A 40-year old Filipino male was managed as a case of clinically amyopathic dermatomyositis (CADM) after presenting only with pruritic photodistributed symmetric erythematous-violaceous patches, nail fold telangiectasia and the pathognomonic Gottron papules. There was no clinical evidence of muscle involvement. The patient shortly presented with a metastatic undifferentiated carcinoma on the cervical lymph nodes. This case demonstrates that dermatomyositis can present uncommonly as CADM with associated metastatic undifferentiated carcinoma.
Human ; Male ; Dermatomyositis ; Carcinoma ; Neoplasms ; Erythema

A 5-year-old female presented a 4-year history of generalized well-demarcated asymptomatic brown to dark brown thin verrucous plaques with a Blaschkoid distribution. Histopathology was consistent with an epidermal nevus. Patient was diagnosed to have systematized verrucous epidermal nevus. Due to the extent of the lesions, surgical management was not feasible. Hence acitretin was given which showed partial decrease in the thickness of the lesions.

An 11-year-old girl previously treated for tinea capitis presented a 3-month history of continuous decrease in hair density on the vertex, frontal, and parieto-temporal areas of the scalp. Hair pull test was negative. Trichoscopic findings showed black dots, micro-exclamation point hairs, regrowing vellus hair, and zigzag hairs. Histopathology showed CD3+ peribulbar lymphocytic infiltrates and occasional eosinophils around the anagen hair follicle consistent with a non-scarring alopecia. A diagnosis of diffuse alopecia areata was made. Patient was given methylprednisolone (0.5 mg/kg/day) for 2 weeks and noted marked increase in hair density except on focal areas of the scalp. Patient eventually admitted to occasional hair pulling. Trichoscopy revealed trichoptilosis, V-sign, tulip hairs, and multiple broken hairs of varying length while a second biopsy showed trichomalacia and pigment casts consistent with trichotillomania. In this case, where co-existence of alopecia areata and trichotillomania is considered to be uncommon, trichoscopy proved to be an important tool in differentiating hair disorders with similar presentation. Knowing key features of hair diseases can help elucidate the diagnosis when presented with an atypical case.
Alopecia Areata ; Trichotillomania

BACKGROUND: Alopecia areata (AA) is an autoimmune hair disorder, with the clinical variants ophiasis and extensive variants AA totalis and universalis, having poor response to therapy. Oral steroids are used to treat the severe variants, requiring prolonged therapy, which leads to side effects while discontinuation leads to high relapse rate. Azathioprine is a steroid-sparing agent for the severe AA forms.

OBJECTIVE: To review the current evidence on the therapeutic efficacy and adverse effects of azathioprine for severe forms of alopecia areata

METHODS: Published articles utilizing azathioprine for alopecia areata were obtained until July 2018 from PubMed, MEDLINE, Cochrane Library, TRIP database, HERDIN, and Google Scholar.

RESULTS: Seven articles underwent a full-length review. Clinical variants include patchy, diffuse, steroid-resistant, reticulate, totalis, universalis, ophiasis, and sisaipho. Doses ranged from 2 to 2.5 mg/kg/day or weekly 5 mg/kg pulse therapy. Initial response ranged from 6 to 12 weeks, with almost complete resolution by 32 weeks. Response was sustained for 6 months upon discontinuation, with only 14% relapsing at 2.5 months. Adverse effects were gastrointestinal discomfort, elevated liver function tests, and myelosuppression.

CONCLUSION: There is emerging evidence on the efficacy and safety of azathioprine for the treatment of extensive forms of alopecia areata. Randomized-controlled trials are needed to evaluate its efficacy.

BACKGROUND: Erythema nodosum leprosum is an immune-mediated complication of leprosy whose underlying mechanism has not yet been fully elucidated, making management difficult.

OBJECTIVES: To determine the serum cytokine profile of ENL compared to non-reactional leprosy states.

METHODS: An open literature search was performed using MEDLINE, Cochrane Library, TRIP and HERDIN electronic databases using the keywords ("cytokines" or "inflammatory mediators") and ("erythema nodosum leprosum" or "ENL") and ("leprosy" or "lepra"). Studies were selected by two independent review authors. Risk of bias was assessed using the Newcastle-Ottawa Scale and statistical analysis was performed using RevMan 5.3 software.

RESULTS: Eight cross-sectional studies with 197 participants were included. Meta-analysis showed that both serum IL-17 and serum IFN-? were significantly decreased (Z 2.39, p = 0.02 and Z 2.74, p = 0.01, respectively) in ENL compared to non-reactional states. However, for IL-1?, IL-6, IL-10, IL-22, TNF-? and TGF-?, no significant differences were found between the two groups.

CONCLUSION: ENL appears to be an exacerbation of the Th2 cytokine response seen in the lepromatous pole of leprosy. However, despite pooling of data, sample sizes remain small resulting in significant heterogeneity. Future studies involving large sample sizes and investigating a wider range of cytokines are encouraged.

BACKGROUND: Alopecia areata is postulated to be an autoimmune disease of which vitamin D may play a role being found in the immune system and hair.

OBJECTIVE: To determine the association between serum 25-hydroxyvitamin D levels in patients with alopecia areata compared with healthy controls.

METHODS: Observational studies on association of vitamin D levels on alopecia areata compared to healthy controls were obtained from all published articles until July 2018 on MEDLINE, Cochrane Library, TRIP, HERDIN, and Google. Review Manager 5.3 was used for the meta-analysis.

RESULTS: The search strategy yielded 13 qualified articles for the full-length review and 11 studies, containing 916 patients, were included in the meta-analysis using the pooled random effects model. The pooled mean difference of the serum 25-hydroxyvitamin D levels between alopecia areata patients and healthy controls was -9.55 (95% CI, -10.51 to -8.59) with heterogeneity (I2=85%).

CONCLUSION: In conclusion, there were reduced levels of serum 25-hydroxyvitamin D levels in alopecia areata compared to healthy controls and vitamin D deficiency was more prevalent in alopecia areata compared to healthy controls. There was also a trend of lower vitamin D levels in the more severe forms of alopecia.

Acquired perforating dermatosis represents one of the perforating skin disorders showing transepidermal elimination of dermal contents. Dermoscopy showing concentric zones of a central keratotic plug, white-gray structureless area and peripheral brown pigmentation may aid in diagnosis and in sample selection for biopsy.
Diabetes Mellitus, Type 2 ; Renal Insufficiency ; Dermoscopy