The effectiveness of finasteride and dutasteride used for 3 years in women with androgenetic alopecia

BACKGROUND

The effectiveness of finasteride and dutasteride in women with androgenetic alopecia has been the subject of debate.

AIM

To evaluate the effectiveness of finasteride and dutasteride on hair loss in women with androgenetic alopecia over a period of 3 years.

METHODS

From a database containing systematically retrieved data on 3500 women treated for androgenetic alopecia between 2002 and 2012 with finasteride 1.25 mg or dutasteride 0.15 mg, a random sample stratified for age and type of medication was taken to yield 30 women in two age categories: below and above 50 years, and for both medications. Hair thickness of the three thinnest hairs was measured from standardized microscopic images at three sites of the scalp at the start of the treatment and after 3 years of continuous medication intake. The macroscopic images were evaluated independently by three European dermatologists/hair experts. The diagnostic task was to identify the image displaying superior density of the hair.

RESULTS

Both age categories showed a statistically significant increase in hair thickness from baseline over the 3-year period for finasteride and dutasteride (signed rank test, P=0.02). Hair thickness increase was observed in 49 (81.7%) women in the finasteride group and in 50 (83.3%) women in the dutasteride group. On average, the number of post-treatment images rated as displaying superior density was 124 (68.9%) in the finasteride group, and 118 (65.6%) in the dutasteride group. Dutasteride performed statistically significantly better than finasteride in the age category below 50 years at the central and vertex sites of the scalp.

CONCLUSIONS

Finasteride 1.25 mg and dutasteride 0.15 mg given daily for 3 years effectively increased hair thickness and arrested further deterioration in women with androgenetic alopecia.

Pain evaluation in patients affected by cutaneous squamous cell carcinoma and actinic keratosis: an observational study

BACKGROUND

Pain is a frequent symptom in cancer patients. The aim of our study was to evaluate the presence of pain in histopathologically-diagnosed hypertrophic actinic keratosis (AK) or cutaneous squamous cell carcinoma (SCC).

METHODS

An observational study evaluating pain presence and intensity in skin cancer was performed, including patients affected either by SCC or by hypertrophic AK. Pain intensity was assessed using the 11-point Numeric Rating Scale, ranging from 0 (absence of pain) to 10 (most intense pain). Both spontaneous pain and pressure-related pain intensity, due to local digital pressure, were evaluated.

RESULTS

In patients with SCC, spontaneous pain was present in 57.5% of the cases, while pressure-related pain was revealed in 80.0% of the cases. In hypertrophic AK patients, spontaneous pain was detected only in 15.0% of the cases, while pressure-related pain was present in 25.0% of the cases. A statistically significant difference between the 2 groups was found in the evaluation of spontaneous and pressure-related pain values, these values being significantly higher in the SCC group. No significant correlations between the degree of inflammation, the histotype or invasiveness of SCCs, and the intensity of pain were found.

CONCLUSIONS

The recognition of pain as a symptom, more frequently associated with SCC, might prove useful in the clinical practice. Further research is needed, in order to better understand and characterize pain associated with different skin neoplasms.

Evaluation of efficacy and tolerability of four weeks bifonazole treatment after nail ablation with 40% urea in mild to moderate distal subungual onychomycosis

BACKGROUND

The aim of this study was to verify efficacy and tolerability of sequential therapy with 40% urea paste followed by 1% bifonazole urea in mild to moderate distal subungual onychomycosis of the toenails.

METHODS

It was an seven weeks open study. Sequential patients affected by mild to moderate distal subungual onychomycosis of the toenails agreed to apply on the affected nail 40% urea paste in occlusion overnight for the first three weeks, with gentle scraping with a spatula the following day, followed by 1% bifonazole cream once a day for 4 weeks. Efficacy evaluation was based on mycology, clinical photography and investigator and patient assessment. Tolerability assessment included subjective and objective evaluations.

