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Draelos Z, Bogdanowicz P, Saurat JH. Top weapons in skin aging and actives to target the consequences of skin cell senescence. J Eur Acad Dermatol Venereol 2024; 38 Suppl 4:15-22. [PMID: 38881445 DOI: 10.1111/jdv.19648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/13/2023] [Indexed: 06/18/2024]
Abstract
Skin aging has long been considered a purely cosmetic problem. However, as life expectancy increases, skin aging is taking on a functional dimension that goes beyond cosmetics and appearance. Preventive or therapeutic strategies are needed to target cellular senescence, a key process underlying the alterations in skin function and appearance that occur with aging, as well as to address the age-related skin changes associated with 'dermatoporosis' and chronic skin insufficiency/fragility syndrome. Thus, given the need for effective anti-aging products that improve both the appearance and function of the skin, it is essential to distinguish active ingredients that have been proven to be effective, among the large number of available over-the-counter cosmeceuticals. This brief review focuses on a core group of topical actives, describing their clinical effects on senescence and aging, and their molecular mechanisms of action. These actives include hyaluronic acid, which has hydrating and viscoelastic properties and has been shown to reduce skin atrophy; retinaldehyde, which activates retinoid receptors and increases cutaneous elasticity; vitamins C and E, which provide stable oxidative protection; and niacinamide, which reduces inflammation and mitigates the effects of senescence.
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Affiliation(s)
- Z Draelos
- Dermatology Consulting Services, PLLC, Department of dermatology Duke University School of Medicine, High Point, North Carolina, USA
| | - P Bogdanowicz
- Department of Pharmacology and Clinical Research, Pierre Fabre Dermo-Cosmétique, Toulouse, France
| | - J-H Saurat
- University of Geneva, Geneva, Switzerland
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2
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Cristina L, Nyffeler RW. Extensive skin laceration on the forearm due to closed reduction of a dislocated shoulder. A case report. Trauma Case Rep 2024; 51:101001. [PMID: 38835528 PMCID: PMC11148510 DOI: 10.1016/j.tcr.2024.101001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2024] [Indexed: 06/06/2024] Open
Abstract
We report the case of an 80-year-old man who suffered an anteroinferior shoulder dislocation with rupture of the rotator cuff following a fall. An attempt at closed reduction under analgosedation resulted in extensive skin laceration on the elbow and forearm. The wound treatment was complex and resulted in numerous complications.
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Affiliation(s)
- Luca Cristina
- Orthopädie Sonnenhof KLG, Bern, Switzerland
- Campus Stiftung Lindenhof Bern (Campus SLB), Bern, Switzerland
| | - Richard W Nyffeler
- Orthopädie Sonnenhof KLG, Bern, Switzerland
- Campus Stiftung Lindenhof Bern (Campus SLB), Bern, Switzerland
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Truchetet A, Goetz C, Bursztejn AC. Prevalence and comorbidities of dermatoporosis: A French prospective observational study in general medicine consultation. J Eur Acad Dermatol Venereol 2023; 37:e1465-e1467. [PMID: 37471483 DOI: 10.1111/jdv.19366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/18/2023] [Indexed: 07/22/2023]
Affiliation(s)
- A Truchetet
- Department of General Medicine, Faculty of Medicine of Nancy and University of Lorraine, Nancy, France
| | - C Goetz
- Clinical Research Support Unit, Metz-Thionville Regional Hospital Center, Metz, France
| | - A C Bursztejn
- Department of Dermatology, Allergology and Venereology, Nancy University Central Hospital and University of Lorraine, Nancy, France
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Romano F, Serpico D, Cantelli M, Di Sarno A, Dalia C, Arianna R, Lavorgna M, Colao A, Di Somma C. Osteoporosis and dermatoporosis: a review on the role of vitamin D. Front Endocrinol (Lausanne) 2023; 14:1231580. [PMID: 37693364 PMCID: PMC10484397 DOI: 10.3389/fendo.2023.1231580] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Osteoporosis (OP) and Dermatoporosis (DP) are expressions of the aging process at the skin and bone levels, respectively. Both conditions are associated with increased morbidity for elderly people, and this requires necessary interventions. They share many common risk factors; among these, vitamin D (VD) deficiency appears to have a role. VD is involved in either disease with many mechanisms, among which immunomodulation. VD deficiency has been linked to OP because it inhibits the body's capacity to absorb calcium and maintain optimal bone health. Available evidence suggests that proper vitaminosis D also appears to be vital in preventing skin age-related issues. DP is often seen in elderly individuals, particularly those with long-term sun exposure and a history of chronic sun damage. VD deficiency can be linked to DP, since its involvement in collagen production, epidermal barrier function, inflammation regulation, wound healing, and sun protection. Aim of this review is to summarize the most updated existing evidence on the role of VD in the development of fragility syndromes such as DP and OP and the possible benefits of VD supplementation as a simple and harmful weapon against aging.
