rate of seborrhea, and may be helpful for acne treated with topical retinoids, contributing to the control of flaking and irritation. The tolerability of biotin is excellent and there is no risk of hypervitaminosis even in the case of high doses. It is important that administration is controlled by physicians and follows a medical diagnosis and prescription. Correct doses used in dermatological conditions are safe and are not at risk of interference with laboratory tests.

Italian Guidelines in diagnosis and treatment of alopecia areata

Alopecia areata (AA) is an organ-specific autoimmune disorder that targets anagen phase hair follicles. The course is unpredictable and current available treatments have variable efficacy. Nowadays, there is relatively little evidence on treatment of AA from well-designed clinical trials. Moreover, none of the treatments or devices commonly used to treat AA are specifically approved by the Food and Drug Administration. The Italian Study Group for Cutaneous Annexial Disease of the Italian Society of dermatology proposes these Italian guidelines for diagnosis and treatment of Alopecia Areata deeming useful for the daily management of the disease. This article summarizes evidence-based treatment associated with expert-based recommendations.

Onychoscopy with red light for vascular pattern identification: a study of 33 patients

BACKGROUND

Nail dermoscopy (onychoscopy) during physical examination assists in correct diagnosis. Often further magnifications are necessary for an effective differential diagnosis. With the addition of a red light to the dermoscope, important vascular features can be visualized.

OBJECTIVE

To describe common features observed at onychoscopy with a new device that combines the regular white light with the red light illumination, demonstrating that it is useful for diagnosis of nail disorders.

METHODS

We enrolled 33 consecutive patients referred to the Nail Diseases Dermatology Unit of the University of Modena and Reggio Emilia and to the Outpatient Consultation for Nail Disease of the Dermatology Unit of the University of Bologna. Patients were assessed with a standard hand-held dermoscope and at the red light dermoscope. Dermoscopic images were collected.

RESULTS

The new prototype was used during daily clinical practice and allowed a more accurate visualization of some details that classic onychoscopy can miss. In particular, with the help of the red light it was possible to better visualize nail lesions that were characterized by some kind of colour change or vascular alterations.

CONCLUSION

The new device of red light for vascular pattern onychoscopy can be a new investigation method to observe nail alterations, especially due to vascular pattern, even with low magnification, without the necessity to use higher resolutions.

Frequency of the Types of Alopecia at Twenty-Two Specialist Hair Clinics: A Multicenter Study

Background

The frequency of different types of alopecia is not clearly reported in recent studies.

Objective

To analyze the frequency of the types of alopecia in patients consulting at specialist hair clinics (SHC) and to assess for global variations.

Methods

Multicenter retrospective study including data from patients evaluated at referral SHC in Europe, America, Africa and Australia.

Results

A total of 2,835 patients (72.7% females and 27.3% males) with 3,133 diagnoses of alopecia were included (73% were non-cicatricial and 27% were cicatricial alopecias). In all, 57 different types of alopecia were characterized. The most frequent type was androgenetic alopecia (AGA) (37.7%), followed by alopecia areata (AA) (18.2%), telogen effluvium (TE) (11.3%), frontal fibrosing alopecia (FFA) (10.8%), lichen planopilaris (LPP) (7.6%), folliculitis decalvans (FD) (2.8%), discoid lupus (1.9%) and fibrosing alopecia in a pattern distribution (FAPD) (1.8%). There was a male predominance in patients with acne keloidalis nuchae, dissecting cellulitis and FD, and female predominance in traction alopecia, central centrifugal cicatricial alopecia, FFA, TE, FAPD and LPP.

Conclusion

AGA followed by AA and TE were the most frequent cause of non-cicatricial alopecia, while FFA was the most frequent cause of cicatricial alopecia in all studied geographical areas.

A survey among dermatologists: diagnostics of superficial fungal infections - what is used and what is needed to initiate therapy and assess efficacy?

BACKGROUND

Superficial fungal infections are common. It is important to confirm the clinical diagnosis by mycological laboratory methods before initiating systemic antifungal treatment, especially as antifungal sensitivity and in vitro susceptibility may differ between different genera and species. For many years, the gold standard for diagnosis of superficial fungal infections has been direct fungal detection in the clinical specimen (microscopy) supplemented by culturing. Lately, newer molecular based methods for fungal identification have been developed.