RESULTS

The ten patients enrolled (mean age 57.5 years) completed the study. Onychomycosis was caused in nine cases by dermatophytes and by Scopulariopsis brevicaulis in one patient. At the end of the study, mycological examination was negative in all 10 patients. Clinical photographs showed a reduction of the percentage of the nail affected by onychomycosis in 8 cases, cure in 2 and considerable reduction of the nail thickness, already evident after 7 days. All patients reported to be satisfied by the treatment, which was judged easy to perform and well tolerated.

CONCLUSIONS

Treatment with urea and bifonazole is effective and well tolerated, and easy to do also by elderly patients.

Periungual pyogenic granulomas due to topical tazarotene for nail psoriasis

Tazarotene is a topically-applied, receptor-selective retinoid that has been shown to modulate several major pathogenic factors of psoriasis. Adverse effects are those of topical application of retinoids, the most common being mild to moderate burning, itching, stinging, and erythema, due to mild to moderate local skin irritation. While pyogenic granuloma-like lesions are a well recognized side effects of systemic retinoids, to our knowledge in the literature there is only one reported case of pyogenic granuloma (PG) following topical application of tazarotene for scalp psoriasis. In this paper we report 2 cases of periungual PGs following application of topical tazarotene and we present a review of the literature.

Androgenetic alopecia

Androgenetic alopecia (AGA) is the most common form of alopecia, affecting up to 80% of men and 50% of women in the course of their life. AGA is caused by a progressive reduction in the diameter, length and pigmentation of the hair. Hair thinning results from the effects of the testosterone metabolite dehydrotestosterone (DHT) on androgen-sensitive hair follicles. In women, AGA produces diffuse thinning of the crown region with maintenance of the frontal hairline (Ludwig pattern AGA). In premenopausal women, AGA can be a sign of hyperandrogenism, together with hirsutism and acnes. Male pattern is characterized by bitemporal recession of the frontal hairline, followed by diffuse thinning at the vertex. Today, scalp dermoscopy is used routinely in patients with androgenetic alopecia, as it facilitates the diagnosis and differential diagnosis with other diseases, allows staging of severity, and allows you to monitor the progress of the disease in time and response to treatment. AGA is a progressive disease that tends to worsen with time. Medical treatment of AGA includes topical minoxidil, antiandrogen agents, 5-alpha reductase inhibitors.

Update on the management of onychomycosis

Onychomycosis is a fungal infection of the nail which is highly prevalent in the general population, particularly among older individuals. Patients seek care because the disease is infectious or simply for an esthetic discomfort. The difficulty in treating onychomycosis results from the deep-seated nature of the infection within the nail unit and the inability of drugs to effectively reach all sites. Present treatment options include both oral and topical drugs, with oral therapies giving better outcomes. New derivatives with a favorable risk-benefit ratio and new formulations of older azoles seem to be promising. The research for new drugs or formulations has the objective of discovering new active antifungals or new technologies to facilitate incorporation or persistence of existing antifungal drugs inside the nail plate. In fact, the same antimycotics that heal skin fungal infections are rendered less efficacious in nail disease. This update has the aim to synthesize and focus the therapies currently in use and new therapeutic approaches on onychomycosis. It also summarizes the newer areas of research in the treatment of onychomycosis as photodynamic and laser therapy.

Nail apparatus melanoma: is trauma a coincidence? Is this peculiar tumor a real acral melanoma?

Nail Apparatus Melanoma (NAM) is rare, particularly in Caucasians. Understanding its pathogenesis and collecting epidemiologic data may be difficult due to its location and the exiguity of the case series of this cancer. Cutaneous melanoma has been thought related to UV radiation, and NAM is considered an acral variant of melanoma, even if the nail presents a specific anatomy. Little is reported about pathogenesis, except reports suggesting traumatic injuries as a causal factor. UV exposure is debated in nail melanoma because of its structure. The nail is, in fact, a unique structure with sun-exposed and non exposed melanocytes. NAM arises from the nail melanocytes, located in the nail matrix, which is the germinative part of the nail and composed of a proximal and distal portion. The proximal nail matrix lays under the proximal nail fold that covers it and is non-sun exposed, while the distant nail matrix, clinically visible as the lunula, is sun-exposed, though lying underneath the nail plate. According to these anatomical data, NAM is a distinct melanoma type, and studies need to classify it as acral melanoma or as a particular type of melanoma with its own pathogenesis and prognostic criteria. This study investigates potential risk factors of NAM, emphasizing (i) trauma and (ii) UV exposure among our NAM patients.