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Affiliation(s)
- Fiammetta Romano
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Domenico Serpico
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Mariateresa Cantelli
- Dermatology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Antonella Di Sarno
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Carmine Dalia
- Internal Medicine S. Maria Della Pietà Hospital Nola, Nola, Italy
| | - Rossana Arianna
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Mariarosaria Lavorgna
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Annamaria Colao
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
- UNESCO Chair “Education for Health and Sustainable Development”, University of Naples “Federico II”, Naples, Italy
| | - Carolina Di Somma
- Endocrinology Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
- UNESCO Chair “Education for Health and Sustainable Development”, University of Naples “Federico II”, Naples, Italy
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5
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Seppälä T, Grünthal V, Koljonen V. Skin Graft Donor Site Healing among Elderly Patients with Dermatoporosis - A Case Series. INT J LOW EXTR WOUND 2022:15347346221087081. [PMID: 35287498 DOI: 10.1177/15347346221087081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We reviewed donor site wound healing among morbid ≥65-year-old patients after split-thickness skin graft (STSG) harvesting. Patients were treated for a pretibial laceration or hematoma in Kymenlaakso Central Hospital, Finland, between 2015 and 2019. Twelve morbid patients with a mean Charlson Comorbidity Index of 7.1 (range 4-12) and a mean age of 80.6 years (range 69-91) were studied. Nine patients were female. Eight had a chronic cutaneous fragility syndrome, eg, dermatoporosis. All donor site areas were located on the thigh and were less than 2% TBSA. One donor site infection occurred. STSG integration on the pretibial wound bed was successful with all patients, and none of the patients needed further operative treatment. Graft thickness varied between 0.010 to 0.014 inches. STSG donor sites healed within the normal range of 21 days in 50% of patients. Among two patients, healing took 25 days, and among four, 37 to 97 days. All donor sites healed via local wound care without the need for regrafting. 4Our study indicates that harvesting STSG from elderly and morbid patients with poor skin condition is safe and does not result in significant complications. Prolonged donor site healing can occur, which can be managed with regular local wound care.
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Affiliation(s)
- Toni Seppälä
- Department of Plastic Surgery, 3836University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Vahur Grünthal
- Department of Surgery, 60673Kymenlaakso Central Hospital, Kotka, Finland
| | - Virve Koljonen
- Department of Plastic Surgery, 3836University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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T S, V G, V K. Pretibial hematomas – a real-world single centre study. JPRAS Open 2022; 32:79-87. [PMID: 35330747 PMCID: PMC8938884 DOI: 10.1016/j.jpra.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/05/2022] [Indexed: 12/02/2022] Open
Abstract
We analyzed treatment, outcome, and risk factors for skin necrosis of 60 patients aged ≥65 years treated for a pretibial hematoma in the province of Kymenlaakso, Finland, between 2015 and 2019. Reviewing patients’ medical records revealed two cohorts with distinct trajectories in outcome. By comparing the cohorts, we were able to discover factors associated with the prognosis for generating skin necrosis and the need for operative treatment. Thirty-five (58.3%) patients healed without any management, and 25 (41.7%) patients were treated with hematoma evacuation, mostly for having generated skin necrosis (72%). Among operatively treated patients’ descriptions, such as “parchment skin” and “poor skin quality” were observed frequently (80%) in the medical records. This pathology, dermatoporosis, was statistically significant (p<0.0001) among patients with a complicated outcome of a pretibial hematoma. In addition to dermatoporosis, patients with hematoma evacuation were more fragile having a higher Charlson comorbidity index (p = 0.005), a greater need for a walking aid (p = 0.0002), and overall compromised independency (p = 0.033). Hospitalization and rehabilitation were prolonged in the operatively treated cohort, 6.4 days vs. 2 days, respectively. We recorded a delay in the diagnosis and hematoma evacuation (mean 6, range 0–51 days). In addition, six (10%) patients were misdiagnosed for having erysipelas or deep vein thrombosis indicating that pretibial hematomas are not recognized. Skin quality should be documented, and prompt surgical hematoma evacuation should be executed in fragile patients with dermatoporosis. This could prevent skin necrosis and the further need of wound care or surgical care, long hospitalization, and rehabilitation periods.
