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Notes: Background The many factors which appear to be implicated in alopecia areata (AA) include genetic and autoimmune disorders as well as emotional stress. Biotinidase deficiency, an inborn error of metabolism, causes alopecia in infants, children and adults. Subjects and methods A fluorimetric method was used to evaluate biontinidase activity in 19 patients before and after 40 days treatment with biotin (20 mg/day p.o). Nineteen members of the medical staff were the controls. Results The mean biotinidase activities in our patients before treatment (3.0 ± 1.50 mmol/1/min) were statistically significantly decreased compared to those of controls (4.75 ± 0.80 mmol/1/min) as well as to those after treatment (4.40 ± 0.84 mmol/1/min). Consequently, 12 of our 19 patients showed a clinical remission of the disease after treatment, and thin white hair appeared on the frontal area of the scalp. Conclusions An evaluation of biotinidase activity is suggested in all patients with AA and supplements of biotin are recommended.

Notes: Background   Sunlight precipitates a series of genetic events that lead to the development of skin cancers such as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). The p53 tumour suppressor gene, which plays a pivotal role in cell division and apoptosis, is frequently found mutated in sunlight-induced skin tumours.Objective   To investigate the immunoreactivity of the p53 gene in non-melanoma skin cancers and to correlate its expression with apoptotic and cell proliferation markers.Methods   We analysed 35 non-melanoma tumours including 19 BCCs and 16 SCCs from sun-exposed skin areas. p53 protein expression was studied immunohistochemically using the DO7 monoclonal antibody against wild-type and mutant p53 forms. The percentage of p53-immunopositive nuclei was measured by image analysis. Cell proliferation and apoptosis were also assessed by image analysis following Ki-67 immunostaining and application of the TUNEL method on paraffin sections, respectively.Results   The percentage of p53-expressing cells varied from 3.5 to 90 in BCCs (median value 54.4%) and from 3.7 to 94 in SCCs (median value 40.3%). The mean value of Ki-67-positive cells was comparable in both groups of tumours with a mean value of 40.6% in BCCs and 34.6% in SCCs. Conversely, the TUNEL assay showed sporadic staining of apoptotic cells within the tumours with a mean value of 1.12% in BCCs and 1.8% in SCCs. p53 protein expression was correlated positively with cell proliferation (r = 0.75, P = 0.000001) and negatively with apoptosis (r = −0.23, P = 0.05).Conclusion   p53 immunoreactivity was high in the majority of the skin carcinomas examined and correlated positively with cell proliferation and negatively with apoptosis. The p53 protein overexpression appears to be related to an inactivated protein resulting from mutations of the p53 gene or other unclear molecular mechanisms.

Notes: A purpuric eruption may be an unusual early manifestation of mycosis fungoides (MF). On the other hand, persistent pigmented purpuric dermatoses (PPPD) may, occasionally, evolve to cutaneous T-cell lymphoma. Coexistence of these two conditions has been reported, but it is extremely rare. We present the case of an elderly woman with a long-standing pruritic, pigmented purpuric eruption. On 1-year follow-up, histological features suggesting early MF were observed and molecular analysis of the rearrangement of T-cell receptor genes revealed clonality. Our patient may represent a case of PPPD evolving to MF, a case of MF clinically featuring PPPD, or an intermediate condition in a nosological continuity extending from PPPD to MF. A persistent pigmented purpuric eruption may rarely be a harbinger of cutaneous T-cell lymphoma. Therefore, vigilant long-term follow-up of PPPD is highly recommended.

Notes: Rosacea is a common chronic dermatosis that evolves in stages. The mite Demodex folliculorum has been implicated in its obscure aetiopathogenesis.〈section xml:id="abs1-3"〉〈title type="main"〉AimTo evaluate the importance of D. folliculorum in the aetiology and course of rosacea.〈section xml:id="abs1-4"〉〈title type="main"〉MethodsWe studied 92 consecutive cases of papulopustular rosacea and 92 age- and sex-matched controls. Prevalence and density of D. folliculorum were estimated by microscopic examination of the expressed follicular content. Histological examination and immunohistochemical study of the inflammatory infiltrate were performed in 10 subjects (five with positive D. folliculorum finding and five with negative finding).〈section xml:id="abs1-5"〉〈title type="main"〉Results D. folliculorum was detected in 83 (90.2%) of the 92 rosacea subjects but only 11 (11.9%) of the controls. The mean mite density was 2.03 mites/visual field in the rosacea group (range 0–5, SD = 1.2) and 0.16 mites/visual field (range 0–2, SD = 0.52) in the control group. The difference was statistically significant (P 〈 0.0001) for both mite prevalence and density. Hair follicle infestation was associated with intense perifollicular infiltrate of predominantly (90–95%) CD4 helper/inducer T cells. We observed an increased number of macrophages and Langerhans cells only in those subjects with a positive D. folliculorum finding.〈section xml:id="abs1-6"〉〈title type="main"〉ConclusionsAlthough Demodex mites do not seem to be the cause of rosacea, they may represent an important cofactor, especially in papulopustular rosacea. Immunohistochemical findings suggest that a delayed hypersensitivity reaction, possibly triggered by antigens of follicular origin, probably related to D. folliculorum, may occur, stimulating progression of the affection to the papulopustular stage.