In situ melanoma of the nail unit in children: report of two cases in fair-skinned Caucasian children

Nail melanoma in children is rarely reported in the literature, and all of the published cases were diagnosed in dark-skinned phototypes or in Asians. We report two cases of in situ nail matrix melanoma presenting as longitudinal melanonychia (LM) in fair-skinned children of Italian origin. Nail plate dermatoscopy revealed a brown background with lines of irregular color, spacing, and thickness in both cases. Histopathology of the excised lesions showed melanoma in situ. Clinical, dermatoscopic, and pathological criteria that permit clear differentiation of benign melanocytic activation or proliferation from nail matrix melanoma are not established for children. The presence of a pigmented band of a single nail in a child usually represents a problem for clinicians, because the clinical and dermatoscopic features that are considered possible indicators of nail unit melanoma in adults are frequently observed in benign melanocytic hyperplasia and nevi in children. There is therefore the need to find parameters useful for clinical and dermatoscopic diagnosis in childhood nail pigmentation and to reach a consensus on management of children with a band of LM.

Nail digital dermoscopy (onychoscopy) in the diagnosis of onychomycosis

BACKGROUND

Distal subungual onychomycosis and traumatic onycholysis are the most common causes of toenail abnormalities, and differential diagnosis is often impossible without mycology.

OBJECTIVES

To identify and describe dermoscopic signs specific for distal subungual onychomycosis that could facilitate its diagnosis and differentiation from traumatic mycologically negative onycholysis and to determine the sensitivity and specificity of these dermoscopic features.

METHODS

We performed a retrospective study at the Outpatient Consultation for Nail Diseases of the Department of Dermatology of the University of Bologna. Dermoscopic digital images of 57 consecutive patients who underwent global photography, videodermoscopy and mycological examination for onycholysis of a single toenail between 1 December, 2010 and 30 June, 2011, were evaluated and compared. Digital dermoscopic images of onycholysis of the great toenail were evaluated for the presence of peculiar dermoscopic features. The presumptive dermoscopic diagnosis was compared with results of mycology.

RESULTS

Evaluation of videodermoscopic images allowed us to identify three recurring peculiar dermoscopic features, two of which were present only in distal subungual onychomycosis (jagged proximal edge with spikes of the onycholytic area and longitudinal striae) and one only in traumatic onycholysis (linear edge - without spikes - of the onycholytic area).

CONCLUSIONS

We found distinctive dermoscopic signs that are exclusive to distal subungual onychomycosis and to traumatic onycholysis. Detection of these signs is simple and can, in selected cases, help to avoid mycology.

Superficial acral fibromyxoma: a clinicopathological and immunohistochemical analysis of 12 cases of a distinctive soft tissue tumor with a predilection for the fingers and toes

AIM

Superficial acral fibromyxoma (SAFM) is a rare soft tissue tumor, recently delineated and documentated as a separate entity. We report 12 cases of SAFM observed in our department from June 2004 to June 2010 and highlight pathological features and differential diagnosis.

METHODS

Radiographic examination of the affected digit was performed in all patients. All the tumors were surgically excised under local anesthesia. Follow-up was made every 6-8 months for a maximum period of five years.

RESULTS

The patients consisted of 8 men and 4 women, age range 28-76 years (mean 51), presenting with a solitary mass or nodule located in the toes and fingers. Histologically the lesions were well circumscribed dermal nodules composed of stellate and spindle cells, arranged in a myxoid matrix. Very low grade atypia and a few mitotic figures were found in only one case. Neoplastic cells showed immunoreactivity for CD34 (12 patients). In contrast focally positive or negative staining was shown for the epithelial membrane antigen (EMA) and CD 99. Actin, S100 protein, HMB45 and cytokeratin were negative. In three cases marked hyperkeratosis and acanthosis of the epidermis was present. Pathological analysis confirmed the diagnosis of superficial acral fibromyxoma. No recurrences were observed even in a long term, 2-5 year follow-up.