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Lu L, Chen L, Xu Y, Liu A. Global Incidence and Prevalence of Bullous Pemphigoid: a Systematic Review and meta-analysis. J Cosmet Dermatol 2022; 21:4818-4835. [PMID: 35080093 DOI: 10.1111/jocd.14797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/20/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Integrated information on the global prevalence and incidence of bullous pemphigoid (BP) is lacking. OBJECTIVE To estimate the incidence and prevalence of BP in a systematic review and meta-analysis. METHODS Observational studies were included by using databases of Medline, EMBASE and Cochrane Library. Subgroup analysis was by continent, age, sex and country income level. Random-effects model was used. Between-study heterogeneity was assessed using the I2 statistic. RESULTS The global incidence was 0.0419 per 1000 person-years (95% CI: 0.0414-0.0424). The incidence was 0.047 per 1000 person-years (95% CI: 0.0462-0.0477), 0.0419 per 1000 person-years (95% CI: 0.0411-0.0426), 0.0072 per 1000 person-years (95% CI: 0.0067-0.0078), 0.003 per 1000 person-years (95% CI: 0.0023-0.0039) in North America, Europe, Asia and Africa, respectively; 0.0202 per 1000 person-years (95% CI: 0.0196; 0.0208) and 0.0181 per 1000 person-years (95% CI: 0.0175; 0.0188) females and males; 0.001 per 1000 person-years (95% CI: 0.001-0.001), 0.002 per 1000 person-years (95% CI:0.001-0.002), 0.004 per 1000 person-years (95% CI: 0.004-0.004); 0.007 per 1000 person-years (95% CI: 0.007-0.008), 0.011 per 1000 person-years (95% CI: 0.011-0.012), 0.017 per 1000 person-years (95% CI: 0.015-0.018) for age < 50, 50-59, 60-69, 70-79, 80-89 and ≥90 years. 0.0038 per 1000 person-years (95% CI:0.0036-0.004112) (I2 = 99%, p<.05) and 0.0456 per 1000 person-years (95% CI:0.0450-0.0462) (I2 = 100%, p<.05). The pooled clinic-based prevalence was 0.79 % (95% CI: 0.75%-0.84%), and 1.13% (95% CI: 1.06%-1.21%), 0.21% (95% CI: 0.17%-0.26%), 0.13% (95% CI:0.1%-0.15%) for Asia, Africa and Europe. CONCLUSIONS This study identified the global incidence and prevalence of BP in terms of spatial and population distributions and among various income level. A relatively higher incidence was in Europe, females, older people and high-income level country. The prevalence was higher in Asia. These findings should be interpreted with caution due to high heterogeneity of included studies.