Notes: The development of androgenetic alopecia is thought to be caused by increased androgen action on hair follicles with menopause. Testosterone, estradiol and sex hormone binding globulin (SHBG) serum levels were determined in ten postmenopausal women with androgenetic alopecia and in ten sex and age matched healthy controls. No statistically significant differences were found in the hormone levels between the patients and the controls. These findings suggest that a genetically determined functional alteration of androgen receptors and/or a metabolic disturbance may exist in the hair follicle keratinocytes in androgenetic alopecia.

Notes: Background Poikiloderma of the face and neck (Civatte) is a rather common, indolent, chronic dermatosis, most often affecting menopausal females. Cumulative excessive sun exposure, a phototoxic or a photoallergic reaction, hormonal changes of menopause and genetic factors have all been incriminated in its obscure aetiopathogenesis. Objectives To evaluate the role of contact sensitization and photosensitivity in the pathogenesis of poikiloderma of Civatte (PC). Methods Thirty-two patients (24 females and eight males, age range 38–74 years) with PC were patch tested with the European standard series and the fragrance series, and were photopatch tested with the photoallergens series. Additionally, photo-testing with a monochromator was performed. Results Thirteen of 32 patients (40·62%) had one or more positive reactions to allergens of the standard series. Eight patients (25%) had positive reactions to fragrance mix and/or Balsam of Peru, which are included in the standard series, or to allergens of the fragrance series. Nickel sulphate was the single most common cause of contact sensitization (18·75%) among our patients. Ninety-seven subjects, who were patch tested with the standard series for suspected allergic contact dermatitis of the face and/or neck, served as age, sex and site controls. Of these, nine (9·27%) had one or more positive reactions to fragrance compounds. Statistical analysis showed a statistically significant difference in the frequency of positive reactions to fragrances between the PC group and the control group (χ2 value = 3·91, P 〈 0·05). In contrast, none of the PC patients had a positive photopatch test for the allergens included in the photoallergens series. The estimated minimal erythemal dose for the PC group was in all cases within normal limits for all wavelengths of ultraviolet (UV) radiation examined. Conclusions Contact sensitization, mostly to perfume ingredients, may develop in PC, possibly playing a pathogenetic part, at least in a subset of patients. Despite negative results of photopatch testing, an allergic photo-contact reaction cannot be definitely excluded. PC seems not to be a photosensitivity disorder of the type of chronic actinic dermatitis. UV radiation-induced dermal connective tissue changes are the predominant histological feature of PC, leading to telangiectasia due to loss of vascular support. Reticular pigmentation may result from a delayed hypersensitivity reaction to perfume and/or cosmetic ingredients. Patch testing with the standard series and avoidance of documented allergens may be of value in patients with PC.

Notes: Fifteen patients with treatment-resistant condylomata acuminata have been treated by application of Dinitrochlorobenzene (DNCB). The agent was applied weekly as a 0.5 or 1% solution in acetone for a period of 6 to 8 weeks. Patients were sensitised 15 days before the onset of treatment by applying a 2% DNCB solution on the right arm in a quantity of 0.15ml. In one patient treatment had to be stopped because of local irritation and one discontinued treament. In the other 13 patients all lesions cleared completely. Patients were followed up for a year and no recurrence has appeared as yet. DNCB seems to be useful agent for treatment-resistant condylomata acuminata and Justifies further clinical trials.

Notes: Summary Background Treatment failures and relapses are not uncommon in onychomycosis. Therefore, it is worthwhile to consider the combination of systemic and topical antifungals to improve the cure rates further and to reduce the duration of systemic treatment. Objectives To evaluate and compare itraconazole pulse therapy combined with amorolfine with itraconazole alone in the treatment of Candida fingernail onychomycosis. Methods Ninety patients with moderate to severe Candida fingernail onychomycosis were randomized into two treatment groups of 45 subjects each. Group 1 received itraconazole pulse therapy for 2 months and applied amorolfine 5% solution nail lacquer for 6 months, while group 2 received monotherapy with three pulses of itraconazole. The primary efficacy criterion was the result of mycological examination at 3 months. The secondary criterion was the combined mycological and clinical response at 9 months. A pharmacoeconomic analysis was also performed to compare the cost-effectiveness of combined therapy vs. monotherapy. Results Eighty-five patients were analysed (73 women and 12 men, mean ± SD age 44·2 ± 12·9 years). Patients had a mean ± SD of 3·64 ± 2·0 nails involved and 228·6 ± 148·0 mm2 of their nail surface diseased. The mean duration of onychomycosis was 11 months. Paronychial involvement was evident in 71 patients. C. albicans was isolated in 85 cases, C. parapsilosis in three and other Candida species in two cases. Side-effects were uncommon and in only one case led to withdrawal. At the 3-month visit, mycological cure was seen in 32 (74%) of 43 patients in group 1 and in 25 (60%) of 42 patients in group 2. At the 9-month visit, a global cure was seen in 40 patients (93%) in group 1 and in 34 patients (81%) in group 2. Statistical analysis showed no statistically significant difference (P 〉 0·1) between the two treatment groups. The cost per cure ratio was 1·63 and 1·70€ for groups 1 and 2, respectively. Conclusions The combination of amorolfine and oral itraconazole, which interfere with different steps of ergosterol synthesis, exhibited substantial synergy. Compared with oral itraconazole alone, the combination achieved greater mycological cure and increased total cure rate. However, no statistically significant difference was documented for this number of observations. Combination treatment with amorolfine and two pulses of itraconazole is at least as safe and effective as three pulses of itraconazole, with a lower cost per patient. In our opinion, the addition of amorolfine to oral itraconazole pulse therapy is of value in the treatment of moderate to severe Candida fingernail onychomycosis.