CONCLUSION

Complete surgical excision of the tumors and a careful follow-up is suggested, despite the benign course previously reported.

Periungual and subungual pyogenic granuloma

BACKGROUND

Nail pyogenic granuloma (PG) is common, often seen as an urgent case, given the recent onset as a bleeding nodule. Nail PGs are due to different causes that act through different pathogenetic mechanisms and may be treated in several ways. Both causes and treatments of nail PG have never been classified.

OBJECTIVES

To classify nail PG according to the pathogenesis, describe the clinical and pathological features and provide guidelines for a correct diagnosis and treatment.

METHODS

A retrospective, observational study was performed reviewing epidemiological and clinical features of 58 cases of PG seen at our Departments in the last 5 years. A review of the literature was also carried out, using PubMed database and dermatological textbooks.

RESULTS

Nail PG is usually due to the following causes: drugs, local trauma and peripheral nerve injury. Histopathology shows similar features in every type of PG, irrespective of cause and location.

CONCLUSIONS

The localization of nail PG, the number of digits involved and clinical history help to identify the cause. When PG is single, especially if it involves the nail bed, histological examination is necessary to rule out malignant melanoma. Treatment must be chosen according to the underlying cause.

Hair loss in women

Hair loss in women is a very common clinical complaint, and is usually associated with severe emotional distress. In this article, the authors review the most common clinical causes of hair loss in women, and emphasize the role of hormonal changes in the regulation of hair loss and hair growth.

Permanent alopecia after busulfan chemotherapy

Systemic chemotherapy is a well known cause of reversible hair loss. Busulfan chemotherapy, however, is responsible for a permanent alopecia that usually occurs in bone marrow transplant patients. We report two patients with permanent alopecia due to busulfan chemotherapy. Both patients had a diffuse alopecia characterized by greatly reduced hair density with short, thin hair. The pathology showed reduced follicular density in the absence of fibrosis, suggesting that alopecia may result either from hair follicle stem cell destruction or from acute damage to the keratinocytes of the lower portion of some follicles.

Androgenetic alopecia in children: report of 20 cases

Androgenetic alopecia (AGA) is the most common type of hair loss in adults. Although there are differences in the age at onset, the disease starts after puberty when enough testosterone is available to be transformed into dihydrotestosterone. We report 20 prepubertal children with AGA, 12 girls and eight boys, age range 6-10 years, observed over the last 4 years. All had normal physical development. Clinical examination showed hair loss with thinning and widening of the central parting of the scalp, both in boys and girls. In eight cases frontal accentuation and breach of frontal hairline were also present. The clinical diagnosis was confirmed by pull test, trichogram and dermoscopy in all cases, and by scalp biopsy performed in six cases. There was a strong family history of AGA in all patients. The onset of AGA is not expected to be seen in prepubertal patients without abnormal androgen levels. A common feature observed in our series of children with AGA was a strong genetic predisposition to the disease. Although the pathogenesis remains speculative, endocrine evaluation and a strict follow-up are strongly recommended.

The natural history of androgenetic alopecia

Androgenetic alopecia (AGA) is the most common cause of hair loss, affecting up to 80% of men and 50% of women in their lifetime. Genetic predisposition to the disease is well known but the responsible genes have not been identified. Polymorphism in the androgen receptor gene has been recently detected in AGA.(1) Although the role of androgens, and particularly dihydrotestosterone (DHT), in causing the disease has been established for a long time, the natural history of AGA is still not completely understood. This paper reviews recent data about natural progression of the disease, as well as factors that may interfere with its course and long-term prognosis.

Bullous tinea pedis in two children. Bullose Tinea pedis bei zwei Kindern

Tinea pedis is a dermatophytic infection with a high prevalence in adults and also occasionally observed in children. We report here two cases of bullous tinea pedis, one due to Trichophyton rubrum in a 6-year-old child and the second due to T. interdigitale in a 10-year-old child. We suggest that, despite the low prevalence of this infection in childhood, a potassium hydroxide test and a culture for fungi should always be performed when a child is examined for an inflammatory eruption of the feet.