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Affiliation(s)
- Lingling Lu
- Henan University of Chinese Medicine, Zhengzhou, P.R. China
| | - Linjiao Chen
- Department of dermatology, Shenzhen Hospital, Beijing University of Chinese Medicine (Longgang), Shenzhen, P.R.China
| | - Yujuan Xu
- Department of Gynae Cology and Obstetrics, Changshu Hospital of Chinese Medicine, Suzhou, P.R.China
| | - Aimin Liu
- Department of Dermatology, Henan Province Hospital of Traditional Chinese Medicine, The Second Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, P.R.China
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Chanca L, Fontaine J, Kerever S, Feneche Y, Forasassi C, Meaume S, Colboc H. Prevalence and risk factors of dermatoporosis in older adults in a rehabilitation hospital. J Am Geriatr Soc 2021; 70:1252-1256. [PMID: 34918778 DOI: 10.1111/jgs.17618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The term dermatoporosis (DP) is used to describe the clinical signs and functional consequences of age-related extreme skin fragility. It is associated with potentially severe complications, including deep dissecting hematomas and extended skin lacerations. No studies have evaluated the prevalence and risk factors of DP in adults aged 75 and older. METHODS The aim of our study was to assess the prevalence, complications, and risk factors of DP in a cohort of older patients hospitalized in a rehabilitation center. A case-control, single-center study was conducted between September and October 2020 in our rehabilitation ward, Rothschild Hospital, Paris, France. A senior dermatologist and a resident in geriatric medicine performed a systematic dermatological examination. The presence of DP, its stage, its location, and complications were collected, as were demographical data, comorbidities, past sun exposure, skin phototype, treatments, and biological data. RESULTS A total of 101 patients (62 women, median age 86 years [extreme values 75-104]) were included. The overall prevalence of DP was 27%. Stage 1 was the most frequent. DP was mainly located on the upper limbs. Ten (37%) patients had a DP complication: eight (30%) skin lacerations and two (7%) deep dissecting hematomas. Multivariate analysis revealed a significant association between DP and age (odds ratio [OR] 5.82, 95% confidence interval [CI] 1.67-24.92, p = 0.009), smoking (OR 8.67, 95% CI 2.59-34.85, p = 0.001), recreational sun exposure (OR 4.23, 95% CI 1.30-15.21, p = 0.02), and anticoagulant therapy (OR 4.53, 95% CI 1.32-17.26, p = 0.02). CONCLUSION Our study is the first to analyze the prevalence and risk factors of DP in older adults in rehabilitation. Frequency of DP makes it relevant for the geriatrician and should be described more to prevent potential severe complications. A multicentric study, with inpatients and outpatients, could evaluate the prevalence of DP in a more representative older adult population.
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Affiliation(s)
- Laura Chanca
- Rothschild Hospital, Sorbonne Université, Department of Geriatric Medicine - Wound and Healing, Paris, France
| | - Juliette Fontaine
- Rothschild Hospital, Sorbonne Université, Department of Geriatric Medicine - Wound and Healing, Paris, France
| | - Sébastien Kerever
- Department of Anesthesiology and Critical Care Medicine, Lariboisière University Hospital, DMU PARABOL, AP-HP. Nord, Paris, France.,Fédération Hospitalo-Universitaire PROMICE, INSERM UMR-S 942 MASCOT, Université de Paris, Paris, France
| | - Yohann Feneche
- Rothschild Hospital, Sorbonne Université, Department of Geriatric Medicine - Wound and Healing, Paris, France
| | - Christine Forasassi
- Rothschild Hospital, Sorbonne Université, Department of Geriatric Medicine - Wound and Healing, Paris, France
| | - Sylvie Meaume
- Rothschild Hospital, Sorbonne Université, Department of Geriatric Medicine - Wound and Healing, Paris, France
| | - Hester Colboc
- Rothschild Hospital, Sorbonne Université, Department of Geriatric Medicine - Wound and Healing, Paris, France
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Steck O, Bertschi N, Luther F, Berg J, Winkel D, Holbro A, Schlapbach C. Rapid and sustained control of itch and reduction in Th2 bias by dupilumab in a patient with Sézary syndrome. J Eur Acad Dermatol Venereol 2020; 35:1331-1337. [DOI: 10.1111/jdv.17001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/05/2020] [Indexed: 12/22/2022]
Affiliation(s)
- O. Steck
- Department of Dermatology, Inselspital Bern University HospitalUniversity of Bern Bern Switzerland
| | - N.L. Bertschi
- Department of Dermatology, Inselspital Bern University HospitalUniversity of Bern Bern Switzerland
| | - F. Luther
- Department of Dermatology, Inselspital Bern University HospitalUniversity of Bern Bern Switzerland
| | - J. Berg
- Department of Hematology University Hospital Basel Basel Switzerland
- Blood Transfusion Center Swiss Red Cross Basel Switzerland
| | - D.J. Winkel
- Radiology & Nuclear Medicine Clinic University Hospital Basel Basel Switzerland
| | - A. Holbro
- Department of Hematology University Hospital Basel Basel Switzerland
- Blood Transfusion Center Swiss Red Cross Basel Switzerland
| | - C. Schlapbach
- Department of Dermatology, Inselspital Bern University HospitalUniversity of Bern Bern Switzerland
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Villeneuve D, Lidove O, Chazerain P, Ziza JM, Sené T. Association between dermatoporosis and history of major osteoporotic fractures: A French prospective observational study in a general practice population. Joint Bone Spine 2020; 87:511-512. [PMID: 32360829 DOI: 10.1016/j.jbspin.2020.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/08/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Delphine Villeneuve
- Department of internal medicine, Fondation A. de Rothschild, 25-29, rue Manin, 75019 Paris, France.