OBJECTIVE

This study was initiated to focus on the current usage of mycological diagnostics for superficial fungal infections by dermatologists. It was designed to investigate whether it was necessary to differentiate between initial diagnostic tests and those used at treatment follow-up in specific superficial fungal infections.

METHODS

An online questionnaire was distributed among members of the EADV mycology Task Force and other dermatologists with a special interest in mycology and nail disease.

RESULTS

The survey was distributed to 62 dermatologists of whom 38 (61%) completed the whole survey, 7 (11%) partially completed and 17 (27%) did not respond. Nearly, all respondents (82-100%) said that ideally they would use the result of direct microscopy (or histology) combined with a genus/species directed treatment of onychomycosis, dermatophytosis, Candida- and Malassezia-related infections. The majority of the dermatologists used a combination of clinical assessment and direct microscopy for treatment assessment and the viability of the fungus was considered more important at this visit than when initiating the treatment. Molecular based methods were not available for all responders.

CONCLUSION

The available diagnostic methods are heterogeneous and their usage differs between different practices as well as between countries. The survey confirmed that dermatologists find it important to make a mycological diagnosis, particularly prior to starting oral antifungal treatment in order to confirm the diagnose and target the therapy according to genus and species.

Cutaneous complications of immunosuppression in 812 transplant recipients: a 40-year single center experience

BACKGROUND

As a consequence of the improvement in survival after solid organ transplantation, to visit transplant recipients with neoplastic and non-neoplastic skin disorders due to immunosuppressive treatment has become common for dermatologists.

METHODS

Our endpoints were: 1) to investigate the most common skin diseases in a population of transplant recipients; 2) their associations with the type of immunosuppressant or transplant received; and 3) to compare our single center 40-year experience with the literature data. We retrospectively analyzed the clinical details of the adult patients transplanted in the years 1974-2014, visited for consultation at the Unit of Dermatology of our hospital.

RESULTS

Pathologic conditions were observed in more than 3/4 of 812 adults during the follow-up (mean 12.1 years): nonmelanoma skin cancers or actinic keratoses were seen in 44.0% (N.=357) of patients, non-neoplastic events in 55.2% (N.=448). Heart transplant had the statistically significant highest rate of NMSC and AK (52.6%, P=0.0352). Patients receiving cyclosporine A developed at least one non-melanoma skin cancer or actinic keratosis in 57.7% of cases (P=0.0001), while tacrolimus showed a lower risk (33%, P=0.0001).

CONCLUSIONS

As transplant recipients are susceptible to skin changes, especially after immunosuppressant treatments, a dermatological follow-up should be scheduled for each patient.

Management of mycoses in daily practice

The guideline recommendations, albeit founded on thorough reviews of clinically relevant literature data, are often not immediately adaptable to everyday life. Considering the marked heterogeneity of superficial mycoses, each of them requires specific management in a real life context; in all cases diagnostic confirmation is required with microscopic and culture examination. In tinea capitis oral therapy is necessary (minimum six weeks) and should be continued until clinical and, above all, mycological healing. In cases of tinea corporis, cruris or pedis, it may be necessary to associate oral therapy to topical treatment. The main oral antifungals are fluconazole, itraconazole and terbinafine. Fluconazole has favorable pharmacokinetic and pharmacodynamic characteristics, and is effective in most superficial mycoses, for example in cases of diffuse or recurrent pityriasis versicolor in which oral therapy with an azole derivative is useful. Topical treatment, lasting 6-12 months, is indicated in onychomycosis that is confined to one nail. In frequent cases of onychomycosis involving multiple nails or recurrence, oral therapy is necessary. Pharmacological history is important, given the possible interactions of some systemic drugs. In chronic or recurrent relapsing vulvovaginitis, first-choice therapy is oral fluconazole with a therapeutic regimen that respects the mycotic biorhythm (200 mg on days 1, 4, 11, 26, and subsequently 200 mg/week for 3 months).

Mohs micrographic surgery for nail unit tumours: an update and a critical review of the literature

Mohs micrographic surgery (MMS) is a good treatment option for epithelial neoplasms, especially when localized in areas where tissue conservation is crucial, such as the nail unit (NU). MMS is a method of radical excision offering high cure rates due to the margin control and functional preservation. Our aim is to provide a review on the use of MMS for the treatment of the most common nail tumours. We revised the current literature on the use of MMS to treat malignant neoplasms (Bowen's disease, squamous cell carcinoma, melanoma, basal cell carcinoma, keratoacanthoma, carcinoma cuniculatum) and benign neoplasms (onychomatricoma and glomus tumour). MMS represents a successful surgical option for nail tumours, firstly in terms of tissue conservation: the NU anatomy is complex and the preservation of the component structures is imperative for its functionality. Secondly, due to the surgical radicality, which is essential not only for the clearing of malignant tumours, but also for benign cases, in order to reduce recurrences. Although a conservative treatment of NU melanoma with MMS has been proposed, in our experience, the conservative approach with functional surgery is a good option for the treatment of non-invasive melanoma (in situ and Ia).

Cicatricial alopecia

Cicatricial alopecias (CAs) are clinical pathological conditions that result in the complete destruction of hair follicles, which are replaced by fibrotic structures. Clinically they are characterized by different inflammatory conditions resulting in the end stage in the complete disappearance of hair follicle and follicular ostia. CAs are classified in primary cicatricial alopecia (PCA) and secondary cicatricial alopecia (SCA). PCA include multiple inflammatory diseases with distinctive clinical and histopathologic features that primarily affect and destroy the hair follicle. On the other way, diseases classified as SCA include inflammatory and neoplastic conditions and physical traumas usually primarily affecting the dermis and causing secondary follicular destruction.

Evidence-based (S3) guideline for the treatment of androgenetic alopecia in women and in men - short version

Androgenetic alopecia is the most common hair loss disorder, affecting both men and women. Initial signs of androgenetic alopecia usually develop during teenage years leading to progressive hair loss with a pattern distribution. Moreover, its frequency increases with age and affects up to 80% Caucasian men and 42% of women. Patients afflicted with androgenetic alopecia may undergo significant impairment of quality of life. The European Dermatology Forum (EDF) initiated a project to develop evidence-based guidelines for the treatment of androgenetic alopecia. Based on a systematic literature research the efficacy of the currently available therapeutic options was assessed and therapeutic recommendations were passed in a consensus conference. The purpose of the guideline is to provide dermatologists with an evidence-based tool for choosing an efficacious and safe therapy for patients with androgenetic alopecia.

Sequential monitoring of pigmented lesions during dabrafenib treatment: a prospective study and a literature overview

BACKGROUND

Targeted therapies in melanoma have shown clinical benefit in incrementing the overall survival of metastatic patients. However, cutaneous adverse events have been frequently associated with these drugs.

METHODS

We report our experience in the management of patients treated with dabrafenib for metastatic melanoma, focusing on the monitoring of pigmented lesions. Dermatologic evaluation was performed during the first visit, at the start of each treatment and subsequently after every four weeks. Global nevi count, videodermoscopy of suspected lesions, and surgical excisions when necessary were performed at the beginning of the treatment and every fourth week. All other cutaneous adverse events (cAEs) were noted and documented. Eleven patients were included.

RESULTS

The most important cAEs included palmo-plantar hyperkeratosis, diffuse xerosis and pigmented lesion changes. Regarding the latter, in 6 patients, especially in the first months of treatment, we observed hyperpigmentation and hyperkeratosis of the nevi, of the pigmented mucosae and, in one patient, hyperkeratotic changes on a cutaneous metastasis. Histopathology of the excised lesions showed one ex novo melanoma occurrence and benign changes to pre-existing nevi.

CONCLUSIONS

The awareness of the importance of sequential monitoring of pigmented lesions, with particular attention to the lesions of new onset, is crucial for the best management of these complex patients.

Management and treatment of nail melanoma

BACKGROUND

An early and prompt nail apparatus melanoma (NAM) diagnosis is associated with less invasive surgical procedures and a better patient's prognosis. The diagnostic delay may be related both to the clinical misinterpretations and to errors in the diagnosing process. Biopsy techniques have been adequately described by nail experts, but the two main problems in the correct choice of the biopsy are probably related to the difficulty in performing surgery in the nail unit and the risk of permanent nail dystrophy.