| | - Olivier Lidove
- Department of internal medicine, Fondation A. de Rothschild, 25-29, rue Manin, 75019 Paris, France; Department of rheumatology and internal medicine - groupe hospitalier Diaconesses - Croix St-Simon, 125, rue d'Avron, 75020 Paris, France
| | - Pascal Chazerain
- Department of rheumatology and internal medicine - groupe hospitalier Diaconesses - Croix St-Simon, 125, rue d'Avron, 75020 Paris, France
| | - Jean-Marc Ziza
- Department of internal medicine, Fondation A. de Rothschild, 25-29, rue Manin, 75019 Paris, France; Department of rheumatology and internal medicine - groupe hospitalier Diaconesses - Croix St-Simon, 125, rue d'Avron, 75020 Paris, France
| | - Thomas Sené
- Department of internal medicine, Fondation A. de Rothschild, 25-29, rue Manin, 75019 Paris, France; Department of rheumatology and internal medicine - groupe hospitalier Diaconesses - Croix St-Simon, 125, rue d'Avron, 75020 Paris, France
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Maglie R, Quintarelli L, Lastrucci I, Senatore S, Montefusco F, Pimpinelli N, Antiga E. Fatal occurrence of acquired haemophilia A in a patient with pemphigus vulgaris. Clin Exp Dermatol 2019; 44:e247-e248. [DOI: 10.1111/ced.14022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2019] [Indexed: 11/29/2022]
Affiliation(s)
- R. Maglie
- Department of Health Science, Section of Dermatology University of Florence Florence Italy
| | - L. Quintarelli
- Department of Health Science, Section of Dermatology University of Florence Florence Italy
| | - I. Lastrucci
- Department of Health Science, Section of Dermatology University of Florence Florence Italy
| | - S. Senatore
- Department of Health Science, Section of Dermatology University of Florence Florence Italy
| | - F. Montefusco
- Department of Health Science, Section of Dermatology University of Florence Florence Italy
| | - N. Pimpinelli
- Department of Health Science, Section of Dermatology University of Florence Florence Italy
| | - E. Antiga
- Department of Health Science, Section of Dermatology University of Florence Florence Italy
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Wollina U, Lotti T, Vojvotic A, Nowak A. Dermatoporosis - The Chronic Cutaneous Fragility Syndrome. Open Access Maced J Med Sci 2019; 7:3046-3049. [PMID: 31850120 PMCID: PMC6910795 DOI: 10.3889/oamjms.2019.766] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/04/2019] [Accepted: 07/05/2019] [Indexed: 11/28/2022] Open
Abstract
Dermatoporosis is an important clinical condition leading to chronic skin fragility. It can be separated into primary and secondary subtypes, with the latter induced by medical drugs and environmental factors. Dermatoporosis can be classified into 4 major stages with increasing morbidity and mortality with the advanced stages. Its aetiology has been related to the epidermal hyalusome. Dermatoporosis is a cause of mortality in the intensive care unit and should be known not only by a dermatologist but another medical speciality as well. Prevention is of major importance. Therapeutic options are limited but available.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Städtisches Klinikum Dresden, Academic Teaching Hospital, Dresden, Germany
| | - Torello Lotti
- Department of Dermatology, University of Rome "G. Marconi", Rome, Italy
| | | | - Andreas Nowak
- Department of Anesthesiology and Intensive Care Medicine, Emergency Medicine and Pain Management, Städtisches Klinikum Dresden, Dresden, Germany
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