METHODS

We retrospectively investigated anamnestic data and diagnostic procedures that all NAM patients referred from 1992 to January 2014, with the following objectives: 1) to evaluate the initial misdiagnoses and quantify the diagnostic delay; 2) to correlate the type of the initial biopsy with the achievement of the correct diagnosis.

RESULTS

In our cases it was easier for a non-dermatologist to misdiagnose NAM for a benign inflammatory disease. Dermatologist instead were easier to refer patients to a tertiary center for nail diseases.

CONCLUSIONS

In the presence of a NAM clinical and dermoscopic suspicion, longitudinal biopsy is recommended in all cases of nail pigmentation (lateral or median), that is estimated in its width as 3-6 mm, or larger than 6 mm. Regarding therapeutic surgery in our experience disarticulation compared to "functional surgical excision" did not correlate with a better prognosis.

Clinical and dermoscopic clues to differentiate pigmented nail bands: an International Dermoscopy Society study

BACKGROUND

Longitudinal melanonychia might be difficult to differentiate and the use of dermoscopy can be useful for the preoperative evaluation and management decision.

OBJECTIVES

The aim of our study was to investigate clinical and dermoscopic criteria of acquired longitudinal melanonychia in adults to identify the best predictors of melanoma using a multivariate analysis and to explore eventual new dermoscopic criteria for nail melanoma diagnosis.

METHODS

In this retrospective observational study, 82 histopathologically diagnosed, acquired nail pigmented bands were collected and examined. All variables were included in the analysis and examined as possible predictors of nail melanoma. Both univariate and multivariable analyses have been performed.

RESULTS

Among 82 cases, 25 were diagnosed as nail melanoma and 57 as benign lesions (including 32 melanocytic nevi and 25 benign melanocytic hyperplasia). Melanoma cases were significantly associated with a width of the pigmented band higher than 2/3 of the nail plate, grey and black colours, irregularly pigmented lines, Hutchinson and micro-Hutchinson signs, and nail dystrophy. Granular pigmentation, a newly defined dermoscopic criterion, was found in 40% of melanomas and only in 3.51% of benign lesions.

CONCLUSIONS

Dermoscopic examination of longitudinal melanonychia provides useful information that could help clinicians to improve melanoma recognition.

Nail involvement as a negative prognostic factor in biological therapy for psoriasis: a retrospective study

BACKGROUND

Psoriasis (Pso) has a strong impact on quality of life and a positive association has been reported between nail psoriasis (NP) and more severe disease, together with a longer duration of skin lesions. The treatment of NP represents a challenge and biological therapy can be recommended for severe disease.

OBJECTIVE

The first end point of this retrospective study was to evaluate the time to achieve Psoriasis Area Severity Index (PASI) 75 in patients with and without NP treated with biological therapy. The second end point was to evaluate the efficacy of biological therapy to improve NP.

METHODS

A total of 127 patients (88 men and 39 women) with moderate to severe Pso referring to our Service between 2007 and 2014 were included. Inclusion criteria were age ≥18 years and a 24 week treatment. The outcome variable was achievement of PASI 75 at 24 weeks with and without NP. All patients were treated with topical therapy and one of four different biological treatments: adalimumab (44.09%), etanercept (18.11%), infliximab (13.39%) and ustekinumab (24.41%). Physical examinations were performed every 4 weeks, and at each visit, the clinician assessed the PASI and Nail Psoriasis Severity Index (NAPSI).

RESULTS

At multivariate Cox regression analysis, a smaller proportion of patients with NP achieved PASI 75 at 24 weeks than patients without NP when adjusted for the epidemiological, clinical features and biological treatment received. With all biological drugs, the NAPSI score began to improve already after 8 weeks (from 18.53 at week 0-2.83 at week 24).

CONCLUSION

Patients with NP reach PASI 75 more slowly than patients without NP. Clinicians should therefore consider that treatment with a biological agent may require a longer period before reaching a satisfying therapeutical goal. Nevertheless, adalimumab, infliximab, ustekinumab and etanercept demonstrated their equal effectiveness in reducing the NAPSI score.